Every finding on record at Orchardview Post-Acute and Rehabilitation Center

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure insulin medications were labeled appropriately to include an open date for 2 residents (Resident #62 and Resident #67) of 7 residents reviewed for insulin storage. The findings include: Review of the facility's undated policy titled, Labeled and Storage, revealed .Guidelines .all medications .used in the facility .will be labeled in accordance with current .federal regulations .the date .initial opened or accessed .should be discarded within 28 days . Review of the medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus (DM), Hypertension, and Chronic Obstructive Pulmonary Disease. Review of a Physician's Order for Resident #62 dated 1/27/2026, revealed .Insulin Glargine [long acting insulin medication used to lower blood glucose levels] Subcutaneous Solution .100 Unit/ML [milliliter] .Inject 12u [units] Subcutaneous .at Bedtime for Diabetes . Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including DM, Hypertension, and Hyperlipidemia. Review of a Physician's Order for Resident #67 dated 3/17/2026, revealed .Semglee Subcutaneous Solution [long acting insulin medication used to lower blood glucose levels] .100 Unit/ML .Inject 44 unit subcutaneous .at Bedtime .for DM . During an observation of medication cart 200-top cart on 6/9/2026 at 7:30AM, revealed an opened Glargine Subcutaneous Solution 100 Unit/ML insulin pen for Resident #62. The opened insulin pen was undated and available for resident use. Further observation revealed an opened Semglee Subcutaneous Solution 100 Unit/ML insulin pen for Resident #67, also undated and available for resident use. During an interview on 6/10/2026 at 8:00AM, Licensed Practical Nurse (LPN) E confirmed the insulin pens were not dated when opened for Resident #62 and Resident #67 and were stored and available for resident use. During an interview on 6/10/2026 at 2:14PM, the Director of Nursing confirmed 2 insulin pens were opened and undated in the medication cart and available for resident use for Resident #62 and Resident #67.

Based on facility policy review, medical record review, observations, and interviews, the facility staff failed to perform appropriate hand hygiene when serving residents' meal service for 2 residents (Residents #18 and #22) on 1 of 2 units observed for meal tray distribution. The Findings include: Review of the facility's undated policy titled, Hand Hygiene guidelines, revealed .All staff will perform proper hand hygiene .residents .before eating . Review of a facility's undated document titled, Tidy Hands Program, revealed .assist with residents handwashing .before meals . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Dementia, Dysphagia, and Need for Assistance with Personal Care. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #18 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident required set up or clean-up assistance with eating. Review of a comprehensive care plan dated 5/26/2026, revealed Resident #18 had a .ADL [Activities of Daily Living] self-care deficit r/t [related to] weakness and dementia .Eating .able to feed self after set up . During an observation on 6/8/2026 at 12:33 PM, Certified Nurse Assistant (CNA) D delivered the meal service to Resident #18. CNA D set up meal for Resident #18 and failed to offer hand hygiene to the resident prior to exiting the room. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Diabetes, Need for Assistance with Personal Care, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed Resident #22 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident required set up or clean-up assistance with ADL's. Review of a comprehensive care plan for Resident #22 dated 8/21/2023, revealed .ADL .staff assistance .assist with meal set up . During an observation on 6/8/2026 at 12:45 PM, CNA D delivered the meal service to Resident #22. CNA D set up meal for Resident #22 and failed to offer hand hygiene to the resident prior to exiting the room. During an interview on 6/8/2026 at 12:50 PM, CNA D confirmed she had not offered hand hygiene while passing the meal service to Residents #18 and #22. During an interview on 6/9/2026 at 1:48 PM, the Director of Nursing stated it was the facility's expectations hand hygiene was to be offered to residents prior to meals. The DON confirmed the facility failed to follow infection control policies when staff did not offer hand hygiene to Resident #18 and #22.

Based on facility policy review, medical record review, and interviews, the facility failed to notify the physician of abnormal laboratory (lab) results for 1 resident (Resident #19) of 3 residents reviewed. The findings include: Review of the facility's undated policy titled, Notification of Changes, revealed .promptly informs .residents' physician .when there is a change requiring notification .significant change in the residents' condition .clinical complications . Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Stroke, Anxiety, Depression, and Diabetes. Review of lab results for Resident #19 dated 4/24/2026, revealed .Glucose 822 (CH) [Critical High] .reference range 74-109 . Continued review revealed there was no documentation the Physician or Nurse Practitioner (NP) were notified of the laboratory results. Continued review revealed it was unclear the exact time the lab company had notified the facility on 4/24/2026 of the critical high-level result for Resident #19. Review of a physician note for Resident #19 dated 4/25/2026, revealed .Patient [Resident #19] seen at request of nursing for follow-up for increased behaviors .Nursing was asked if patient had any recent labs and reported he did have labs with a high glucose (blood sugar) but was not sure if it had been called to anyone [provider] .Review of lab show that patient had a result of a critical glucose of 822 at 0300 [3: 00 AM] today .Nursing was asked if they had rechecked this reading and they said No .Nursing was asked to check patients glucose and glucometer was reading high [high glucometer reading are typically 600 or above] .Nursing was advised to give 10 units of lispro (medication to lower blood sugar) and recheck glucose in 1 hour and contact provider with the results .Orders were also given for patient to receive normal saline 500 ml [millimeter] bolus. Orders for CBC [Complete Blood Count], CMP [Comprehensive Metabolic Panel] .Nursing to call provider back and glucose was still reading high after normal saline bolus, 10 units lispro .Orders were given to give another 10 units of lispro and an additional 500 ml bolus of normal saline .Nursing to call provider for call and recheck in an hour .Nursing reported patient .sending him to hospital . During a telephone interview on 6/10/2026 at 9:13 AM, Nurse Practitioner (NP) A stated she could not remember Resident #19 and did not have access to his medical records at the time of the interview. NP A further stated there was a delay in notification to the provider of the critical high glucose lab value of Resident #19. During a telephone interview on 6/10/2026 at 10:00 AM, Licensed Nurse Practitioner (LPN) B stated on 4/25/2026 at the beginning of the day shift, the LPN entered into the electronic lab system on the computer and checked to see if any labs had resulted. LPN B stated Resident #19 had a critical blood glucose of 822 (normal range 70-100) and reported it to NP A on 4/25/2026 immediately after viewing the result. LPN B further stated she gave Resident #19 extra doses of insulin and a bolus of fluids as ordered. LPN B further stated Resident #19 was transported to the emergency room for further evaluation. During an interview on 6/10/2026 at 10:45 AM, the Director of Nursing (DON) stated it was the facility's expectation for nursing staff to report any critical lab results to the provider immediately and there had been a delay in reporting the critical high lab value for Resident #19 to the provider. During an interview on 6/10/2026 at 11:00 AM, NP C stated she had not been notified by the facility nursing staff of Resident #19's critical high lab results on 4/24/2026. During an interview on 6/10/2026 at 11:57 AM, the Medical Director (MD) stated he had not been informed of the critical high glucose level for Resident #19 until he was notified by NP A on 4/25/2026 (1 day after receipt of lab value, exact timeframe was unknown). The MD stated Resident #19 had routinely had high glucose level readings and was being treated by the providers. The MD further stated the resident did not have an adverse outcome or harm from the delay in the notification.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 residents (Resident #30 and Resident #31) of 67 residents reviewed for abuse. The facility's failure to prevent resident to resident abuse resulted in actual HARM for Resident #31. The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation of Property, Exploitation, and Injuries of Unknown Source, revised 10/24/2022, revealed .organizations intention to prevent the occurrence of abuse .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .stakeholder observes a resident exhibiting any form of abuse toward another resident the stake holder will intervene immediately and interrupt the incident and remove or separate the residents involved . Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including Anxiety, Seizures, Depression, and Stroke. Review of a comprehensive care plan for Resident #30 dated 6/30/2023, revealed the resident utilized a wheelchair for locomotion. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #30 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident utilized a wheelchair for locomotion. Review of a Nurse Practitioner note for Resident #30 dated 9/10/2024, revealed .Resident seen due to reports of him having an altercation with another resident last night .Resident states that he did hit another resident [Resident #31] yesterday .states he does not want to have another altercation . Review of a Psychiatric Nurse Practitioner note for Resident #30 dated 9/14/2024, revealed .Attempted to discuss recent altercation with peer [Resident #31] .[Resident #30] refused to provide details . Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Dementia, Psychotic Disorder, Mood Disorder, Depression, Anxiety, and Difficulty Speaking. Review of the Medication Administration Record (MAR) for Resident #31 dated 6/1/2024 through 6/30/2024, revealed .Hydroxyzine .1 tablet by mouth three times a day related to ANXIETY DISORDER . Review of an admission MDS for Resident #31 dated 7/1/2024, revealed the resident was rarely/never understood. Staff assessment for mental status revealed Resident #31 experienced short and long-term memory problems and was severely impaired for daily decision-making skills. Review of a Behavior note for Resident #31 dated 9/4/2024, revealed the resident's Hydroxyzine (antianxiety medication) was discontinued related to the resident's frequent refusal of the medication. Review of a Nurse Practitioner note for Resident #31 dated 9/6/2024, revealed .Resident seen due to aggressive behaviors .shoved a bedside table that was in front of another resident though the other resident was not hit .[Antipsychotic medication injection] administered .particular resident who is confused [Staff were unable to identify who this resident was] seemingly agitating him .Angry .not redirectable . Review of a facility investigation dated 9/9/2024, revealed a resident-to-resident altercation occurred between Resident #30 and Resident #31. Certified Nursing Assistant (CNA) G reported to the charge nurse [Licensed Practical Nurse (LPN) I] she observed Resident #31 crying and bleeding in the hallway. LPN I notified the Administrator of the resident-to-resident altercation. The Administrator reported to the building, reviewed the camera footage, and observed Resident #31 strike resident #30, who then struck back Resident #31 in the nose. Further review of the facility investigation revealed Resident #31 was sent to the hospital and was determined to have a fractured nose after the event occurred and returned to the facility the same day. The facility substantiated resident-to-resident abuse with injury in the investigation. Review of a Behavior note for Resident #31 dated 9/9/2024, revealed Resident #31 was transported to the hospital for an altercation [with Resident #30]. Review of a Computed Tomography (CT) scan result [a test that uses x-rays, and a computer to make detailed images of the body] for Resident #31 dated 9/9/2024, revealed a fractured nose. Review of a Nurse Practitioner note for Resident #31 dated 9/10/2024, revealed .[Resident #31] .resting in [wheelchair] .on 1:1 [one on one] supervision after an altercation with another resident [Resident #30] .[Resident #31] hit [Resident #30] on the arm .[Resident #30] then hit [Resident #31] in the face resulting in a broken nose .[Resident #31] was sent to ER [emergency room ] and has returned to the facility .[Resident #31] frequently refuses medications which is within his right .[Resident #31] declined his medication today . Review of a comprehensive care plan for Resident #31 initiated 9/16/2024, revealed . inappropriate behaviors related to impaired communication .dementia .mood disorder .Resident gets agitated at times . During an interview on 1/7/2025 at 1:00 PM, Resident #30 was able to recall the event and stated Resident #31 hit him on the arm when he was sitting in his wheelchair waiting to go smoke and he was not harmed in the altercation. Resident #30 stated he hit Resident #31 back in the face. Resident #30 stated Resident #31 started bleeding and crying after Resident #30 hit Resident #31. Resident #30 denied any other altercations before or after this incident. During a telephone interview on 1/7/2025 at 6:00 PM, CNA G stated on the night of the event she observed Resident #30, who was waiting to go smoke, sitting in his wheelchair in the hallway and later observed Resident #31 in his wheelchair approach Resident #30. CNA G stated nothing alarmed her about the approach. CNA G stated she entered a different resident's room to provide care and when she exited the room, CNA G observed Resident #31 bleeding and crying sitting in his wheelchair in the hallway next to Resident #30. CNA G stated that she separated the residents, remained in the area, and called the nurse, who then called the Administrator. CNA G stated Resident #30 told her he was hit by Resident #31, and he hit Resident #31 back. During a facility investigation review, medical record review, and interview on 1/8/2025 at 10:30 AM, the Administrator reviewed the facility's investigation of the altercation between Resident #30 and Resident #31 on 9/9/2024, reviewed Resident #30's CT scan results which revealed a fractured nose, and the Administrator confirmed resident-to-resident abuse with injury occurred. During an interview on 1/8/2025 at 3:00 PM, the Family Nurse Practitioner (FNP) stated she was familiar with Resident #30 and Resident #31. The FNP stated she evaluated both residents after the event and stated Resident #30 told her he was hit by Resident #31 first, and he hit Resident #31 back. The FNP also stated Resident #31 had expressive aphasia, and when the FNP asked Resident #31 if Resident #30's statement was true, Resident #31 shook his head indicating Resident #30's statement was true. Further interview revealed the FNP stated the resident-to-resident altercation was the cause of Resident #31's fractured nose.

Based on facility policy review, observation, and interview, the facility failed to ensure dented cans (3 of 3) were discarded and not available for resident use, which had the potential to affect 67 of 67 residents. The findings include: Review of the facility's undated policy titled, Food Safety Requirements, revealed .when food arrives damaged or concerns are noted .remove these foods from use .dented cans are returned to the vendor upon delivery .if dented cans are identified after delivery, the staff will not use the canned goods for food preparation and will be separated (to be returned to the vendor or will be discarded) . During an observation and interview on 1/6/2025 at 11:37 AM, in the dry storage room, with the Certified Dietary Manager (CDM), revealed two 6.88-pound cans of pork and beans and one 7.312-pound can of cranberry sauce was dented on the side of each can. The CDM stated the kitchen staff if any dented cans were observed, they were to be discarded. The CDM confirmed the dented cans of pork and beans and cranberry sauce were available for resident use and should have been discarded.

Based on facility policy review, medical record review, and interview the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) timely for 2 residents (Resident #5 and Resident #65) of 3 residents reviewed for beneficiary notification. The findings include: Review of the facility's undated policy titled, Medicare Eligibility, Coverage and Notices, revealed .Facility will provide the residents .[or] .representatives with timely notices regarding Medicare Eligibility and Coverage .(NOMNC) .shall be issued .when Medicare covered service(s) are ending . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Kidney Disease, Difficulty Walking, Lack of Coordination, and Seizures. Review of a Physical Therapy note for Resident #5 dated 11/28/2024, revealed the resident was discharged from Physical Therapy services on 11/28/2024. Review of an Occupational Therapy note for Resident #5 dated 11/28/2024, revealed the resident was discharged from Occupational Therapy services on 11/28/2024. Review of a facility document titled, NOTICE OF MEDICARE NON-COVERAGE, dated 11/28/2024, revealed the resident's last day of coverage was 11/28/2024, and the resident signed the document on 11/28/2024. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Weakness, Need for Assistance with Personal Care, Difficulty Walking, and Difficulty Swallowing. Review of a Physical Therapy note for Resident #65 dated 11/26/2024 revealed the resident was discharged from Physical Therapy services on 11/26/2024. Review of an Occupational Therapy note for Resident #65 dated 11/26/2024 revealed the resident was discharged from Occupational Therapy services on 11/26/2024. Review of a Speech Therapy note for Resident #65 dated 11/26/2024 revealed the resident was discharged from Speech Therapy services on 11/26/2024. Review of a facility document titled, NOTICE OF MEDICARE NON-COVERAGE, dated 11/26/2024, revealed the resident's last day of coverage was 11/26/2024, and the resident signed the document on 11/26/2024. During a record review and interview on 1/8/2025 at 10:00 AM, the Administrator reviewed the NOMNC document the facility provided to Resident #5 and Resident #65. The Administrator stated Resident #5 and Resident #65 received a NOMNC the same day services were discontinued, and the Administrator confirmed the NOMNCs were not served timely.

Based on facility policy review, facility documentation review, medical record review, and interview the facility failed to protect 1 resident (Resident #421) from exploitation of 67 residents reviewed for exploitation. The finding include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .Exploitation .taking advantage of a resident for personal gain .Employee Training .will include .Prohibiting .preventing all forms of .exploitation .Identifying what constitutes .exploitation . Review of the medical record revealed Resident #421 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Respiratory Failure, Chronic Pain Syndrome, Major Depressive Disorder, And Anxiety. Resident #421 was discharged from the facility 11/29/2024. Review of the Physician's Orders for Resident #421 dated 12/29/2023, revealed the resident was ordered Morphine ER (an extended-release pain medication) every 12 hours for chronic pain. The order was discontinued on 6/27/2024. Review of the Physician's Orders for Resident #421 dated 6/27/2024, revealed the resident was ordered Oxycodone (pain medication) 15 milligrams (MG) every 8 hours for chronic pain. The order was discontinued on 7/1/2024. Review of the Physician's Orders for Resident #421 dated 7/1/2024, revealed the resident was ordered Oxycodone 15 MG every 6 hours for chronic pain. The order was discontinued on 9/23/2024. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #421 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Resident #421used a wheelchair for mobility and required partial to moderate assistance with transfers, toileting, and bathing. Resident #421 received opioid medications. Review of the Physician's Orders for Resident #421 dated 9/23/2024, revealed an order for Oxycodone Oral Concentrate 10 MG/0.5 milliliters (ML), administer 0.5 ML by mouth every 6 hours for chronic pain. Crush controlled medications until liquids are received and then discontinue tablets of oxycodone. Review of the Incident Reporting System (IRS) document provided by the facility dated 9/23/2024, revealed Resident #421 reported to Certified Nursing Assistant (CNA) E that she (Resident #421) had given narcotic pain medications to CNA A in exchange for vaping materials (a handheld electronic device to breathe a mist vapor into your lungs). Resident #421 was interviewed by the Administrator and Assistant Director of Nursing (ADON) and admitted she had provided CNA A with pain medication she had pocketed under her tongue. Resident #421 was interviewed and assessed by the facility's Nurse Practitioner (NP) changes were made to the resident's pain medication formulation. CNA A admitted to accepting Resident #421's pain medication, then quit and walked out of the facility. The allegation was verified by evidence collected during the investigation (verbal admittance by Resident #421 and CNA A). Review of a typed statement by the NP dated 9/24/2024, revealed the NP had met with Resident #421 on 9/23/2024 with another nurse present. The resident admitted she had been .trading her oxycodone for vapes . with CNA A. Resident #421 gave CNA A 1 pain pill (Oxycodone) in exchange for 1 vape cartridge about every 3-4 days .for a few months . Resident #421 reported CNA A .had brought her some headphones a while back and they became friends . and at some point CNA A asked her what type of medications she was on, and discussed exchanging the pain medications for the vapes. In 6/2024, Resident #421's pain medication was changed to oxycodone due to insurance and that was when the exchange began. Resident #421 stated on 9/23/2024, she had asked CNA A to buy her a soft drink and the CNA then informed the resident they were no longer friends, because the last pill she had given her was only a partial pill. The resident admitted CNA A had done this (refused to get her requested items) to her before to get an extra pill from her and now she (Resident #421) .had enough and was tired of her taking advantage of her . Resident #421 reported the last time she gave CNA A a pill was between 9/18/2024-9/20/2024. Review of the NP note for Residsent #421 dated 9/24/2024, revealed .a situation occur [occurred] regarding resident diverting her medications to a staff member .Resident does report that she has been trading an oxycodone for vape cartridges with one of the CNAs . Review of the comprehensive care plan for Resident #421 revised 10/24/2024, revealed the resident had care plan interventions for behaviors, smoking, being resistant to care, fabricating stories, and chronic pain with history of substance abuse. During an interview on 1/7/2024 at 2:16 PM, the ADON stated when she arrived at the facility on 9/23/2024, CNA E reported to her (ADON), Resident #421 had been trading her pain medication with CNA A for vaping cartridges. The ADON immediately reported the alleged incident to Administrator F (previous Administrator) and began an immediate investigation of the alleged incident. Resident #421 informed the ADON and Administrator F she had been trading her pain medication (Oxycodone) for vaping cartridges with CNA A but was unable to state how long the exchange had taken place. Resident #421 was tearful and stated it was her (Resident #421) mistake and knew what she had done was wrong. The ADON stated Resident #421 had been caught numerous times vaping in her room in the past several months and had been talked to several times about the dangers of vaping in her room. The ADON stated she was present in Administrator F's office when CNA A was questioned about the alleged incident, .at first [CNA A] denied it and said she would never do anything like that . CNA A was informed by Administrator F she was going to be suspended pending further investigation and the police were going to be notified, then CNA A admitted she had been trading pain medication from Resident #421 in exchange for vaping cartridges. CNA A then stated she quit, got up, and walked out the Administrator's office and exited the facility. The ADON stated during the investigation Resident #421's medications were reviewed and compared with the narcotic sheets with no discrepancies noted. During an interview on 1/7/2024 at 2:35 PM, CNA E stated she was unsure of the exact date Resident #421 had informed her she (Resident #421) had been trading her pain pills with CNA A for vaping cartridges. CNA E stated Resident #421 had shown her a picture on her personal cell phone from CNA A of a partially dissolved unknown pill (indicating CNA A did not get a whole pill from Resident #421). CNA E stated Resident #421 informed her after she was administered her pain medication (Oxycodone), she held the pill in her mouth, after the nurse would leave, she would spit the medication out, and put it away for CNA A. CNA E stated she immediately reported the incident to her supervisor and the ADON. CNA E stated CNA A visited Resident #421 frequently and never suspected any wrong doing between the two and thought they were just friends. Resident #421 did not tell CNA E how long the exchanges of pain medication for vaping cartridges had occurred.

Based on facility policy review, medical record review, facility investigation documentation review, and interviews, the facility failed to report an allegation of abuse to the required state entities within 2 hours for 2 residents (Residents #52 and #30) of 67 residents reviewed for abuse. The findings include: Review of the facility's undated policy titled, Abuse, Neglect, Misappropriation, Exploitation, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .of resident .The facility will designate .in the facility who is responsible for reporting allegations or suspected abuse .to the state survey agency .in accordance with state law .facility will follow State and federal guidelines for .reporting . Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including Cellulitis, Diabetes, and Intellectual Disabilities. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #52 was never/rarely understood. Review of a fall investigation report dated 12/8/2024 revealed Resident #52 had a fall to the floor from a Geri-chair (a chair used for residents with mobility issues who have difficulty sitting upright in a conventional wheelchair) due to improper staff assistance/resident care. Review of the fall incident description dated 12/8/2024, revealed, .Person Preparing Report .[ Director of Nursing (DON)] .Nursing Description .CNA [Certified Nursing Assistant] J made report that resident had fallen from Geri-chair that was in upright position due to another CNA K grabbing the resident by (L) [left] forearm and pulling her [Resident #52] up, upon doing that resident slide out onto the floor on .buttocks .Immediate Action Taken .[CNA J] called for the RN [Registered Nurse L] and reported to the RN of what just occurred . No injuries were noted. Review of the facility document titled, Reportable Incident Summary, revealed .Resident [Resident #52] .Incident date & time: December 8, 2024 . Review of the facility form Incident Reporting System (IRS) report, revealed the alleged abuse occurred on 12/8/2024 at 8:00 AM and was reported on 12/9/2024 at 8:30 AM. (This was one day after the incident occurred.) Review of the facility's investigation for Resident #52 revealed the ombudsman was notified of the alleged abuse which occurred on 12/8/2024 on 12/9/2024. (This was one day after the incident occurred.) Review of a Progress note for Resident #52 revealed the alleged abuse was reported to Adult Protective Services (APS) on 12/10/2024. (This was 2 days after incident occurred.) During an interview on 1/7/2025 at 10:07 AM, the Interim Administrator stated RN L was terminated due to not reporting the alleged abuse involving Resident #52. During an interview on 1/7/2025 at 1:20 PM, the DON stated she recalled the alleged abuse regarding Resident #52. The DON further stated the incident which involved Resident #52 occurred on 12/8/2024 but was not reported to DON or Administrator until 12/9/2024. The DON stated the alleged abuse was reported to the state agency 24 hours after the incident occurred. The DON further stated the charge nurse, RN L was terminated due to failure to report the alleged abuse. During an interview on 1/8/2025 at 10:15 AM, the Interim Administrator confirmed the alleged abuse involving Resident #52 was not reported timely according to federal regulations. 50480 Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including Anxiety, Seizures, Depression, and Stroke. Review of an annual MDS assessment dated [DATE], revealed Resident #30 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Nurse Practitioner's note for Resident #30 dated 9/10/2024, revealed .Resident seen due to reports of him having an altercation with another resident last night .Resident states that he did hit another resident [Resident #31] yesterday . Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Stroke, Dementia, Psychotic Disorder, Mood Disorder, Depression, Anxiety, and Difficulty Speaking. Review of an admission MDS assessment for Resident #31 dated 7/1/2024, revealed the resident scored a 0 on the BIMS assessment which indicated the resident could not complete the interview and had severe cognitive impairment. Review of a Behavior note for Resident #31 dated 9/9/2024, revealed resident #31 was transported to the hospital for an altercation [with Resident #30]. Review of a Nurse Practitioner's note for Resident #31 dated 9/10/2024, revealed .[Resident #31] .resting in [wheelchair] .on 1:1 [one on one] supervisor after an altercation with another resident [Resident #30] .[Resident #31] hit [Resident #30] on the arm .[Resident #30] then hit [Resident #31] in the face resulting in a broken nose . Review of a facility investigation dated 9/9/2024, revealed a resident-to-resident altercation between Resident #30 and Resident #31 had occurred. Further review of the facility investigation revealed Resident #31 was sent to the hospital and was determined to have a fractured nose after the event occurred and returned to the facility the same day. The facility substantiated resident-to-resident abuse in the investigation. Further review revealed the resident-to resident altercation was reported to APS on 9/13/2024, which was 3 days after the incident had occurred. During a record review and interview on 1/8/2025 at 10:30 AM, the Administrator reviewed the facility's investigation of Resident #30 and Resident #31's altercation which occurred on 9/9/2024 and confirmed APS was not notified until 9/13/2024. The Administrator confirmed the resident-to-resident altercation was not reported timely per state and federal regulations. During a telephone interview on 1/8/2025 at 1:00 PM, the APS consultant confirmed the facility reported the resident-to-resident altercation which occurred on 9/9/2024, between Resident #30 and Resident #31, on 9/13/2024.

Based on facility contract review, facility policy review, medical record review, and interview, the facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for 1 residents (Resident #19) of 3 residents reviewed for hospice services. The findings include: Review of the facility's hospice contract titled, Hospice Care Guidelines, dated 2/2023, revealed .policy of this facility to provide and/or arrange .hospice services .obtain the following information from hospice .most recent plan of care . Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Adult Failure to Thrive. Review of a Physician's Order for Resident #19 dated 8/27/2024, revealed .Admit to Hospice. Review of the comprehensive care plan dated 8/27/2024, revealed Resident #19 .under hospice care . Review of the hospice communication binder (located at the nurses' station) revealed the hospice plan of care for Resident #19 had a .Certification date .8/27/2024 to 11/24/2024 . Continued review revealed no further documentation of a new recertification period for hospice service and no revised care plan after 11/24/2024. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 scored a 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident received hospice services. During an interview on 1/8/2025 at 8:05 AM, the Social Services Director (SSD) stated she was the hospice coordinator for the facility. The SSD stated there were hospice plan of care binders located at each nurse station for each resident that received hospice services. The SSD confirmed Resident #19 remained on hospice service and the hospice plan of care had not been updated for Residents #19.

Based on policy review, medical record review, and interviews, the facility failed to ensure proper infection control practices were followed during a noon and a breakfast meal for 2 residents (Residents #67 and #17) and during housekeeping services for 2 residents (Residents #16 and #54) of 21 residents reviewed for COVID-19 Transmission-Based Precautions. The findings include: Review of the facility's undated policy titled, Covid 19 Management of Residents, revealed .appropriate isolation signage, and staff wearing N95 respirator, eye protection, gown, and gloves upon entry to the room .The door will be kept closed .Residents with Confirmed COVID-19 .Isolate using Transmission-Based Precautions . Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Chronic Obstructive Pulmonary Disorder, Acute Respiratory Failure, and Stroke. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #67 was rarely/never understood. Review of the Nurse's Notes for Resident #67 dated 12/30/2024, revealed . rapid Covid [test used to diagnosis COVID-19 infection] (+) [positive]. NP [Nurse Practitioner] and daughter aware of positive test . Review of a comprehensive care plan for Resident #67 revised 12/31/2024 revealed the resident had an Isolation care plan for an active Covid-19 infection. Review of the Physician's Orders for Resident #67 dated 12/31/2024, revealed .Isolation Precautions due to confirmed COVID-19 . During an observation on 1/6/2025 at 12:35 PM, Droplet Precaution signage and personal protective equipment (PPE) including masks, gowns, eye protection to include goggles/face shields, and gloves was hanging on Resident #67's door. CNA D delivered the lunch meal tray to Resident #67 and was not wearing eye protection to deliver the meal tray. CNA D stated Resident #67 had COVID-19. CNA D stated she was unaware to don eye protection to include a face shield or goggles before entering the room to deliver the lunch meal tray. CNA D confirmed she had not donned eye protection before entering the resident's room to deliver the lunch meal tray. 41291 Review of the medical record revealed Resident #17 was admitted to facility on 6/14/2023 with diagnoses including Parkinsonism, Protein-Calorie Malnutrition, Cirrhosis of Liver, and Chronic Viral Hepatitis C. Review of the Nurse's Notes for Resident #17 dated 12/30/2024, revealed the resident's representative was notified of possible exposure to COVID-19. Review of the Physician Orders for Resident #17 dated 12/31/2024, revealed the resident was placed in isolation due to exposure to COVID-19. Review of the Medication Administration Note for Resident #17 dated 12/31/2024, 1/3/2025, 1/4/2025, and 1/7/2025, revealed the resident had negative COVID-19 test results. During an observation on 1/7/2025 at 7:45 AM, CNA B was observed in Resident #17's room assisting with the breakfast meal. CNA B was sitting on the edge of the resident's bed with her N-95 mask pulled down under her nose. Further observation revealed CNA B was not wearing a gown, gloves, or eye protection. On the outside of the door signage was posted for Droplet Precaution, Enhanced Barrier Precautions, and Sequence for Putting on Personal Protective Equipment (PPE). There was a yellow cloth pocket over the door container with gowns, gloves, masks, and eye protection. Continued observation revealed CNA B exited Resident #17's room with the breakfast tray in her hands and placed the breakfast tray on the dirty food tray cart at the end of the hallway, then pulled her N-95 mask back over her nose. During an interview and observation on 1/7/2025 at 7:47 AM, CNA B stated she was unaware Resident #17 was in isolation. CNA B walked to Resident #17's room and confirmed there was a signage on the resident's door indicating Resident #17 was in isolation precautions. CNA B confirmed she had her N-95 mask pulled down under her nose and was not wearing the recommended PPE (gowns, gloves, or eye protection) while assisting Resident #17 with his breakfast meal. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Chronic Bronchitis, and Covid-19 (added 1/6/2025). Review of the Nurses Note for Resident #16 dated 1/4/2025, revealed the resident had a positive COVID-19 test result. Review of the Physician's Order for Resident #16 dated 1/4/2025, revealed .Isolation precautions due to confirmed COVID-19 .for 10 days . Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including Dementia, and Adult Failure to Thrive. Review of the Physician's Orders for Resident #54 dated 1/2/2025, revealed .Isolation precautions due to confirmed COVID-19 .for 10 days . Review of the MAR for Resident #54 dated 1/3/2025, revealed the resident had a positive COVID-19 test result on 1/2/2025 and was placed in isolation. During an observation on 1/7/2025 at 7:55 AM, Housekeeper C was in Residents #16 and #54's room with the door open. On the outside of the residents doors signage was posted for Droplet Precaution, Enhanced Barrier Precautions, and Sequence for Putting on Personal Protective Equipment (PPE). There was a yellow cloth pocket container on the residents doors with gowns, gloves, masks, and eye protection. Housekeeper C was observed wiping both residents over bed tables, the sink, and bathroom door handle. Housekeeper C was observed not [NAME] an N9 (wore a surgical mask), no eye protection (had on eyeglasses), and no gown, with a cleaning rag in one hand and bottle of disinfectant in the other hand. During an interview on 1/7/2025 at 7:57 AM, Housekeeper C stated she was not aware Residents #16 and #54 were in isolation. She confirmed she was not wearing the appropriate PPE (N-95, gown, or eye protection) and had not changed her gloves prior to exiting Residents #16 and #54's room. During an interview on 1/8/2025 at 8:26 AM, Family Nurse Practitioner (FNP) stated her expectation was for all staff to wear the recommended PPE when entering isolation rooms. During an interview on 1/8/2025 at 1:12 PM, the Infection Control Preventionist (ICP) stated it was her expectation for employees to follow the guidance posted on isolation room doors and to wear the recommended PPE; for droplet precaution rooms that would include gowns, gloves, N-95 mask, and eye protection.

Based on facility policy review, medical record review, facility investigation documentation review, and interview, the facility failed to protect the residents' right to be free from sexual abuse for 1 resident (Resident #2) by Resident #3 and physical abuse for 2 residents (Residents #4 and #5) by Resident #1 of 7 residents reviewed for abuse. The abuse resulted in actual harm to residents #4 and #5 when Resident #1 threw a chair at Resident #4 and #5 resulting in Resident #4 receiving a scrape down his left shin and Resident #5 receiving a bruise and swelling on his right knee. The findings include : Review of the facility's policy titled, Abuse .Prevention Program, revised 4/2021, revealed .Residents have the right to be free from abuse .This includes .sexual or physical abuse .The resident abuse .prevention program consists of a facility-wide commitment .to support the following objectives .Protect residents from abuse .by anyone including .other residents . 1. Review of the medical records and facility investigation documentation revealed on 5/12/2024 a resident to residents' altercation occurred between Resident #1, Resident #4, and Resident #5 when Resident #5 punched at Resident #4 and threw a chair at Resident #4 and Resident #5. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Anxiety, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4's Brief Interview for Mental Status (BIMS) score was 15 indicating the resident was cognitively intact. Review of facility incident report dated 5/12/2024 for Resident #4 revealed the resident had a scrape down his left shin approximately (approx.) 8 inches in length due to Resident #1 hitting Resident #4 with a chair no other injuries were noted. Review of a Progress note for Resident #4 dated 5/15/2024 revealed the resident was seen by the Social Services Director (SSD) Resident #4 did not have any concerns following the incident. Review of a psychiatric note for Resident #4 dated 5/15/2024 revealed the resident denied any symptoms of anxiety or depression. The resident reported I am fine. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Dementia, and Depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5's BIMS score was 13 indicating the resident was cognitively intact. Review of facility incident report dated 5/12/2024 for Resident #5 revealed the resident had a bruise and swelling on his right knee approx. 2 inches by 2 inches due to Resident #1 hitting Resident #5 with a chair no other injuries were noted. Review of a Progress note for Resident #5 dated 5/15/2024 revealed the resident was seen by SSD. Resident #5 did not have any concerns following the incident. Review of psychiatric notes for Resident #5 dated 5/15/2024 revealed the resident denied any signs or symptoms of anxiety or depression. The resident reported he was doing okay. Review of the medical record revealed Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Wernicke's Encephalopathy (Neurological Disorder), History of Traumatic Brain Injury, and Schizophrenia, he was discharged to the hospital on 5/12/2024. Review of the quarterly MDS assessment dated [DATE] revealed Resident #1's BIMS score was 6 indicating the resident had severe cognitive impairment. Review of Resident #1's current care plan revealed .The resident is/has potential to be verbally/physically aggressive. He kicks and swats at staff at times .Date initiated 06/19/2022 . Review of a Psychiatric Progress note for Resident #1 dated 5/7/2024 revealed .Patient has been having increased behaviors, agitation, Seroquel increased, and he was sent to the hospital. He was seen today .He was pleasant and talkative . Review of a facility investigation revealed on 5/12/2024 at 4:05 PM, in the smoking area Resident #1 became agitated and began punching at Resident #4 striking him in the face Resident #1 grabbed a chair. The Activities Assistant attempted to remove the chair from the resident who threw the chair at Resident #4 striking him on his lower leg. Resident #1 grabbed the chair again and threw it at Resident #5 striking him on his knee. The facility substantiated abuse for Resident #4 and Resident #5. During an interview on 7/8/2024 at 9:00 AM, Resident #4 stated .he [Resident #1] hit me with a chair in the hand and in the leg .he swung at me and hit me in the face he didn't leave no marks on me or noting .yeah [feels safe at facility] .no [no concerns] .I am okay . During an interview on 7/8/2024 at 1:40 PM the Activities Assistant stated .I was out there [smoking area] before he [Resident #1] got there and when he come out he sat there and he talked to people [other residents] .after a while [Resident #4] come out to smoke and [Resident #1] started talking to him and I couldn't hear what [Resident #4] said but he [Resident #1] just got agitated .[Resident #1] picked up a chair and I thought he was going to move the chair but then he hit [Resident #4] with it and I tried to get the chair but before I could get to him he already hit [Resident #5] .when I tried to get the chair he grabbed my arm but he didn't hurt it .they [Resident #4 and #5] are fine I aint seen anything different with them they just got some bruises it wasn't nothing major . During an interview on 7/9/2024 at 11:30 AM, Resident #5 stated he [Resident #1] just got mad for no reason he started arguing .he got the chair and he hit me on the knee it was bruised .it didn't have no cut or nothing like that I've been hit worse than that before that wouldn't nothing .oh yeah [feels safe at facility] .oh yeah I'm doing fine . During an interview on 7/10/2024 at 12:45 PM, the Administrator stated .yes they [Resident #4 and Resident #5] got hit . 2. Review of the medical records and facility investigation documentation revealed on 5/17/2024 a resident-to-resident sexual act occurred when Resident #3 was observed performing a sexual act on Resident #2 . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, and Mild Cognitive Impairment Unknown Etiology. Review of the admission MDS assessment dated [DATE] revealed Resident #2's BIMS score was 9 indicating the resident had moderate cognitive impairment, A Social Services (SS) BIMS was completed on 5/17/2024 revealing the residents BIMS was 3, indicating the resident had severe cognitive impairment. The resident required assistance of one or more persons with activities of daily living (ADL's). Medical record review of a current care plan for Resident #2 revealed .Resident has Impaired cognition related to difficulty recalling things short and long term secondary to diagnoses of Dementia .Redirect as needed .Date Initiated 05/15/2024 . Review of psychiatric notes for Resident #2 dated 5/21/2024 and 5/28/2024 revealed the resident was involved in a resident-to-resident event no noted psychosocial harm was noted the resident stated he felt safe at the facility and voiced no concerns staff denied any depression, anxiety, mood, or behavior changes. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Dementia, Depression, and Cerebral Ischemic Attack, the resident was discharged to assisted living on 5/20/2024. Continued review revealed Resident #3 had no prior history of sexual behaviors. Review of the admission MDS assessment dated [DATE] revealed Resident #3's BIMS score was 13 indicating the resident was cognitively intact. Resident #3 came from an assisted living facility he is no longer at the facility no prior history of sexual behaviors, Resident #1 was sent out to the hospital and was still in the hospital, care plans were updated and psych was consulted for all residents safeguards were implemented it was immediately reported investigation was conducted and result was reported, all notifications were made. Review of the facility investigation documentation revealed on 5/17/2024 at 5:15 PM, Certified Nurse Assistant (CNA) H and CNA G witnessed Resident #3 in Resident #2's room on the floor on his knees in front of Resident #2 who was seated in his wheelchair. Resident #2's shirt was up, and his shorts were down exposing his penis. Resident #3's hands were on Resident #2's knees. The facility did not verify or refute the allegation. During an interview with Resident #2 on 7/8/2024 at 11:20 AM, in the dining room the resident stated .no I don't have any [concerns] .no I haven't had any problems with nobody [staff or residents] .yes I do feel safe 100% safe .no [no abuse including sexual abuse] I don't remember anything wrong I don't have no problems with nobody . During an interview on 7/8/2024 at 1:50 PM License Practical Nurse (LPN) C stated .I conducted an interview on [Resident #3] his BIM score turned out to be a 13 or 12 and then I asked him about the incident and I let him know right away this was a safe space and we just had questions .he told me I plead the fifth .I told him I have to make sure that you know what is going on as well as [Resident #2] .he said he gave me a look earlier in the day and I just wanted to repay the favor and when I asked him what does that mean and he said I plead the fifth again .he did say he put the cushion in the floor so his knees don't get banged up .I did talk to [Resident #2's] wife .she said she was shocked her husband was a lady's man and he never gave any kind of inclination to that . During an interview on 7/8/2024 at 2:45 PM Registered Nurse (RN) B stated .I did interview [Resident #2] .I asked him how he was doing he said he was doing fine .I asked him if there was anything going on and he acted like he didn't know what I was talking about .I said I think you had a visitor from one of the other residents and he said yes and I said did you invite him in and he said no he just came in and I said so were you talking and he said yeah we were talking .I said did anything else happen and he said no .I talked to him a little bit more and asked him again before I left if he was okay and he said everything was fine .he looked the same he had a smile on his face he was his normal self he wasn't upset in any way or nervous or anything .I went back a little bit later to check on him and to do a BIMS and I think it was about a 3 or a 4 .he was his same self he did not seem upset at all . During a telephone interview on 7/9/2024 at 11:55 AM, CNA G stated .me and [CNA H] were doing our round .it was around 5:00 [5:00 PM] .when we walked up there the door [Resident #2's room door] was closed so she [CNA H] knocked on the door and opened the door the door bumped [Resident #3s] wheelchair .she stuck her head in the room to see what she bumped .she looked back .give me a look and I knew something wasn't right .she asked [Resident #3] did you fall he was on his knees in front of [Resident #2's] wheelchair . and [Resident #2] had his shirt pulled up and his shorts pulled down in the front and had his penis out .[Resident #3] said no I didn't fall .she [CNA H] went to get the nurse and I stayed there with them [Resident #2 and #3] .I don't know if he [Resident #2] understood what was going on .[Resident #3] had a pad in the floor and he had his knees on it when he was in front of the chair .he got the pad and put it back in his chair and got back up in his chair. [Resident #2] still did not pull his pants up or pull his shirt down he just sat there . During a telephone interview on 7/9/2024 at 12:45 PM, CNA H stated .I went to the door and I knocked on the door and I pushed the door open a little bit and when I got through the door [Resident #3] was on his knees on a pad in the floor in front of [Resident #2s] wheelchair with his hands on [Resident #2's] knees and his head was between [Resident #2's legs] and I saw [Resident #2's] privates were pulled out and his t shirt was pulled up .I did not see him doing the physical part .I said are you okay and he [Resident #3] said your rude and I said I'm sorry and I asked him if he fell and he said no and then [Resident #2] kind of laughed he was laughing he wasn't upset at all it was like he thought it was funny .he [Resident #3] did not ever say I was doing this or that and [Resident #2] didn't say anything happened or seemed upset he was just laughing .they were separated I didn't leave them in the room alone .[Resident #2] is just the same person he always has been he's not sad at all .I have him during the day when I work he seems fine and he didn't act like he was upset that [Resident #3] was in there and they were both talking in the hallway just before that happened .I don't know whether [Resident #2] could consent to something like that .based on what I did see there is no doubt what was happening he [Resident #3] was doing the dirty to [Resident #2] he was giving him a blow job he was doing a sexual act with him .

Based on facility policy review, medical record review, facility investigation documentation review, and interview, the facility failed to protect the residents' right to be free from sexual abuse for 1 resident (Resident #2) by Resident #3 and physical abuse for 2 residents (Residents #4 and #5) by Resident #1 of 7 residents reviewed for abuse. The abuse resulted in actual harm to residents #4 and #5 when Resident #1 threw a chair at Resident #4 and #5 resulting in Resident #4 receiving a scrape down his left shin and Resident #5 receiving a bruise and swelling on his right knee. The findings include : Review of the facility's policy titled, Abuse .Prevention Program, revised 4/2021, revealed .Residents have the right to be free from abuse .This includes .sexual or physical abuse .The resident abuse .prevention program consists of a facility-wide commitment .to support the following objectives .Protect residents from abuse .by anyone including .other residents . 1. Review of the medical records and facility investigation documentation revealed on 5/12/2024 a resident to residents' altercation occurred between Resident #1, Resident #4, and Resident #5 when Resident #5 punched at Resident #4 and threw a chair at Resident #4 and Resident #5. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Anxiety, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4's Brief Interview for Mental Status (BIMS) score was 15 indicating the resident was cognitively intact. Review of facility incident report dated 5/12/2024 for Resident #4 revealed the resident had a scrape down his left shin approximately (approx.) 8 inches in length due to Resident #1 hitting Resident #4 with a chair no other injuries were noted. Review of a Progress note for Resident #4 dated 5/15/2024 revealed the resident was seen by the Social Services Director (SSD) Resident #4 did not have any concerns following the incident. Review of a psychiatric note for Resident #4 dated 5/15/2024 revealed the resident denied any symptoms of anxiety or depression. The resident reported I am fine. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Dementia, and Depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5's BIMS score was 13 indicating the resident was cognitively intact. Review of facility incident report dated 5/12/2024 for Resident #5 revealed the resident had a bruise and swelling on his right knee approx. 2 inches by 2 inches due to Resident #1 hitting Resident #5 with a chair no other injuries were noted. Review of a Progress note for Resident #5 dated 5/15/2024 revealed the resident was seen by SSD. Resident #5 did not have any concerns following the incident. Review of psychiatric notes for Resident #5 dated 5/15/2024 revealed the resident denied any signs or symptoms of anxiety or depression. The resident reported he was doing okay. Review of the medical record revealed Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Wernicke's Encephalopathy (Neurological Disorder), History of Traumatic Brain Injury, and Schizophrenia, he was discharged to the hospital on 5/12/2024. Review of the quarterly MDS assessment dated [DATE] revealed Resident #1's BIMS score was 6 indicating the resident had severe cognitive impairment. Review of Resident #1's current care plan revealed .The resident is/has potential to be verbally/physically aggressive. He kicks and swats at staff at times .Date initiated 06/19/2022 . Review of a Psychiatric Progress note for Resident #1 dated 5/7/2024 revealed .Patient has been having increased behaviors, agitation, Seroquel increased, and he was sent to the hospital. He was seen today .He was pleasant and talkative . Review of a facility investigation revealed on 5/12/2024 at 4:05 PM, in the smoking area Resident #1 became agitated and began punching at Resident #4 striking him in the face Resident #1 grabbed a chair. The Activities Assistant attempted to remove the chair from the resident who threw the chair at Resident #4 striking him on his lower leg. Resident #1 grabbed the chair again and threw it at Resident #5 striking him on his knee. The facility substantiated abuse for Resident #4 and Resident #5. During an interview on 7/8/2024 at 9:00 AM, Resident #4 stated .he [Resident #1] hit me with a chair in the hand and in the leg .he swung at me and hit me in the face he didn't leave no marks on me or noting .yeah [feels safe at facility] .no [no concerns] .I am okay . During an interview on 7/8/2024 at 1:40 PM the Activities Assistant stated .I was out there [smoking area] before he [Resident #1] got there and when he come out he sat there and he talked to people [other residents] .after a while [Resident #4] come out to smoke and [Resident #1] started talking to him and I couldn't hear what [Resident #4] said but he [Resident #1] just got agitated .[Resident #1] picked up a chair and I thought he was going to move the chair but then he hit [Resident #4] with it and I tried to get the chair but before I could get to him he already hit [Resident #5] .when I tried to get the chair he grabbed my arm but he didn't hurt it .they [Resident #4 and #5] are fine I aint seen anything different with them they just got some bruises it wasn't nothing major . During an interview on 7/9/2024 at 11:30 AM, Resident #5 stated he [Resident #1] just got mad for no reason he started arguing .he got the chair and he hit me on the knee it was bruised .it didn't have no cut or nothing like that I've been hit worse than that before that wouldn't nothing .oh yeah [feels safe at facility] .oh yeah I'm doing fine . During an interview on 7/10/2024 at 12:45 PM, the Administrator stated .yes they [Resident #4 and Resident #5] got hit . 2. Review of the medical records and facility investigation documentation revealed on 5/17/2024 a resident-to-resident sexual act occurred when Resident #3 was observed performing a sexual act on Resident #2 . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, and Mild Cognitive Impairment Unknown Etiology. Review of the admission MDS assessment dated [DATE] revealed Resident #2's BIMS score was 9 indicating the resident had moderate cognitive impairment, A Social Services (SS) BIMS was completed on 5/17/2024 revealing the residents BIMS was 3, indicating the resident had severe cognitive impairment. The resident required assistance of one or more persons with activities of daily living (ADL's). Medical record review of a current care plan for Resident #2 revealed .Resident has Impaired cognition related to difficulty recalling things short and long term secondary to diagnoses of Dementia .Redirect as needed .Date Initiated 05/15/2024 . Review of psychiatric notes for Resident #2 dated 5/21/2024 and 5/28/2024 revealed the resident was involved in a resident-to-resident event no noted psychosocial harm was noted the resident stated he felt safe at the facility and voiced no concerns staff denied any depression, anxiety, mood, or behavior changes. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Dementia, Depression, and Cerebral Ischemic Attack, the resident was discharged to assisted living on 5/20/2024. Continued review revealed Resident #3 had no prior history of sexual behaviors. Review of the admission MDS assessment dated [DATE] revealed Resident #3's BIMS score was 13 indicating the resident was cognitively intact. Resident #3 came from an assisted living facility he is no longer at the facility no prior history of sexual behaviors, Resident #1 was sent out to the hospital and was still in the hospital, care plans were updated and psych was consulted for all residents safeguards were implemented it was immediately reported investigation was conducted and result was reported, all notifications were made. Review of the facility investigation documentation revealed on 5/17/2024 at 5:15 PM, Certified Nurse Assistant (CNA) H and CNA G witnessed Resident #3 in Resident #2's room on the floor on his knees in front of Resident #2 who was seated in his wheelchair. Resident #2's shirt was up, and his shorts were down exposing his penis. Resident #3's hands were on Resident #2's knees. The facility did not verify or refute the allegation. During an interview with Resident #2 on 7/8/2024 at 11:20 AM, in the dining room the resident stated .no I don't have any [concerns] .no I haven't had any problems with nobody [staff or residents] .yes I do feel safe 100% safe .no [no abuse including sexual abuse] I don't remember anything wrong I don't have no problems with nobody . During an interview on 7/8/2024 at 1:50 PM License Practical Nurse (LPN) C stated .I conducted an interview on [Resident #3] his BIM score turned out to be a 13 or 12 and then I asked him about the incident and I let him know right away this was a safe space and we just had questions .he told me I plead the fifth .I told him I have to make sure that you know what is going on as well as [Resident #2] .he said he gave me a look earlier in the day and I just wanted to repay the favor and when I asked him what does that mean and he said I plead the fifth again .he did say he put the cushion in the floor so his knees don't get banged up .I did talk to [Resident #2's] wife .she said she was shocked her husband was a lady's man and he never gave any kind of inclination to that . During an interview on 7/8/2024 at 2:45 PM Registered Nurse (RN) B stated .I did interview [Resident #2] .I asked him how he was doing he said he was doing fine .I asked him if there was anything going on and he acted like he didn't know what I was talking about .I said I think you had a visitor from one of the other residents and he said yes and I said did you invite him in and he said no he just came in and I said so were you talking and he said yeah we were talking .I said did anything else happen and he said no .I talked to him a little bit more and asked him again before I left if he was okay and he said everything was fine .he looked the same he had a smile on his face he was his normal self he wasn't upset in any way or nervous or anything .I went back a little bit later to check on him and to do a BIMS and I think it was about a 3 or a 4 .he was his same self he did not seem upset at all . During a telephone interview on 7/9/2024 at 11:55 AM, CNA G stated .me and [CNA H] were doing our round .it was around 5:00 [5:00 PM] .when we walked up there the door [Resident #2's room door] was closed so she [CNA H] knocked on the door and opened the door the door bumped [Resident #3s] wheelchair .she stuck her head in the room to see what she bumped .she looked back .give me a look and I knew something wasn't right .she asked [Resident #3] did you fall he was on his knees in front of [Resident #2's] wheelchair . and [Resident #2] had his shirt pulled up and his shorts pulled down in the front and had his penis out .[Resident #3] said no I didn't fall .she [CNA H] went to get the nurse and I stayed there with them [Resident #2 and #3] .I don't know if he [Resident #2] understood what was going on .[Resident #3] had a pad in the floor and he had his knees on it when he was in front of the chair .he got the pad and put it back in his chair and got back up in his chair. [Resident #2] still did not pull his pants up or pull his shirt down he just sat there . During a telephone interview on 7/9/2024 at 12:45 PM, CNA H stated .I went to the door and I knocked on the door and I pushed the door open a little bit and when I got through the door [Resident #3] was on his knees on a pad in the floor in front of [Resident #2s] wheelchair with his hands on [Resident #2's] knees and his head was between [Resident #2's legs] and I saw [Resident #2's] privates were pulled out and his t shirt was pulled up .I did not see him doing the physical part .I said are you okay and he [Resident #3] said your rude and I said I'm sorry and I asked him if he fell and he said no and then [Resident #2] kind of laughed he was laughing he wasn't upset at all it was like he thought it was funny .he [Resident #3] did not ever say I was doing this or that and [Resident #2] didn't say anything happened or seemed upset he was just laughing .they were separated I didn't leave them in the room alone .[Resident #2] is just the same person he always has been he's not sad at all .I have him during the day when I work he seems fine and he didn't act like he was upset that [Resident #3] was in there and they were both talking in the hallway just before that happened .I don't know whether [Resident #2] could consent to something like that .based on what I did see there is no doubt what was happening he [Resident #3] was doing the dirty to [Resident #2] he was giving him a blow job he was doing a sexual act with him .

Based on facility policy review, medical record review, and interview, the facility failed to ensure 1 resident (Resident #1) of 5 residents reviewed for medication administration was free of a significant medication error after receiving another resident (Resident #2's) prescribed medication which resulted in actual harm to Resident #1. The findings include: Review of the facility's policy titled, Administering Medications, revised 4/2019, revealed .Medications are administered in a safe and timely manner .as prescribed .Medication errors are documented, reported, and reviewed by the QAPI [Quality Assurance Performance Improvement] committee to inform process changes and or need for additional staff training .The individual administering medications verifies the resident's identity before giving the resident his/her medications . Review of the facility's undated policy titled, Medication Error guidelines, revealed .The licensed nurses shall ensure medications will be administered .According to physician's orders . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Diabetes Mellitus, Hypertension, Obstructive Sleep Apnea, Other Disorders of the Lungs, Chronic Obstructive Pulmonary Disorder (COPD) and Pickwickian Syndrome (also called obesity hypoventilation syndrome, throws off the balance of oxygen and carbon dioxide in your lungs). Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had moderate cognitive impairment and received antianxiety, antidepressants, diuretic, and opioid medications. Review of a comprehensive care plan dated 11/27/2023, revealed Resident #1 had .risk for adverse side effects related to anti-anxiety medication, ineffective breathing patterns r/t [related to] COPD, OSA [Obstructive Sleep Apnea], and Pickwickian Syndrome-she is dependent on CPAP [Continuous Positive Airway Pressure/a machine to keep breathing airways open while asleep] at HS [night] .chronic pain d/t [due to] osteoarthritis, cerebral palsy, thoracic spondylosis [the natural wearing down in the mid-back] . Review of the Physician's Orders for Resident #1 dated 4/2024, revealed Resident #1 had the following orders: oxygen 2-4 liters via (by) nasal cannula, Hydrocodone-Acetaminophen tablet (medication used to treat pain) 5-325 milligram (mg) every 6 hours, and Lorazepam (medication used to treat anxiety) 0.5 mg as needed. Further review revealed the resident had a physician's order to wear the CPAP device at night. The nurse was to assist the resident in placing the CPAP device on . Review of the Nurse's Note for Resident #1 dated 4/6/2024, revealed .[Resident #1] was given wrong medication buprenorphine 8-2mg [buprenorphine 8mg-a medication used to opioid use disorder and naloxone 2 mg-an opioid antagonist to treat opioid overdose] .Resident was lethargic .V/S [vital signs] decreased .Resident [Resident #1] became responsive and refused to go to ER [emergency room ]. Resident was sent to ED [Emergency Department] for Eval [Evaluation]. Resident family and medical director notified of incident . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Rheumatoid Arthritis, Osteoporosis, Crohn's Disease, and Opioid Dependence. Review of a quarterly MDS assessment dated [DATE], revealed Resident #2 was cognitively intact, received antianxiety, antidepressant, and opioid medications. Review of the comprehensive care plan dated 4/1/2024, revealed Resident #2 .received Suboxone for opioid abuse treatment, at risk for adverse side effects .administer medications as ordered .has chronic pain r/t rheumatoid arthritis and osteoporosis . Review of the Physician's Orders for Resident #2 dated 4/2024, revealed Narcan Nasal Liquid (medication used to treat narcotic overdose) 4 MG/0.1ML (milliliter) and Buprenorphine HCl (hydrochloride)-Naloxone HCl (Suboxone) Sublingual (under the tongue) Tablet 8-2 MG (buprenorphine 8mg-a medication used to opioid use disorder and naloxone 2 mg-an opioid antagonist to treat opioid overdose). Review of the Individual Resident's Controlled Substance Record for Resident #2 dated 4/6/2024 at 6:00 AM, revealed .med [medication] error . Review of the emergency room documentation for Resident #1 dated 4/6/2024, revealed the resident presented with altered mental status after receiving another resident's medications (Resident #2's). The resident was believed to have received Suboxone.She received Narcan . no change [in condition] .hypoxic [low oxygen] requiring a non-rebreather [mask] .rhonchi [movement of fluids and secretions in larger airways in asthma and respiratory infections] .hypercarbia [an increase in carbon dioxide in the blood stream] .CPAP was not on last night . Review of a Medication Error Incident/Investigation report for Resident #1 dated 4/6/2024, revealed the time of the incident 5:00 AM-5:45 AM, .Nurse supervisor [Registered Nurse/RN B] was advised by agency nurse [Licensed Practical Nurse /LPN A] she gave [Resident #1] .suboxone 8-2ml [milliliter] that was intended for [Resident #2] . Review of the hospital documentation for Resident #1 dated 4/6/2024-4/19/2024 revealed during the course of the hospital stay the resident was admitted to the hospital with hypercarbic respiratory failure and was intubated after arrival on 4/6/2024. A hospital ICU stay from 4/6/2024-4/19/2024 occurred and the patient was discharged on [DATE] to a higher level of care. During an interview on 5/6/2024 at 10:10 AM, Resident #2 stated an agency nurse (unable to recall the nurse's name) handed her a cup of medications and Resident #2 informed the nurse the medication was not her medication and told the nurse .go get me my .suboxone . Resident #2 stated she knew it was not suboxone because suboxone was a strip that goes under the tongue and the medication given to her was pills. During a telephone interview on 5/8/2024 at 8:38 AM, LPN A stated she was able to recall the medication error regarding Resident #1 which occurred on 4/6/2024. LPN A stated Resident #1 and Resident #2's names were similar, the rooms were close together, and thought this was the reason she made the error. LPN A stated Resident #1 was awake until 4:00 AM and had refused to wear her (Resident #1) CPAP and at 6:00 AM the nurse went in and administered Resident #1 her medication wrong medication). LPN A stated she went into Resident #2's room to administer medications and resident [#2] refused the medications and stated those medications did not belong to her (Resident #2). LPN A stated she went to assess Resident #1, took the resident's blood pressure, attempted to arouse the resident, and notified the RN Supervisor of the medication error. The RN supervisor and LPN A notified EMS (Emergency Medical Service), physician, and the Resident #1's family of the medication error. LPN A stated she cooperated with the facility staff to investigate the medication error and had not been reassigned to the facility. During an interview on 5/9/2024 at 1:50 PM, the Director of Nursing confirmed LPN A had not followed the five rights of medication administration and Resident #1 received the wrong medication which belonged to Resident #2 on 4/6/2024.

Based on facility policy review, medical record review, and interview the facility failed to revise a comprehensive person-centered care plan related to falls for 1 resident (Resident #12) of 16 residents reviewed for comprehensive care plans. The findings include: Review of the facility's undated policy titled, Fall Prevention & Management Program, revealed .When any resident experiences a fall, the facility will .review the resident's care plan and update as indicated . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, revealed, .Care plan interventions are chosen .after data gathering, proper sequencing of events .careful consideration of .resident's problem areas and their causes .interventions address the underlying source(s) of the problem area(s) .not just symptoms or triggers .care plans are revised as .residents conditions change .The interdisciplinary team reviews and updates the care plan .when the desired outcome is not met . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Need for Assistance with Personal Care, Muscle Weakness, and Dysarthria (difficulty walking). Review of a 5-Day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 had severe cognitive impairment. Review of the facility's documentation for Resident #12 dated 3/18/2024, revealed .Incident location .Reception/Lobby .pt [patient] was discovered in floor by staff .pt wanted to get out of chair but did not ask for assist [assistance] .Action Taken .assisted back into wheelchair .Injuries Observed .Skin Tear .Left elbow . Further review revealed a new fall intervention was not implemented by the facility following Resident #12's fall on 3/18/2024. Review of the facility's documentation for Resident #12 dated 3/24/2024, revealed .Incident Location .Resident's Room .Resident was noted to be in the floor when nurse walked by .Immediate Action Taken .Resident sent to hospital for evaluation .Injuries Observed at Time of Incident .Injury Type .Hematoma .Injury Location .Left eye/eyebrow . Further review revealed a new fall intervention was not implemented by the facility following Resident #12's fall on 3/24/2024. During an interview on 5/8/2024 at 11:47 AM, the MDS Nurse stated she was responsible for updating resident care plans. The MDS Nurse confirmed the comprehensive care plan for Resident #12 was not revised to reflect new fall interventions after the resident fell on [DATE] and 3/24/2024.

Based on facility policy review, medical record review, and interview the facility failed to implement new fall interventions for 1 resident (Resident #12) of 4 residents reviewed for falls. The findings include: Review of the facility's policy titled, Accidents and Incidents- Investigating and Reporting, revised 6/2017, revealed .The following data .shall be included on the Report of Incident/Accident form .The disposition of the injured .Any corrective action taken .Follow-up information .Other pertinent data . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Need for Assistance with Personal Care, Muscle Weakness, and Dysarthria (difficulty walking). Review of a 5-Day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 had severe cognitive impairment. Review of the facility's documentation for Resident #12 dated 3/18/2024, revealed .Incident location .Reception/Lobby .pt [patient] was discovered in floor by staff .pt wanted to get out of chair but did not ask for assist [assistance] .Action Taken .assisted back into wheelchair .Injuries Observed .Skin Tear .Left elbow . Further review revealed a new fall intervention was not implemented for Resident #12's fall on 3/18/2024. Review of the facility's documentation for Resident #12 dated 3/24/2024, revealed .Incident Location .Resident's Room .Resident was noted to be in the floor when nurse walked by .Immediate Action Taken .Resident sent to hospital for evaluation .Injuries Observed at Time of Incident .Injury Type .Hematoma .Injury Location .Left eye/eyebrow . Further review revealed a new fall intervention was not implemented for Resident #12's fall on 3/24/2024. During an interview on 5/8/2024 at 11:47 AM, the Assistant Director of Nursing and MDS Nurse confirmed the facility failed to implement new fall interventions after Resident #12 fell on [DATE] and 3/24/2024.

Based on facility policy review, medical record review, and interviews the facility failed to ensure the medical record was accurate and complete for 4 residents (Resident #7, #17, #3, and #12) of 8 residents reviewed for blood glucose monitoring and insulin administration. The findings include: Review of the facility's policy titled, Guidelines for Charting and Documentation, dated 4/2012, revealed .the purpose of charting and documentation is to provide .complete account of the resident's care .response to care .be concise .accurate .and complete .do not leave blank lines . Review of the facility's policy titled, Administering Medications, dated 4/2019, revealed .the individual administering the medication initials [documents administration] the resident's MAR [Medication Administration Record] .after giving each medication . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, and Bipolar Disorder. Review of the Physician's Orders for Resident #7 dated 11/2023, revealed . Novolin R [fast-acting insulin] Injection Solution 100 UNIT/ML [milliliter] .if [blood sugar level] 151 - 200 = 2 units .201 - 250 = 4 units .251 - 300 = 6 units .301 - 350 = 8 units .351 - 400 = 10 units .before meals and at bedtime . Review of the MAR for Resident #7 dated 4/2024, revealed the Novolin R insulin administration and the blood sugar check had a missed entry on 11/15/2023 at 8:00 AM. Review of a 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 was cognitively intact and had an active diagnosis of Diabetes. Further review revealed the resident received insulin. Review of a comprehensive care plan dated 4/23/2024, revealed Resident #7 .has Diabetes .Diabetes medication as ordered .Blood Sugar as ordered by doctor . During an interview on 5/9/2024 at 10:45 AM, Registered Nurse (RN) Supervisor A stated she was assigned to Resident #7 on 11/15/2023 (shift and date of the missed entry). RN Supervisor A stated she omitted the documentation of Resident #7's blood sugar level and/or insulin administration on the MAR by accident but followed the physician's orders. RN Supervisor A stated after she conducted the blood sugar check, if insulin was indicated she administered it per physician's orders. RN Supervisor A stated she was aware of the requirement to document blood sugar checks and insulin administration on Resident #7 ' s MAR. RN Supervisor A stated she failed to ensure the information was recorded appropriately in the documentation system. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Diabetes, Morbid Obesity, and Hypertension. Review of the Physician's Orders for Resident #17 dated 11/2023, revealed .NovoLog [fast acting insulin] .if [blood sugar level] 151 - 200 = 2 units .201 - 250 = 5 units .251 - 300 = 7 units .301 - 350 = 10 units .351 - 400 = 12 unit .Notify provider id [if] BS [blood sugar] over 400 . Review of the MAR for Resident #17 dated 11/2023, revealed the Novolog insulin administration and the blood sugar check had a missed entry on 11/13/2023 at 4:30 PM. Review of a quarterly MDS assessment dated [DATE], revealed Resident #17 had severe cognitive impairment and had an active diagnosis of Diabetes. Further review revealed the resident received insulin. Review of a comprehensive care plan dated 4/3/2024, revealed Resident #17 .has DM [Diabetes Mellitus] .Accuchecks [blood sugar checks] as ordered by doctor .Administer medication as ordered by doctor . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Chronic Myeloid Leukemia, Diabetes, and Chronic Kidney Disease. Review of the Physician's Orders for Resident #3 dated 11/2023, revealed .Humalog [fast-acting insulin] .if [blood sugar level] 151 - 200 = 2 units .201 - 250 = 4 units .251 - 300 = 6 units .301 - 350 = 8 units .351 - 400 = 10 units .401 - 999 = 15 units .Notify provider id [if] BS over 400 . Review of the MAR for Resident #3 dated 11/2023, revealed the Humalog insulin administration and the blood sugar check had multiple missed entries on 11/13/2023 at 5:00 PM, 11/16/2023 at 5:00 PM, and 11/17/2023 at 5:00 PM. Review of an admission MDS assessment dated [DATE], revealed Resident #3 was cognitively intact and had an active diagnosis of Diabetes. Further review revealed the resident received insulin. Review of a comprehensive care plan dated 11/17/2023, revealed Resident #3 .Diabetes .blood sugar as ordered .diabetes medication as ordered . During an interview on 5/8/2024 at 3:45 PM, RN Supervisor A stated she was assigned to Resident #3 on 11/13/2023, 11/16/2023, and 11/17/2023 (shift and days of missed entries). RN Supervisor A stated she failed to document Resident #3's blood sugar levels and/or insulin administration on Resident #12 ' s MAR by accident but followed the physician's orders. RN Supervisor A stated after she conducted the blood sugar check, if insulin was indicated she administered it per physician's orders. RN Supervisor A stated she was aware of the requirement to document blood sugar checks and insulin administration on Resident #3 ' s MAR. RN Supervisor A failed to ensure the information was recorded appropriately in the documentation system. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Need for Assistance with Personal Care, Dysarthria (difficulty walking), and Diabetes. Review of a comprehensive care plan dated 2/22/2024, revealed Resident #12 .has Diabetes .blood sugar as ordered . Review of a 5-Day MDS assessment dated [DATE], revealed Resident #12 had severe cognitive impairment and had an active diagnosis of Diabetes. Further review revealed the resident received insulin. Review of the Physician's Orders for Resident #12 dated 4/2024, revealed .Insulin Lispro .if [blood sugar level] 151 - 200 = 2 units .201 - 250 = 5 units .251 - 300 = 7 units .301 - 350 = 10 units .351 - 400 = 12 units . Review of the MAR for Resident #12 dated 4/2024, revealed Insulin Lispro administration with a blood sugar check had multiple missed entries on 4/19/2024 at 9:00 PM, 4/24/2024 at 9:00 PM, 4/27/2024 at 9:00 PM, 4/28/2024 at 9:00 PM, 4/29/2024 at 4:30 PM, and 4/29/2024 at 9:00 PM. Review of the MAR for Resident #12 dated 5/2024, revealed Insulin Lispro administration with the blood sugar check had a missed entry on 5/3/2024 at 9:00 PM. During an interview on 5/9/2024 at 8:01 AM, Family Nurse Practitioner (FNP) A stated she had not observed any missed documentation on the MARs but stated the omissions were an oversight regarding documentation. FNP A stated there had been no adverse resident outcomes from the omissions on the MARs and had no concerns with Diabetes management at the facility. During a telephone interview on 5/9/2024 at 8:42 AM, FNP B stated the facility notified her of any abnormal blood sugar values to include high and low readings and had not noticed any missed entries on the MARs. FNP B stated any missed entries on the MARs are related to the failure to ensure documentation is complete and accurate. FNP B stated the facility conducted blood sugar readings and administered insulin appropriately. FNP B stated there had been no adverse resident outcomes from the omissions on the MARs and had no concerns with Diabetes management at the facility. During an interview on 5/9/2024 at 9:47 AM, RN Account Manager for the pharmacy stated she visited the facility monthly and as needed to complete medication administration observations. RN Account Manager stated the omissions observed on the MAR is related to a documentation issue. During a telephone interview on 5/9/2024 at 10:08 AM, Licensed Practical Nurse (LPN) B stated she was assigned to Resident #12 on 4/27/2024 and 4/28/2024 (the shift and dates of missed entries). LPN B stated she omitted the documentation of Resident #12's blood sugar levels and/or insulin administration on the MAR as an oversight but followed the physician's orders. LPN B stated after she conducted the blood sugar check, if insulin was indicated she administered it per physician's orders. LPN B stated she was aware of the requirement to document blood sugar checks and insulin administration on the MAR, but failed to ensure the information was recorded appropriately in the documentation system. During a telephone interview on 5/9/2024 at 10:12 AM, LPN E stated she was assigned to Resident #12 on 4/19/2024, 4/24/2024, and 5/3/2024 (the shift and dates of the missed entries). LPN E stated she omitted the documentation of Resident #12's blood sugar levels and/or insulin administration on the MAR but followed the physician's orders. LPN E stated after she conducted the blood sugar checks and if insulin was indicated she administered it per physician's orders. LPN E stated she was aware of the requirement to document blood sugar checks and insulin administration on Resident #12 ' s MAR. LPN E stated she failed to ensure the information was recorded appropriately in the documentation system for Resident #12. During a telephone interview on 5/9/2024 at 10:16 AM, LPN C stated she was assigned to Resident #12 on 4/29/2024 (the shift and date of the missed entry). LPN C stated she omitted the documentation of Resident #12's blood sugar levels and/or insulin administration on the MAR but followed the physician's orders. LPN C stated after she conducted the blood sugar check, if insulin was indicated she administered it per physician's orders. LPN C stated she was aware of the requirement to document blood sugar checks and insulin administration on the MAR for Resident #12. During a telephone interview on 5/9/2024 at 10:33 AM, the Pharmacy Consultant stated during his monthly regimen reviews for the residents, he had not identified any concerns with insulin administration. During an interview on 5/9/2024 at 12:25 PM, the Medical Director stated the omissions (related to insulin administration and blood sugar checks) observed for Residents #7, #17, #3, and #12 were related to incomplete documentation on the residents ' MAR. During an interview on 5/9/2024 at 1:40 PM, the Director of Nursing (DON) confirmed the medical records for Residents #7, #17, #3, and #12 were not considered complete or accurate when the blood glucose levels, and insulin administration were not documented appropriately (omitted) on the MAR.

Based on facility policy review, medical record review, interviews, and observations, the facility failed to implement the comprehensive care plan for providing showers and bed baths for 28 residents (#9, #13, #20, #22, #26, #28, #31, #36, #37, #40, #41, #2, #5, #10, #12, #14, #15, #17, #18, #19, #21, #23, #24, #25, #27, #32, #33, and #39) and failed to ensure the comprehensive care plan was person centered for shower and bathing preferences for 6 residents (#13, #1, #16, #30, #34, and #38) of 42 care plans reviewed. The facility's failure resulted in psychosocial harm to 11 residents (#9, #13, #20, #22, #26, #28, #31, #36, #37, #40, and #41). The findings include: Review of the facility policy titled, Care Plan Comprehensive, Revised 11/8/2022, showed .To ensure .each resident's person-centered, comprehensive care plan .is reviewed and revised by the interdisciplinary team .who have knowledge of the resident and .needs .The care plan must be reviewed after each assessment .and revised based on .preferences and needs of the resident . Resident #9 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Type 2 Diabetes Mellitus, Schizophrenia, Fusion of Spine, and Intraspinal Abscess. Review of the comprehensive care plan dated 9/9/2022 showed, Resident #9 had an Activities of Daily Living (ADL) self-care performance deficit with an intervention including .showers 2xs [times] .week . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #9 required extensive 2 staff assistance for dressing, personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #9 had received 2 showers and 4 bed baths from 11/1/2022-2/5/2023. During an interview and observation on 1/10/2023 at 2:40 PM, Resident #9 stated he had not received a shower. The staff provide peri-care (perineal care - cleaning of the private parts) routinely and he was unsure why he had not received the scheduled showers. The resident's hair appeared greasy. During an interview on 2/6/2023 at 10:35 AM, Certified Nurse Aide (CNA) #7 stated Resident #9 had reported to her (unsure of the exact date) he had not received showers and felt nasty. Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Anxiety Disorder, Chronic Pain Syndrome, and Dementia. Review of the comprehensive care plan dated 6/5/2021 and revised on 3/18/2022, showed Resident #13 had an ADL self-care performance deficit and the resident's shower schedule and preference for bathing was not indicated. Review of a quarterly MDS assessment dated [DATE], showed Resident #13 was independent with set up help for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #13 received 4 showers and 1 bed bath from 11/1/2022-2/5/2023. During an observation and interview on 1/9/2023 at 3:44 PM, Resident #13 was asked if he had received a shower and the resident stated .you must be joking .I have not had a shower in over a month . The resident's hair was greasy, and he stated he would like to have a shower. During an interview on 2/9/2023 at 7:40 AM, Resident #13 stated he felt .unclean . when he did not receive a shower. Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Depressive Disorders, Diabetes Mellitus, Morbid Obesity, Overactive Bladder, Chronic Pain Syndrome, and Bipolar Disorder Disease. Review of the comprehensive care plan dated 9/9/2022, showed Resident #20 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #20 required extensive 1 staff assistance for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #20 received 3 showers and 3 bed baths from 11/1/2022-2/5/2023. During an interview on 2/6/2023 at 9:05 AM, Resident #20 stated she had not received showers and it made her feel crappy when she had not received the scheduled showers. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Fusion of Spine Cervical Region, Major Depressive Disorder, Chronic Pain Syndrome, and Dementia. Review of the comprehensive care plan dated 9/9/2022, showed Resident #22 had an ADL self-care performance deficit with an intervention including .Showers 2xs .week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #22 required extensive 1 staff assistance for dressing, personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #22 received 11 showers and 1 bed bath between 11/1/2022-2/5/2023. During an interview on 2/6/2023 at 2:25 PM, Resident #22 stated .it [showers] was a problem .I felt bad because I was not getting a shower . Resident #26 was admitted to the facility on [DATE] with diagnoses including Muscle Wasting and Atrophy, Chronic Obstructive Pulmonary Disease, and Depression. Review of the comprehensive care plan dated 7/23/2022, showed Resident #26 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #26 required limited 1 staff assistance for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #26 received 9 showers and no bed baths between 11/1/2022-2/5/2023. During an interview on 2/6/2023 at 5:30 AM, Resident #26 stated she had not received scheduled showers. The resident stated when she did not receive the showers .it upsets me .I want to be clean . Resident #28 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Type 2 Diabetes Mellitus, Chronic Pain Syndrome, and Personality Disorder. Review of the comprehensive care plan dated 6/8/2021, showed Resident #28 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week .Assist with shower/bed bath per residents preference as scheduled 2xs per week .PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #28 required extensive 1 staff assistance for dressing, personal hygiene, and was totally dependent on staff for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #28 received 9 showers and 7 bed baths between 11/1/2022-2/5/2023. During an interview on 2/6/2023 at 4:40 AM, Resident #28 stated she had not received the scheduled showers .I was mad .I was not getting my showers . Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Diabetes Mellitus, and Depression. Review of the comprehensive care plan dated 7/15/2022, showed Resident #31 had an ADL self-care performance deficit with an intervention including .May have showers 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #31 required extensive 1 staff assistance for dressing, personal hygiene, and bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #31 had received 15 showers and 2 bed baths between 11/1/2022-2/5/2023. During an interview on 2/6/2023 at 8:05 AM, Resident #31 stated she had not received scheduled showers. The resident stated when she had not received a shower, it made her feel .terrible and yucky .I wiped myself off, but it was not doing the job . Resident #36 was admitted to the facility on [DATE], was discharged on [DATE], and readmitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Disease, Depression, and Morbid (Severe) Obesity. Review of the comprehensive care plan dated 4/5/2022, showed Resident #36 had an ADL self-care performance deficit with an intervention including .showers 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #36 required extensive 2 staff assistance with dressing, personal hygiene, and required extensive 1 person assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #36 had received 1 shower and 6 bed baths between 11/1/2022-2/5/2023 (Resident #36 was out of the facility from 1/1/2023-1/6/2023). During an interview on 2/6/2023 at 12:00 PM, Resident #36 stated .I want to feel clean .I don't like to be dirty .I don't want to get in trouble for telling you this . Resident #37 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Lack of Coordination, Major Depressive Disorder, and Seizures. Review of the comprehensive care plan dated 9/11/2022, showed Resident #37 had an ADL self-care performance deficit with an intervention including .showers offered 2xs .week and PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #37 required limited 1 staff assistance with dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #37 received 4 showers and no bed baths between 11/1/2022-2/5/2023. During an interview on 1/9/2023 at 2:15 PM, Resident #37 stated .they .don't give me a shower . During an interview on 2/6/2022 at 9:22 AM, Resident #37 stated she had not received routine showers and it made her .feel dirty . Resident #40 was admitted to the facility on [DATE], discharged on [DATE] and readmitted [DATE] with diagnoses including Osteomyelitis of Vertebra, Lumbar Region, Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, Depression, Essential Hypertension, and Chronic Kidney Disease. Review of the comprehensive care plan dated 9/19/2022, showed Resident #40 had an ADL self-care performance deficit with an intervention of .may have showers 2xs .week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #40 required extensive 1 staff assistance with dressing, personal hygiene, and totally dependent on 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #40 received 8 showers and 6 bed baths between 11/1/2022-11/19/2023 and 11/30/2023-2/5/2023. During an interview on 2/6/2023 at 5:15 AM, Resident #40 stated she had not received the scheduled showers. Resident #40 stated .when I didn't get a shower .It made me angry . Resident #41 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Acute Respiratory Failure with Hypoxia, Repeated Falls, Systemic Lupus Erythematosus, Morbid Obesity with Alveolar Hypoventilation, Depression, Congestive Heart Failure, and Anxiety Disorder. Review of the comprehensive care plan dated 9/19/2022 showed Resident #41 had an ADL self-care performance deficit with an intervention of .showers offered 2xs .week . Review of a quarterly MDS assessment dated [DATE], showed Resident #41 required extensive 1 staff assistance for dressing, 1 staff supervision assistance with personal hygiene, and totally dependent of 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #41 received 14 showers and no bed baths between 11/1/2022-2/5/2023. During an interview on 2/6/2023 at 5:20 AM, Resident #41 stated .I kept asking for a shower and they [the facility staff] said they couldn't get to me .I went 12 days without a shower .I felt nasty .I didn't get a shower .I like to maintain my appearance . Resident #2 was admitted to the facility on [DATE] with diagnoses including Lack of Coordination, Diabetes Mellitus, Hepatic Failure, Cirrhosis of the Liver, Acute Hepatitis C, and Rheumatic Heart Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #2 required limited 1 staff assistance with dressing, personal hygiene, and was totally dependent on staff for bathing. Review of a quarterly MDS assessment dated [DATE], showed Resident #2 required limited 1 staff assistance for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the comprehensive care plan revised 12/21/2022, showed Resident #2 had an Activities of Daily Living (ADL) self-care performance deficit with an intervention including .Showers offered 2xs .week and prn . Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #2 received 4 showers from 11/1/2022-2/5/2023. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dislocation of other Internal Joint Prosthesis, Repeated Falls, Lack of Coordination, Essential Hypertension, and Dementia with Severe Psychotic Disturbance. Review of the comprehensive care plan dated 9/9/2022, showed Resident #5 had an ADL self-care performance deficit with an intervention including .May have showers 2xs .week and PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #5 required extensive assistance of 2 staff members for dressing, personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #5 had received 5 showers from 11/1/2022-2/4/2023. Resident #10 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Adult Failure to Thrive, and Repeated Falls. Review of the comprehensive care plan dated 9/11/2022, showed Resident #10 had an ADL self-care performance deficit with an intervention including .showers 2xs per week and PRN [as needed] . Review of a quarterly MDS assessment dated [DATE], showed Resident #10 required total dependence of 2 staff assistance for dressing, personal hygiene, and bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #10 received 10 showers and 14 bed baths from 11/1/2022-2/5/2023. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Muscle Weakness, Chronic Pain Syndrome, Moderate Protein-Calorie Malnutrition, Schizoaffective Disorder, Recurrent Depressive Disorders, Generalized Anxiety Disorder, and Dementia. Review of a comprehensive care plan dated 11/11/2020 and revised 12/8/2022, showed Resident #12 had an ADL self-care deficit with an intervention including .May have showers 2 x .week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #12 required extensive 1 staff assistance for dressing, personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #12 received 2 showers and 2 bed baths between 11/1/2022-2/5/2023. Resident #14 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dementia, Diabetes Mellitus, Stage 3 Chronic Kidney Disease, Major Depressive Disorder, and Interstitial Pulmonary Disease. Review of a comprehensive care plan dated 4/24/2022, showed Resident #14 had an ADL self-care performance deficit with an intervention including .showers 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #14 required extensive 1 staff assistance for dressing, personal hygiene and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #14 received 12 showers and 2 bed baths between 11/1/2022-2/5/2023. Resident #15 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke), Vascular Dementia, Hemiplegia and Hemiparesis. Review of a comprehensive care plan dated 9/9/2022, showed Resident #15 had an ADL self-care deficit with an intervention including .showers offered 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #15 required extensive 2 staff assistance with dressing, extensive 1 staff assistance with personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #15 received 6 showers and 8 bed baths between 11/1/2022-2/5/2023. Resident #17 was admitted to the facility on [DATE] with diagnoses including Cognitive Communication Deficit, Chronic Pain Syndrome, Cirrhosis of the Liver, and Generalized Anxiety Disorder. The resident was discharged from the facility on 1/23/2023. Review of a comprehensive care plan dated 8/26/2022, showed Resident #17 had an ADL self-care performance deficit with an intervention including .showers 2xs per week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #17 had moderate cognitive impairment, required limited 1 staff assistance for dressing, extensive 1 staff assistance with personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #17 received 7 showers and no bed baths between 11/1/2022-1/23/2023. Resident #18 was admitted to the facility on [DATE], discharged on [DATE], and readmitted on [DATE] with diagnoses including Cerebral Infarction, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Gastrostomy Status. Review of the comprehensive care plan revised 12/29/2022, showed Resident #18 had an ADL self-care performance deficit with an intervention including .showers 2xs per week and prn . Review of a discharge MDS assessment dated [DATE], showed Resident #18 required extensive assistance for dressing, personal hygiene, and was totally dependent on staff for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #18 had received 1 shower and 2 bed baths between 11/12/2022-2/5/2023. Resident #19 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Bipolar Disorder, and Schizoaffective Disorder. Review of the comprehensive care plan dated 9/9/2022, showed Resident #19 had an ADL self-care performance deficit with an intervention including .showers offered 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #19 required limited 1 staff assistance for dressing, extensive 1 staff assistance for personal hygiene, and was totally dependent of 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #19 received 11 showers and no bed baths between 11/1/2022-2/5/2023. Resident #21 was admitted to the facility on [DATE] with diagnoses including Dementia, Major Depressive Disorder, Bipolar Disorder, and Adult Failure to Thrive. Review of the comprehensive care plan dated 9/9/2022, showed Resident #21 had an ADL self-care performance deficit with an intervention including .showers offered 2xs .week and PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #21 required extensive 2 staff assistance for dressing, personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #21 received 10 showers and 7 bed baths from 11/1/2022-2/5/2023. Resident #23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Nontraumatic Subdural Hemorrhage, Atrial Fibrillation, and Dementia. Review of the comprehensive care plan revised 9/10/2022, showed Resident #23 had an ADL self-care performance deficit with an intervention including .Offer Showers x [times] 2 .week . Review of a quarterly MDS assessment dated [DATE], showed Resident #23 required extensive assistance 2 staff members for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #23 received 5 showers and 1 bed bath from 11/1/2022-2/5/2023. Resident #24 was admitted to the facility on [DATE] with diagnoses including Nontraumatic Intracerebral Hemorrhage, Psychosis, and Dementia. Review of the comprehensive care plan dated 9/11/2022, showed Resident #24 had an ADL self-care performance deficit with an intervention including .Showers 2xs .week and PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #24 required limited assistance of 1 staff member for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #24 received 1 shower and 1 bed bath from 11/1/2022-2/5/2023. Resident #25 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Fracture of Vertebra, Nontraumatic Subdural Hemorrhage, and Schizophrenia. Review of the comprehensive care plan dated 6/8/2022, showed Resident #25 had an ADL self-care performance deficit with an intervention including .May have showers 2xs per week .and PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #25 required supervision of 1 staff assistance for dressing, extensive 1 staff assistance for personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #25 received 9 showers and no bed baths between 11/1/2022-2/5/2023. Resident #27 was admitted to the facility on [DATE], discharged from the facility 12/17/2022, and readmitted on [DATE] with diagnoses including Muscle Weakness, Chronic Obstructive Pulmonary Disease, and Depression. Review of the comprehensive care plan dated 11/30/2022, showed Resident #27 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week . Review of an admission MDS assessment dated [DATE], showed Resident #27 required total assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #27 received 9 showers and 2 bed baths between 11/28/2022-2/5/2023. Resident #32 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Hemiplegia and Hemiparesis, Traumatic Brain Injury, and Dementia. Review of the comprehensive care plan revised 7/31/2022, showed Resident #32 had an ADL self-care performance deficit with an intervention in place including .Showers/bed bath offered 2xs per week per his preference . Review of a quarterly MDS assessment dated [DATE], showed Resident #32 required extensive 2 staff assistance with dressing, extensive 1 staff assistance with personal hygiene, and required 2 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #32 received 5 showers and 10 bed baths between 11/1/2022-2/5/2023 Resident #33 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Dementia, and Type 2 Diabetes Mellitus. Review of the comprehensive care plan dated 6/17/2022, showed Resident #33 had an ADL self-care performance deficit with an intervention including .showers offered 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #33 required extensive 1 staff assistance with dressing, personal hygiene, and bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #33 received 14 showers and 1 bed bath between 11/1/2022-2/5/2023. Resident #39 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Hemiparesis and Hemiplegia following Cerebral Infarction, Dementia without Behavior Disturbance, Lack of Coordination, Depression, Essential Hypertension, and Gangrene. Review of the comprehensive care plan dated 9/9/2022, showed Resident #39 had an ADL self-care performance deficit with an intervention of .showers 2xs .week . Review of a quarterly MDS assessment dated [DATE], showed Resident #39 required extensive 1 person staff assistance with dressing, personal hygiene, and bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #39 had received 13 showers and 2 bed baths between 11/1/2022-2/5/2023. Resident #1 was admitted to the facility on [DATE] with diagnoses including Polyneuropathy, Type 2 Diabetes Mellitus, Chronic Pulmonary Edema, Respiratory Failure with Hypoxia, and Alzheimer's Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #1 required extensive 1 staff assistance with dressing, personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of the comprehensive care plan dated 11/14/2022, showed Resident #1 had an ADL self-care performance deficit with no interventions to address a schedule for showers or the resident's shower preference. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #1 had received 8 showers from 11/4/2022-2/5/2023, a period of 94 days. Resident #16 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Paranoid Schizophrenia, Cerebral Infarction, and Anxiety Disorder. Review of a quarterly MDS assessment dated [DATE], showed Resident #16 required extensive 1 staff assistance for dressing, limited 1 staff assistance for personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of a comprehensive care plan revised 11/4/2022, showed Resident #16 had an ADL self-care deficit with an intervention including .Assist with ADLs as needed by providing one staff assist . Continued review showed the care plan did not reflect scheduled shower days or the resident's preference for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #16 had received 1 shower on 2/1/2023 and no bed baths. Resident #30 was admitted to the facility on [DATE] with diagnoses including Fracture of Femur, Essential Hypertension, and Dementia. The resident was discharged from the facility on 1/27/2023. Review of an admission MDS assessment dated [DATE], showed the activity of bathing had not occurred. Review of the comprehensive care plan dated 12/22/2022, showed Resident #30 had an ADL self-care performance deficit care plan and did not reflect scheduled shower days or the resident's preference for bathing. The facility did not provide shower documentation from 12/22/2022-12/31/2022. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/21/2022-1/27/2023 showed Resident #30 had received 1 shower and no bed baths. Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Cerebral Infarction, Hemiplegia and Hemiparesis, Heart Failure, and Hyperlipidemia. Review of the comprehensive care plan dated 6/29/2022, showed Resident #34 had an ADL self-care performance deficit with no intervention to address a schedule for showers. Review of a quarterly MDS assessment dated [DATE], showed Resident #34 required extensive 2 staff assistance with dressing, extensive 1 person assistance with personal hygiene, and 2 staff total dependence for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #34 received 1 shower and no bed baths between 11/1/2022-2/5/2023. Resident #38 was admitted to the facility on [DATE] with diagnoses including, Cerebral Infarction, Dementia, Anxiety Disorder, Hemiparesis and Hemiplegia. Review of the comprehensive care plan dated 12/2/2022, showed Resident #38 had an ADL self-care performance deficit with no intervention to include a shower schedule or preference for bathing. Review of an admission MDS assessment dated [DATE], showed Resident #38 required extensive 1 staff assistance with dressing, total dependence of 2 staff assistance for personal hygiene, and extensive 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #38 had received 4 showers and 7 bed baths between 12/3/2022-2/5/2023. During an interview on 1/13/2023 at 3:32 PM, the Director of Nursing (DON) stated the expectation was for the residents to receive a shower 2 times a week according to their care plan and confirmed the resident care plans were not followed. During an interview on 1/13/2023 at 3:53 PM, the MDS Coordinator stated the resident's bathing schedule and bathing preference should be placed on the resident's care plan. She also stated, I try to place it [bathing schedule or preference] on there [the care plan] but missed some. During an interview on 2/7/2023 at 10:30 AM, the MDS Coordinator stated after she had identified the activity of bathing had not occurred during the MDS assessments on several of the residents, she notified the DON. The MDS Coordinator stated she informed the DON the staff had not documented the showers. Refer to tags F-677

Based on review of the facility policy, medical record review, interviews, and observations, the facility failed to provide showers and bathing for 33 residents (#9, #10, #13, #14, #20, #22, #26, #28, #31, #36, #37, #40, #41, #1, #2, #5, #12, #15, #16, #17, #18, #19, #21, #23, #24, #25, #27, #30, #32, #33, #34, #38, and #39) of 64 residents reviewed. The facility failed to provide incontinence care for 4 residents (#10, #14, #32, and #11) of 14 residents reviewed for incontinence care. The facility's failure resulted in psychosocial harm to 13 residents (#9, #10, #13, #14, #20, #22, #26, #28, #31, #36, #37, #40, and #41). The facility was cited F-677 at a scope and severity of H (Harm) which constitutes Substandard Quality of Care. The findings include: Review of the facility policy titled, Aspects of Daily Nursing Care, effective date 9/22/2022, showed .Residents will be provided with care, treatment and services to assist the resident in attaining and maintaining .psychosocial well-being to ensure quality of life .Clinical services is responsible for the assessment and delivery of nursing needs .activities of daily living [ADL] .to prevent complications of psychosocial intervention . Resident #9 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Type 2 Diabetes Mellitus, Schizophrenia, Fusion of Spine, and Intraspinal Abscess. Review of the comprehensive care plan dated 9/9/2022 showed Resident #9 had an Activities of Daily Living (ADL) self-care performance deficit with an intervention including .showers 2xs [2 times] .week . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #9 scored a 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact, required extensive 2 staff assistance for dressing, and personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #9 had not received a shower or bed bath for the 30-day period. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #9 had received 1 shower on 12/4/2022 and 1 bed bath for the period. The documentation showed a period of 33 days between 11/1/2022-12/4/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #9 had received 1 shower on 1/11/2023 and 2 bed baths. The documentation showed a period of 58 days between 12/4/2022-1/31/2023 the resident had not received showers or baths. Review of the ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023 showed Resident #9 had not received a shower and had received 1 bed bath. Review of the ADL-Bathing and Skin Alert documentation showed Resident #9 had received 2 showers and 4 bed baths from 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #9 had not refused any baths or showers. During an interview and observation on 1/10/2023 at 2:40 PM, Resident #9 stated he had not received a shower. The staff provide peri-care (perineal care - cleaning of the private parts) routinely and he was unsure why he had not received the scheduled showers. The resident's hair appeared greasy. During an interview on 2/6/2023 at 9:56 AM, Resident #9 stated he had not received the scheduled showers and it made him feel .dirty .I have bad under arm odor, and I didn't smell too good . During an interview on 2/6/2023 at 10:35 AM, Certified Nurse Aide (CNA) #7 stated Resident #9 had reported to her (unsure of the exact date) he had not received showers and felt nasty. Resident #10 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Adult Failure to Thrive, and Repeated Falls. Review of the comprehensive care plan dated 9/11/2022, showed Resident #10 had severe cognitive impairment, and an ADL self-care performance deficit with an intervention including .showers 2xs per week and PRN [as needed] .has bowel/bladder incontinence r/t [related to] dementia, impaired mobility .Check resident every 2 hours and assist with toileting . Review of a quarterly MDS assessment dated [DATE], showed Resident #10 scored a 6 on the BIMS, indicating cognitive impairment, and required total dependence of 2 staff assistance for dressing, personal hygiene, and bathing. The resident was always incontinent of bladder and bowel. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #10 had received 4 showers, on 11/1/2022, 11/5/2022, 11/13/2022, 11/19/2022, and 2 bed baths. The documentation showed a period of 7 days between 11/5/2022-11/13/2022 and 10 days between 11/19/2022-11/30/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #10 had received 5 showers on 12/3/2022, 12/17/2022, 2/24/2022, 12/28/2022, 12/30/2022 and 4 bed baths. The documentation showed a period of 14 days between 11/19/2022-12/3/2022 and 14 days between 12/3/2022-12/17/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #10 had received 2 showers and 6 bed baths. The documentation showed a period of 14 days between 12/28/2022-1/11/2023, and a period of 13 days between, 1/18/2023-1/31/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #10 had not received a shower and received 2 bed baths. The documentation showed a period of 18 days between 1/18/2023-2/5/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #10 received 11 showers and 14 bed baths from 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #10 had not refused any baths or showers. During an observation and interview in the resident's room with the Director of Nursing (DON) and CNA #2 on 1/11/2023 at 6:10 AM, Resident #10 was lying in bed with her eyes closed and the bed linens and gown was saturated with urine, a brown ring was on the resident's incontinence pad, and a strong odor of urine was noted. CNA #2 confirmed Resident #10 was saturated with urine. The DON stated her expectation was for residents to be provided incontinence care every 2 hours. Resident #10 was unable to be interviewed on 1/11/2023 due to her severe cognitive impairment. During an observation and interview on 2/6/2023 at 4:30 AM, with CNA #11 and Licensed Practical Nurse (LPN) #4, Resident #10 was lying in bed with eyes closed, the bed linen and gown was saturated with urine, the incontinence pad had a brown ring, and the room smelled of urine. CNA #11 stated she had provided incontinence care around 3:00 AM. CNA #11 and LPN #4 confirmed Resident #10 was saturated with urine, the incontinence pad had a brown ring, and the room smelled of urine. During an interview on 2/6/2023 at 8:28 AM, CNA #5 stated she had witnessed Resident #10 saturated with urine multiple times (unable to recall the exact dates) and had reported it to the nurses and DON. During an interview on 2/7/2023 at 10:43 AM, CNA #16 stated she had often observed Resident #10 saturated with urine when she arrived on shift. Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Anxiety Disorder, Chronic Pain Syndrome, and Dementia. Review of the comprehensive care plan dated 6/5/2021 and revised on 3/18/2022, showed Resident #13 had an ADL self-care performance deficit and did not reflect a shower schedule or the resident's preference for bathing. Review of a quarterly MDS assessment dated [DATE], showed Resident #13 scored a 12 on the BIMS, indicating moderate cognitive impairment. The resident was independent with set up help for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed the resident had received 1 shower on 11/29/2022 and 1 bed bath. The documentation showed a period of 28 days between 11/1/2022-11/29/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #13 had received 1 shower on 12/16/2022 and no bed baths. The documentation showed a period of 16 days between 11/29/2022-12/16/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #13 had received 1 shower on 1/20/2023 and no bed baths. The documentation showed a period of 34 days between 12/16/2022-1/20/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #13 received 1 shower on 2/3/2023 and no bed baths. Review of the ADL-Bathing and Skin Alert documentation showed Resident #13 received 4 showers and 1 bed bath from 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #13 had not refused any baths or showers. During an observation and interview on 1/9/2023 at 3:44 PM, Resident #13 was asked if he had received a shower and the resident stated .you must be joking .I have not had a shower in over a month . The resident's hair was greasy, and he stated he would like to have a shower. During an interview on 2/9/2023 at 7:40 AM, Resident #13 stated prior to 2 weeks ago, he had not received scheduled showers. The resident stated he wanted a shower and felt .unclean . when he did not receive a shower. Resident #14 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dementia, Diabetes Mellitus, Stage 3 Chronic Kidney Disease, Major Depressive Disorder, and Interstitial Pulmonary Disease. Review of a comprehensive care plan dated 4/24/2022, showed Resident #14 had an ADL self-care performance deficit with an intervention including .showers 2xs per week . TOILET USE .The resident requires assistance .for toileting needs .Incontinence Care Plan .Check and change monitor for incontinence . Review of a quarterly MDS assessment dated [DATE], showed Resident #14 scored a 14 on the BIMS which indicated the resident was cognitively intact. The resident required extensive 1 staff assistance for dressing, personal hygiene, and was totally dependent on 2 staff assistance for bathing. The resident was totally dependent on 2 staff assistance for toilet use. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #14 had received 3 showers on 11/20/2022, 11/27/2022, 11/29/2022, and had received 1 bed bath. The documentation showed a period of 19 days from 11/1/2022-11/20/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #14 received 4 showers on 12/9/2022, 12/13/2022, 12/16/2022, 12/20/2022, and no bed baths. The documentation showed a period of 10 days between 12/20/2022-12/31/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #14 had received 3 showers on 1/11/2023, 1/17/2023, 1/31/2023, and 1 bed bath. The documentation showed a period of 21 days between 12/20/2022-1/11/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #14 had received 1 shower on 2/1/2023 and no bed baths. Review of the ADL-Bathing and Skin Alert documentation showed Resident #14 received 12 showers and 2 bed baths between 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #14 had not any refused baths or showers. During an observation and interview with Registered Nurse (RN) #2 on 1/11/2023 at 5:02 AM, Resident #14 was lying in bed with eyes closed and bed linens, gown, and brief were saturated with urine, with a brown ring on the incontinence pad. RN #2 stated .yeah that one is pretty wet .It's saturated with urine both the brief and pad .its brown ringed . During an interview on 2/6/2023 at 5:05 AM, LPN #4 stated she observed Resident #14 saturated with urine when she arrived on shift and was unable to recall the exact dates. LPN #4 stated Resident #14 .seemed upset because she hadn't been changed and was left wet during the night . Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Depressive Disorders, Diabetes Mellitus, Morbid Obesity, Overactive Bladder, Chronic Pain Syndrome, and Bipolar Disorder Disease. Review of the comprehensive care plan dated 9/9/2022, showed Resident #20 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #20 scored a 12 on the BIMS which indicated moderate cognitive impairment. The resident required extensive 1 staff assistance for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #20 received 1 shower on 11/1/2022 and 1 bed bath. The documentation showed a period of 29 days between 11/2/2022-11/30/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #20 had not received a shower, and received 1 bed bath. The documentation showed a period of 60 days between 11/1/2022-12/31/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #20 had received 2 showers on 1/11/2023, and 1/2023, and 1 bed bath. The documentation showed a period of 70 days between 11/2/2022-1/31/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #20 had not received a shower or a bed bath. Review of the ADL-Bathing and Skin Alert documentation showed Resident #20 received 3 showers and 3 bed baths from 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #20 had not refused any baths or showers. During an interview on 2/6/2023 at 9:05 AM, Resident #20 stated she had not received showers and it made her feel crappy when she had not received the scheduled showers. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Fusion of Spine Cervical Region, Major Depressive Disorder, Chronic Pain Syndrome, and Dementia. Review of the comprehensive care plan dated 9/9/2022, showed Resident #22 had an ADL self-care performance deficit with an intervention including .Showers 2xs .week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #22 scored a 14 on the BIMS which indicted the resident was cognitively intact. The resident required extensive 1 staff assistance for dressing and personal hygiene and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #22 had received 3 showers on 11/5/2022, 11/6/2022, 11/30/2022, and 1 bed bath. The documentation showed a period of 23 days between 11/6/2022-11/30/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #22 had received 3 showers on 12/16/2022, 12/22/2022, 12/28/2022, and no bed baths. The documentation showed a period of 15 days between 11/30/2022-12/16/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #22 had received 3 showers on 1/6/2023, 1/11/2023, 1/20/2023, and no bed baths. The documentation showed a period of 8 days between 12/28/2022-1/6/2023, and 8 days between 1/11/2023-1/20/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #22 had received 2 showers on 2/1/2023, 2/4/2023, and no bed baths. The documentation showed a period of 11 days between 1/20/2023-2/1/2023 the resident had not received showers or baths. Review of the ADL-Bathing and Skin Alert documentation showed Resident #22 received 11 showers and 1 bed bath between 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #22 had not refused any baths or showers. During an interview on 2/6/2023 at 2:25 PM, Resident #22 stated she received showers currently, but prior to 2 weeks ago .it [showers] was a problem .I felt bad because I was not getting a shower . Resident #26 was admitted to the facility on [DATE] with diagnoses including Muscle Wasting and Atrophy, Chronic Obstructive Pulmonary Disease, and Depression. Review of the comprehensive care plan dated 7/23/2022 showed Resident #26 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week . Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/11/2022-11/30/2022, showed Resident #26 had received 1 shower on 11/13/2022 and no bed baths. The documentation showed a period of 17 days between 11/11/2022-11/30/2022 the resident had not received showers or baths. Review of a quarterly MDS assessment dated [DATE], showed Resident #26 scored a 14 on the BIMS which indicated the resident was cognitively intact. The resident required limited 1 staff assistance for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #26 had received 2 showers on 12/6/2022, 12/16/2022, and no bed baths. The documentation showed a period of 9 days between 12/6/2022-12/16/2022 and 14 days between 12/16/2022-12/31/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #26 had received 5 showers on 1/4/2023, 1/11/2023, 1/20/2023, 1/21/2023, 1/24/2023, and no bed baths. The documentation showed a period of 18 days between 12/16/2022-1/4/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #26 had received 1 shower on 2/3/2023 and no bed baths. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #26 received 9 showers and no bed baths between 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #26 had not refused any baths or showers. During an interview on 2/6/2023 at 5:30 AM, Resident #26 stated prior to 2-3 weeks ago, she had not received scheduled showers. The resident stated when she did not receive the showers .it upsets me .I want to be clean . Resident #28 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Type 2 Diabetes Mellitus, and Chronic Pain Syndrome. Review of the comprehensive care plan dated 6/8/2021, showed Resident #28 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week .Assist with shower/bed bath per residents preference as scheduled 2xs per week .PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #28 had a BIMS of 13, indicating cognitively intact, required extensive 1 staff assistance for dressing, personal hygiene, and was totally dependent on staff for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #28 received 2 showers on 11/4/2022, 11/29/2022, and 4 bed baths. The documentation showed a period of 24 days between 11/4/2022-11/29/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #28 had received 4 showers on 12/9/2022, 12/13/2022, 12/16/2022, 12/23/2022, and had received 1 bed bath. The documentation showed a period of 7 days between 11/29/2022-12/9/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #28 had received 3 showers on 1/6/2023, 1/17/2023, 1/31/2023, refused a shower on 1/10/2023, and had received 2 bed baths. The documentation showed a period of 10 days between 12/27/2022-1/6/2023 the resident had not received showers or baths. The facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #28 had not received a shower or a bed bath and refused a shower on 2/3/2023. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #28 received 9 showers and 7 bed baths between 11/1/2022-2/5/2023, a period of 97 days. During an interview on 2/6/2023 at 4:40 AM, Resident #28 stated prior to the past 2 weeks, she had not received scheduled showers .I was mad .I was not getting my showers . Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Diabetes Mellitus, and Depression. Review of the comprehensive care plan dated 7/15/2022, showed Resident #31 had an ADL self-care performance deficit with an intervention including .May have showers 2xs per week . Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #31 received a total of 4 showers on 11/13/2022, 11/14/2022, 11/23/2022, 11/27/2022, and had received 2 bed baths. The documentation showed a period of 12 days between 11/1/2022-11/12/2022 and 8 days between 11/14/2022-11/23/2022 the resident had not received showers or baths. Review of a quarterly MDS assessment dated [DATE], showed Resident #31 scored a 13 on the BIMS which indicated the resident was cognitively intact. The resident required extensive 1 staff assistance for dressing, personal hygiene, and bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #31 received 3 showers on 12/4/2022, 12/6/2022, 12/24/2022, and 1 bed bath. The documentation showed a period of 17 days between 12/4/2022-12/24/2022 the resident did not receive showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #31 had received 3 showers on 1/6/2023, 1/18/2023, 1/25/2023, and no bed baths. The documentation showed a period of 12 days between 12/24/2022-1/6/2023 and 11 days between 1/6/2023-1/18/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #31 had received 1 shower on 2/4/2023 and no bed baths. The documentation showed a period of 9 days between 1/25/2023-2/4/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #31 had received 11 showers and 3 bed baths between 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #31 had not refused any baths or showers. During an interview on 1/10/2023 at 2:31 PM, CNA #5 stated Resident #31 had not received scheduled showers. During an interview on 2/6/2023 at 8:05 AM, Resident #31 stated prior to the past 2 weeks she had not received scheduled showers. The resident stated when she had not received a shower, it made her feel .terrible and yucky .I wiped myself off, but it was not doing the job . The resident stated the staff had informed her there was not enough staff to assist her with a shower. Resident #36 was admitted to the facility on [DATE], discharged on [DATE] and readmitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Disease, Depression, and Morbid (Severe) Obesity. Review of the comprehensive care plan dated 4/5/2022, showed Resident #36 had an ADL self-care performance deficit with an intervention including .showers 2xs per week . Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #36 had not received a shower and received 3 bed baths. The documentation showed a period of 30 days between 11/1/2022-11/30/2022 the resident did not receive showers or baths. Review of a quarterly MDS assessment dated [DATE], showed Resident #36 scored an 11 on the BIMS which indicated moderate cognitive impairment. The resident required extensive 2 staff assistance with dressing and personal hygiene and required extensive 1 person assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #36 had not received a shower and received 2 bed baths. The documentation showed a period of 61 days between 11/1/2022-12/31/2022 the resident did not receive showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #36 had received no showers and 1 bed bath. The documentation showed a period of 87 days between 11/1/2022-1/31/2023 the resident had not received showers or baths (the resident was out of the facility from 1/1/2023-1/6/2023). Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed the resident had a shower on 2/4/2023 and no bed baths. Review of the facility's ADL-Bathing and Skin Alert showed Resident #36 had received 1 shower and 6 bed baths between 11/1/2022-1/11/2023, a period of 92 days. Medical record review showed Resident #36 had not refused any baths or showers. During an interview on 2/6/2023 at 12:00 PM, Resident #36 stated she had a .glorious shower on Saturday [2/4/2023] . Resident #36 stated prior to 2/4/2023, she had not received scheduled showers .I want to feel clean .I don't like to be dirty .I don't want to get in trouble for telling you this . Resident #37 was admitted to the facility on [DATE] with diagnosis including Parkinson's Disease, Lack of Coordination, Major Depressive Disorder, and Seizures. Review of the comprehensive care plan dated 9/11/2022, showed Resident #37 had an ADL self-care performance deficit with an intervention including .showers offered 2xs .week and PRN . Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #37 had not received a shower or a bed bath. The documentation showed a period of 30 days between 11/1/2022-11/30/2022 the resident had not received showers or baths. Review of a quarterly MDS assessment dated [DATE], showed Resident #37 scored an 11 on the BIMS which indicated moderate cognitive impairment. The resident required limited 1 staff assistance with dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #37 had received 1 shower on 12/9/2022 and no bed baths. The documentation showed a period of 38 days between 11/1/2022-12/9/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #37 had received 3 showers on 1/11/2022, 1/19/2023, 1/31/2023, and no bed baths. The documentation showed a period of 32 days the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Check documentation dated 2/1/2023-2/5/2023 showed, Resident #37 had not received a shower or a bed bath. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #37 received 4 showers and no bed baths between 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #37 had not refused any baths or showers. During an interview on 1/9/2023 at 2:15 PM, Resident #37 stated .they .don't give me a shower . During an interview on 2/6/2022 at 9:22 AM, Resident #37 stated she received showers now. The resident stated she had not received routine showers prior to the past couple of weeks and it made her .feel dirty . Resident #40 was admitted to the facility on [DATE], discharged from the facility on 11/19/2022, and readmitted [DATE] with diagnoses including Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, and Depression. Review of the comprehensive care plan dated 9/19/2022, showed Resident #40 had an ADL self-care performance deficit with an intervention of .may have showers 2xs .week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #40 scored a 15 on the BIMS which indicated the resident was cognitively intact. The resident required extensive 1 staff assistance with dressing, personal hygiene, and totally dependent on 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/19/2022, showed Resident #40 had received 1 shower on 11/1/2022 and 2 bed baths. The documentation showed a period of 18 days between 11/1/2022-11/19/2022 the resident did not receive showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #40 had received 4 showers on 12/9/2022, 12/13/2022, 12/16/2022, 12/23/2022, and 1 bed bath. The documentation showed a period of 37 days between 11/1/2022-12/9/2022 the resident did not receive showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #40 had received 2 showers on 1/6/2023, 1/17/2023, and 3 bed baths. The documentation showed a period of 13 days between 12/23/2022-1/6/2023 and 14 days between 1/17/2023-1/31/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #40 received 1 shower on 2/3/2023 and no bed baths. The shower documentation showed Resident #40 received 8 showers and 6 bed baths between 11/1/2022-11/19/2023 and 11/30/2023-2/5/2023, a period of 83 days. Medical record review showed Resident #40 had not refused any baths or showers. During an interview on 2/6/2023 at 5:15 AM, Resident #40 stated she had not received scheduled showers prior to the past 2 weeks. Resident #40 stated .when I didn't get a shower .It made me angry . Resident #41 was admitted to the facility on [DATE] with diagnoses including Systemic Lupus Erythematosus, Morbid Obesity, Depression, and Congestive Heart Failure. Review of the comprehensive care plan dated 10/6/2022 showed Resident #41 had an ADL self-care performance deficit with an intervention of .showers offered 2xs .week . Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #[TRUNCATED]

Based on review of the Facility Assessment, review of Resident Census and Conditions of Residents Form Center for Medicare and Medicaid Services (CMS)-672, review of Job Descriptions, medical record review, observations, interviews, and review of staffing schedules and time punches, the facility failed to ensure sufficient staffing levels to meet Activities of Daily Living (ADL) care needs of 33 residents (#9, #10, #13, #14, #20, #22, #26, #28, #31, #36, #37, #40, #41, #1, #2, #5, #12, #15, #16, #17, #18, #19, #21, #23, #24, #25, #27, #30, #32, #33, #34, #38, and #39) of 64 residents reviewed for bathing. The facility failed to ensure sufficient staffing levels to meet the care needs related to incontinence care for 4 dependent residents (#10, #11, #14, and #32) of 13 residents reviewed for incontinence care. The facility's failure resulted in psychosocial harm to 13 residents (#9, #10, #13, #14, #20, #22, #26, #28, #31, #36, #37, #40 and #41). The findings include: Review of the document titled, Facility Assessment, dated 9/21/2022, showed .Our Resident Profile .average daily census .65 [residents] .Staffing plan .Based on .resident population and their needs for care and support .overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs .Position .Nurse Aides [Certified Nursing Assistants] [CNA] .Total Number Needed .13-15 a day [penciled in a change of 12-14] . Review of the facility's document titled, CMS-672 Resident Census and Conditions of Residents, dated 1/9/2023, showed the facility had a census of 64 residents, 39 residents with occasional or frequent incontinence of bladder, and 37 residents with occasional or frequent incontinence of bowel. The form showed 24 residents required assistance of 1-2 staff for bathing and 40 residents were dependent on staff for bathing. Review of the facility's document titled, CMS-672 Resident Census and Conditions of Residents, dated 2/6/2023, showed the facility had a census of 64 residents, 48 residents with occasional or frequent incontinence of bladder, and 44 residents with occasional or frequent incontinence of bowel. The form showed 24 residents required assistance of 1-2 staff for bathing and 40 residents were dependent on staff for bathing. Review of the facility document titled, Certified Nursing Assistant [CNA] Job Description, Updated 9/4/2020, showed .Essential Functions .Provide basic nursing care to patients [residents] .that includes actions that meet psychosocial needs and physical needs .Perform basic patient care responsibilities considering needs specific to the standard of care .Maintain awareness of the needs of the .geriatric .patient population .Coordinate .patient care under the direct supervision of an RN [Registered Nurse] .Ability to complete work assignments .in a timely manner . Review of the facility document titled Licensed Practical Nurse (LPN) Job Description, Updated 9/4/2020, showed .Under supervision of a registered nurse, provides quality care to patients .Provide basic nursing care to patients .that meet psychosocial needs and physical needs .Ensures quality .nursing services to patients .Assist patients with personal hygiene .Provide emotional support to patients .listen to concerns and feedback . Review of the facility document titled Registered Nurse (RN) Job Description, Updated 9/4/2020, showed .Job Summary Registered Nurses at the Skilled Nursing Facility provide direct bedside care and act as patient advocate .Provide basic nursing care to patients .that meet psychosocial needs and physical needs .Provides direct and individualized nursing care .under the supervision of the Director of Nursing [DON] .patient advocate and ensuring that other health care team members are providing care according to the resident's care plan and personal wishes . Resident #9 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Type 2 Diabetes Mellitus, Schizophrenia, Fusion of Spine, and Intraspinal Abscess. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #9 was cognitively intact, required extensive 2 staff assistance for dressing, personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL (Activities of Daily Living)-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #9 had not received a shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #9 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #9 had received 1 shower. Review of the ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023 showed Resident #9 had not received a shower. During an interview on 2/6/2022 at 5:09 AM, Certified Nurse Aide (CNA) #11 stated Resident #9 had not received a shower in a couple of weeks (unsure of the exact dates). During an interview on 2/6/2023 at 9:56 AM, Resident #9 stated .I wasn't getting them [showers] before you [surveyors] came . The resident stated when he had not received the scheduled showers, it made him feel .dirty .I have bad under arm odor, and I didn't smell too good . During an interview on 2/6/2023 at 10:35 AM, CNA #7 stated Resident #9 had reported to her (unsure of the exact date) he had not been receiving showers and felt nasty. The CNA stated the nurses did not assist the CNAs with resident care. Resident #10 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Adult Failure to Thrive, and Repeated Falls. Review of a quarterly MDS assessment dated [DATE], showed Resident #10 had severe cognitive impairment, required total dependence of 2 staff assistance for dressing and toilet use, total dependence of 1 staff assistance for personal hygiene, and was always incontinent of bladder and bowel. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #10 had received 4 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #10 had received 5 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #10 had received 2 showers. During an observation and interview in the resident's room with the Director of Nursing (DON) and CNA #2 on 1/11/2023 at 6:10 AM, Resident #10 was lying in bed with her eyes closed, the bed linens and gown were saturated with urine, and a brown ring was observed on the resident's incontinence pad. CNA #2 confirmed Resident #10 was saturated with urine. The DON stated her expectation was for resident's to be provided incontinence care every 2 hours. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #10 had not received a shower. During an observation and interview on 2/6/2023 at 4:30 AM, with CNA #11 and Licensed Practical Nurse (LPN) #4, Resident #10 was lying in bed with eyes closed, the bed linens and gown were saturated with urine, and a brown ring was observed on the resident's incontinence pad. Further observation showed the resident's room smelled of urine. CNA #11 stated she had provided incontinence care around 3:00 AM. CNA #11 and LPN #4 confirmed Resident #10 was saturated with urine, the incontinence pad had a brown ring, and the room smelled of urine. During an interview on 2/6/2023 at 8:28 AM, CNA #5 stated she had witnessed Resident #10 saturated with urine multiple times (unable to recall the exact dates). During an interview on 2/7/2023 at 10:43 AM, CNA #16 stated she had observed Resident #10 saturated with urine multiple times when she arrived on shift. The CNA stated the nurses did not routinely assist the CNAs with resident care. Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Anxiety Disorder, Chronic Pain Syndrome, and Dementia. Review of a quarterly MDS assessment dated [DATE], showed Resident #13 had moderate cognitive impairment, was independent with set up help for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed the resident had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #13 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #13 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #13 had received 1 shower. During an observation and interview on 1/9/2023 at 3:44 PM, Resident #13 stated .I have not had a shower in over a month . The resident's hair appeared greasy. During an interview on 2/9/2023 at 7:40 AM, Resident #13 stated prior to 2 weeks ago he had not received the scheduled showers. The resident stated he wanted a shower and felt .unclean . when he did not receive a shower. Resident #14 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dementia, Diabetes Mellitus, Stage 3 Chronic Kidney Disease, Major Depressive Disorder, and Interstitial Pulmonary Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #14 had moderate cognitive impairment, required extensive 1 staff assistance for dressing, personal hygiene, and was totally dependent on 2 staff assistance for bathing and toilet use. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #14 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #14 had received 4 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #14 had received 3 showers and refused 1. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #14 had received 1 shower. During an observation and interview with Registered Nurse (RN) #2 on 1/11/2023 at 5:02 AM, Resident #14 was lying in bed with eyes closed, bed linens, gown, and brief were saturated with urine, and a brown ring was on the incontinence pad. RN #2 stated .yeah that one is pretty wet .It's saturated with urine both the brief and pad .its brown ringed . During an interview on 2/6/2023 at 5:05 AM, LPN #4 stated she observed Resident #14 saturated with urine when she arrived on shift and was unable to recall the exact dates. LPN #4 stated Resident #14 .seemed upset because she hadn't been changed and was left wet during the night . During an interview on 2/6/2023 at 5:19 AM, LPN #5 stated Resident #10 and Resident #14 were often observed saturated with urine when she arrived on shift and .they [residents] would feel bad and not be able to sleep . when saturated with urine. Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Depressive Disorders, Diabetes Mellitus, Morbid Obesity, Overactive Bladder, Chronic Pain Syndrome, and Bipolar Disorder Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #20 had moderate cognitive impairment, required extensive 1 staff assistance for dressing and personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #20 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #20 had not received a shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #20 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #20 had not received a shower. During an interview on 2/6/2023 at 9:05 AM, Resident #20 stated she had not received showers, there was not enough staff, and it made her feel crappy when she had not received the scheduled showers. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Fusion of Spine Cervical Region, Major Depressive Disorder, Chronic Pain Syndrome, and Dementia. Review of a quarterly MDS assessment dated [DATE], showed Resident #22 was cognitively intact, required extensive 1 staff assistance for dressing and personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #22 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #22 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #22 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #22 had received 2 showers. During an interview on 2/6/2023 at 2:25 PM, Resident #22 stated .it [showers] was a problem .I felt bad because I was not getting a shower . Resident #26 was admitted to the facility on [DATE] with diagnoses including Muscle Wasting and Atrophy, Chronic Obstructive Pulmonary Disease, and Depression. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/11/2022-11/30/2022, showed Resident #26 had received 1 shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #26 was cognitively intact, required limited 1 staff assistance for dressing and personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #26 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/10/2023, showed Resident #26 had received 5 showers. Review of the ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023 showed Resident #26 had received 1 shower. During an interview on 2/6/2023 at 5:30 AM, Resident #26 stated she had not received the scheduled showers. The resident stated when she did not receive the showers .it upsets me .I want to be clean . Resident #28 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction and Type 2 Diabetes. Review of a quarterly MDS assessment dated [DATE], showed Resident #28 had moderate cognitive impairment, required extensive 1 staff assistance for dressing and personal hygiene, and was totally dependent on staff for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #28 had received 2 showers and 4 bed baths. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #28 had received 4 showers and 1 bed bath. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #28 had received 3 showers and 2 bed baths. The resident had refused 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #28 had not received a shower or a bed bath and had refused 1 shower. During an interview on 2/6/2023 at 4:40 AM, Resident #28 stated prior to the past 2 weeks, she had not received scheduled showers .I was mad .I was not getting my showers . Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Diabetes Mellitus, and Depression. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #31 had received 4 showers. Review of a quarterly MDS assessment dated [DATE], showed Resident #31 had moderate cognitive impairment and required extensive 1 staff assistance for dressing, personal hygiene, and bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #31 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #31 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #31 had received 2 showers. During an interview on 1/10/2023 at 2:31 PM, CNA #5 stated Resident #31 had not received the scheduled showers and Resident #31 had stated night shift had not provided the scheduled showers. The resident was scheduled for showers on Wednesdays and Saturdays and night shift was responsible for the resident's shower. During an interview on 2/6/2023 at 8:05 AM, Resident #31 stated when she had not received a shower, it made her feel .terrible and yucky .I wiped myself off, but it was not doing the job . The resident further stated the staff had informed her there was not enough staff to assist her with a shower. Resident #36 was admitted to the facility on [DATE], discharged on [DATE] and readmitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Disease, Depression, and Morbid (Severe) Obesity. Review of the facility's shower documentation dated 11/1/2022-11/30/2022, showed Resident #36 had not received a shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #36 had moderate cognitive impairment, required extensive 2 staff assistance with dressing and personal hygiene, and required extensive 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Care Alert shower documentation dated 12/1/2022-12/31/2022, showed Resident #36 had not received a shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #36 had not received a shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023 showed Resident #36 had received 1 shower. During an interview on 2/6/2023 at 12:00 PM, Resident #36 stated she had not received scheduled showers and .I want to feel clean .I don't like to be dirty .I don't want to get in trouble for telling you this .when you all [surveyors] are here .there is more people [staff] .there are no problems at all . Resident #37 was admitted to the facility on [DATE] with diagnosis including Parkinson's Disease, Lack of Coordination, Major Depressive Disorder, and Seizures. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #37 had not received a shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #37 had moderate cognitive impairment, required limited 1 staff assistance with dressing and personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #37 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #37 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #37 had not received a shower. During an interview on 2/6/2022 at 9:22 AM, Resident #37 stated she had not received routine showers and it made her .feel dirty . Resident #37 further stated the facility did not have enough staff to provide the showers .people quit . Resident #40 was admitted to the facility on [DATE], discharged from the facility on 11/19/2022, and readmitted [DATE] with diagnoses including Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, and Depression. Review of a quarterly MDS assessment dated [DATE], showed Resident #40 was cognitively intact, required extensive 1 staff assistance with dressing and personal hygiene, and totally dependent on 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/19/2022, showed Resident #40 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #40 had received 4 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #40 had received 2 showers. Revie of the facility's ADL-Bathing and Skin Care Alert documentation showed Resident #40 had received 1 shower. During an interview on 2/6/2023 at 5:15 AM, Resident #40 stated .when I didn't get a shower .It made me angry . Resident #41 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Systemic Lupus Erythematosus, Morbid Obesity, Depression, and Congestive Heart Failure. Review of the facility's shower documentation dated 11/1/2022-11/30/2022, showed Resident #41 had received 4 showers. Review of a quarterly MDS assessment dated [DATE], showed Resident #41 was cognitively intact, required extensive 1 staff assistance for dressing, 1 staff supervision assistance with personal hygiene, and totally dependent of 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #41 had received 5 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #41 had received 4 showers. Review of the ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023 showed Resident #41 had received 1 shower. During an interview on 2/6/2023 at 5:20 AM, Resident #41 stated .they [the facility staff] told me there was not enough staff to give me my showers .I kept asking for a shower and they said they couldn't get to me .I went 12 days without a shower .I felt nasty .I didn't get a shower .I like to maintain my appearance . Resident #1 was admitted to the facility on [DATE] with diagnoses including Polyneuropathy, Type 2 Diabetes Mellitus, Chronic Pulmonary Edema, Respiratory Failure with Hypoxia, and Alzheimer's Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had moderate cognitive impairment. The resident required extensive 1 staff assistance with dressing and personal hygiene and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/4/2022-11/30/2022, showed Resident #1 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #1 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #1 had received 3 showers. Review of a Skin Alert sheet dated 1/30/2023, showed the resident refused a shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #1 had not received a shower. Resident #2 was admitted to the facility on [DATE] with diagnoses including Lack of Coordination, Diabetes Mellitus, Hepatic Failure, Cirrhosis of the Liver, Acute Hepatitis C, and Rheumatic Heart Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #2 was cognitively intact, required limited 1 staff assistance with dressing and personal hygiene, and was totally dependent on staff for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #2 had received 1 shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #2 required limited 1 staff assistance for dressing and personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #2 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #2 had received 4 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023 showed Resident #2 had received a shower on 2/4/2023. Review of a nursing note dated 2/2/2023, showed the resident was offered a shower on this date and refused. During an interview on 2/6/2023 at 4:20 AM, Resident #2 stated he received showers when the staff were not busy. Sometimes .they do not have enough staff to supervise me in the shower . Resident #5 was admitted to the facility on [DATE], was discharged on [DATE] and was readmitted on [DATE] with diagnoses including Dislocation of other Internal Joint Prosthesis, Repeated Falls, Lack of Coordination, Essential Hypertension, and Dementia with Severe Psychotic Disturbance. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #5 had received 1 shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #5 had moderate cognitive impairment. The resident required extensive assistance of 2 staff members for dressing and personal hygiene and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/21/2022, and 12/22/2022-12/31/2022, showed Resident #5 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #5 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #5 had received 1 shower on 2/4/2023. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Muscle Weakness, Chronic Pain Syndrome, Moderate Protein-Calorie Malnutrition, Schizoaffective Disorder, Recurrent Depressive Disorders, Generalized Anxiety Disorder, and Dementia. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #12 had not received a shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #12 had moderate cognitive impairment, required extensive 1 staff assistance for dressing, personal hygiene and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #12 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #12 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #12 had not received a shower. Resident #15 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Dementia, Hemiplegia, and Hemiparesis. Review of a quarterly MDS assessment dated [DATE], showed Resident #15 had severe cognitive impairment, required extensive 2 staff assistance with dressing, extensive 1 staff assistance with personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #15 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #15 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #15 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #15 had not received a shower. Resident #16 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Paranoid Schizophrenia, Cerebral Infarction, and Anxiety Disorder. Review of a quarterly MDS assessment dated [DATE], showed Resident #16 required extensive 1 staff assistance for dressing, limited 1 staff assistance for personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #16 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #16 had received 5 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #16 had received 4 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #16 had received 1 shower. Resident #17 was admitted to the facility on [DATE] with diagnoses including Cognitive Communication Deficit, Chronic Pain Syndrome, Cirrhosis of the Liver, and Generalized Anxiety Disorder. The resident was discharged on [DATE]. Review of a quarterly MDS assessment dated [DATE], showed Resident #17 required limited 1 staff assistance for dressing, extensive 1 staff assistance with personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #17 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #17 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/23/2023, showed Resident #17 had not received showers. Resident #18 was admitted to the facility on [DATE], discharged on [DATE], and readmitted on [DATE] with diagnoses including Cerebral Infarction, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Gastrostomy Status. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/12/2022-11/30/2022, showed Resident #18 had not received a shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #18 had moderate cognitive impairment, required extensive 1 staff assistance for dressing and personal hygiene, and was totally dependent on staff for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #18 had not received a shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #18 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #18 had not received a shower. Resident #19 was admitted to the facility on [DATE] with diagnoses including Hemiplegia

Based on the review of the facility policy, review of facility documentation, and interview, the facility failed to take action aimed at performance improvement, to measure the success of the intervention, and track performance to ensure improvements after identifying insufficient staffing needs in the facility. The facility failed to identify care needs had not been provided including showers and baths, incontinence care, and cleanliness for 33 dependent residents (#9, #10, #13, #14, #20, #22, #26, #28, #31, #36, #37, #40, #41, #1, #2, #5, #12, #15, #16, #17, #18, #19, #21, #23, #24, #25, #27, #30, #32, #33, #34, #38, and #39) of 64 residents reviewed for care needs. The facility's failure resulted in psychosocial harm to 14 residents (#9, #10, #13, #14, #20, #22, #26, #28, #31, #36, #37, #40, and #41). The findings include: Review of the facility policy, titled Quality Assurance and Performance Improvement (QAPI) Program, revised 2/2020, showed .This facility shall develop, implement, and maintain an ongoing .QAPI Program that is focused on .care and quality of life for our residents .The QAPI plan describes the process for identifying and correcting quality deficiencies .Identifying and prioritizing quality deficiencies .Systematically analyzing underlying causes of systemic quality deficiencies .Developing and implementing corrective action .Monitoring or evaluating the effectiveness of corrective action .and revising as needed . During an interview on 1/10/2023 at 3:38 PM, the former Social Service Director (SSD) stated she had multiple residents complain they had not received a shower.They wanted a shower .I let the nurse know .I know [Resident #25 and Resident #26] has requested a shower .One told me she would like to get her hair washed but can't think of her name .[Resident #26's daughter] has mentioned she didn't feel like they [the residents] were getting showered . The former SSD stated she had notified the Administrator and the DON of Resident #26's daughter and the residents' complaints. During an interview on 1/11/2023 at 10:57 AM, the Nurse Practitioner (NP) stated the residents had complained about not getting showers and she had noticed residents being more unkempt. The NP stated she had notified the Administration of the facility (date of notification was not specified). During an interview on 2/6/2023 at 4:29 AM, Certified Nursing Assistant (CNA) #12 stated the CNAs were unable to complete the scheduled showers and she had reported to the charge nurse when she was unable to provide the showers. During an interview on 2/6/2023 at 5:05 AM, Licensed Practical Nurse (LPN) #4 stated she had noticed a month or so ago, the resident showers were not being completed for 3-4 weeks on the night shift and she reported the concerns to Registered Nurse (RN) #4. During an interview on 2/6/2023 at 5:13 AM, RN #4 stated the showers had not been provided .not enough staff . The RN stated she had reported her concerns to the Director of Nursing (DON) .about a month ago . During an interview on 2/6/2022 at 5:19 AM, LPN #5 stated RN #4 was aware the scheduled showers had not been provided on the night shift .said she knew . LPN #5 stated she had observed Resident #10 and Resident #14 often saturated with urine when she arrived on shift, and she had reported it to RN #4. During an interview on 2/6/2023 at 5:20 AM, Resident #41 revealed .I kept asking for a shower and they [facility staff] said they could not get to me . The resident stated she reported the concern to the shift supervisor (date and supervisor unknown). During an interview on 2/6/2023 at 5:30 AM, Resident #26 stated prior to about 2-3 weeks ago, she had not received the scheduled showers and stated she had complained to the Social Worker (no longer employed at the facility) and the Administrator but was unable to recall the date. During an interview on 2/6/2023 at 8:05 AM, Resident #31 stated she had not received routine showers. The resident stated she had reported to someone at the facility (unsure who) she had not received showers. During an interview on 1/10/2023 at 2:31 PM, CNA #5 stated Resident #31 had not received the scheduled showers. Resident #31 stated night shift had not provided the scheduled showers and it had been reported to the DON (date unknown). During an interview on 2/6/2022 at 9:20 AM, CNA #13 stated residents did not receive the scheduled showers consistently. The DON was made aware (date unknown) residents were not provided showers as scheduled. During an interview on 2/6/2023 at 9:56 AM, Resident #9 stated .I wasn't getting them [showers] before you [surveyors] came. Resident #9 stated he reported to multiple staff at the facility (unable to recall who) he did not receive the showers. During an interview on 2/6/2023 at 10:35 AM, CNA #7 stated multiple residents had complained the showers were not provided and the residents looked unkempt. Resident #9 reported to CNA #7 (unsure of the exact date) he had not received a shower and felt nasty. CNA #7 stated the DON had been made aware multiple residents had complained showers had not been provided. During an interview on 2/6/2023 at 12:00 PM, Resident #36 stated she complained to staff (unable to remember who she spoke with) at the times she had not received the showers. The resident stated staff informed her she received a bed bath which was considered a shower. During an interview on 2/6/2023 at 2:15 PM, Resident #41 stated she had not received the scheduled showers and had reported it to the shift supervisor. During an interview on 2/6/2023 at 2:25 PM, Resident #22 stated .it [showers] was a problem .I reported it to the nurse on my hall . During an interview on 2/7/2023 at 8:11 AM, LPN #8 stated .I don't know if the administration asks about staffing needs . During an interview on 2/7/2023 at 8:42 AM, LPN #9 stated the facility did not have enough staff to care for the residents. Multiple residents had complained the showers were not given, incontinence care was not provided timely, and it had been reported to RN #1. During an interview on 2/7/2023 at 9:28 AM, CNA #15 stated on 2/3/2023 when she arrived on shift, Residents #10 and Resident #32 were saturated with urine and she reported it to LPN #8. During an interview on 2/7/2023 at 9:54 AM, LPN #10 stated the night shift staff often report they were not able to provide the scheduled showers .too busy . and stated the night shift supervisor was aware. During an interview on 2/7/2023 at 10:30 AM, the Minimum Data Set (MDS) Coordinator stated after she had identified the activity of bathing had not occurred during the MDS assessments on several of the residents and she notified the DON. The MDS Coordinator stated she informed the DON the showers had not been documented. During an interview on 2/7/2023 at 1:34 PM, CNA #8 stated when the facility was short staffed .we can't get showers done . The CNA stated she had reported residents not receiving showers to the supervisor (date unknown). During an interview on 2/8/2023 at 9:30 AM, the district Ombudsman stated she had concerns related to multiple residents not receiving scheduled showers. She also stated she had reported the concerns to the Administrator and the DON on 8/4/2022. The Ombudsman also stated she had several follow up conversations and emails with the Administrator and the DON related to the residents bathing schedule concerns. The Ombudsman stated the concerns had not been resolved and was .dismayed to be told by the residents it was still an issue . The Ombudsman provided emailed documentation which showed the concerns were discussed on 10/28/2022, 11/4/2022, and 11/15/2022. During an interview on 2/8/2023 at 1:35 PM, the Medical Director stated the previous administration and the previous DON .made a big deal with corporate that I had harassed the nurses because I had asked for the residents to get the showers .we [facility current QAPI members] had monthly QAPI meetings and discussed showers not being given .night shift should help with the shower burden .the problems have been discussed . The Medical Director stated 2 things happened which attributed to the showers not being provided, and stated it was related to the natural flow of things with the change in administration, and implementation of a system. During an interview on 2/9/2023 at 4:00 PM, the DON stated there was enough staff to meet the needs of the residents due to the number of nurses on each shift and incontinence care should be provided every 3 hours and as needed. She also stated she was not aware of the extent of the problems with showers until about 2 weeks ago when surveyors entered the building on 1/9/2023. The DON further stated she and the Administrator had met with the Ombudsman (did not give an exact date) about concerns related to the showers for Resident #2 and Resident #13. The DON stated it was a lack of shower documentation, she had interviewed the residents (#2 and #13) and .they did not have problems . The DON further stated she had not interviewed additional residents to determine if showers had been provided. She also stated the Medical Director and the NP had not reported a problem or issues with the resident showers .it was never brought up . During an interview on 2/9/2023 at 4:00 PM, the Administrator stated he was not aware the residents had not received the showers as scheduled for weeks or days at a time until .this very moment [2/9/2023] .not aware of the extent of the problems with showers and timely incontinence care . The Administrator stated the residents, nor the staff had reported concerns related to showers or incontinence care. He also stated he and the DON had met with the Ombudsman (did not give an exact date) about her concerns related to the showers for Resident #2 and Resident #13. The Administrator confirmed residents at the facility had not received the showers .like they [residents] wanted .or like they were supposed to .residents should be changed every 2 hours . He also stated the showers needed to be addressed and there was a Performance Improvement Plan (PIP) in place. The Administrator stated the Medical Director and the NP had not reported a problem or issues with the resident showers. Review of the PIP dated 12/2022 showed the facility identified concerns related to the documentation of bathing. Continued review showed the PIP had not identified the actual activities of bathing had not occurred. Refer to tags F-656, F-677, and F-725

Based on facility policy review, medical record review, review of facility grievances, interview, and observation, the facility failed to prevent neglect for 8 dependent residents (#1, #2, #3, #4, #5, #6, #7, and #8) of 10 dependent residents reviewed for abuse. The facility's failure resulted in psychosocial harm for Residents #1, #2, #3, #4, and #6. The facility was cited F-600 at a scope and severity of H, which constitutes Substandard Quality of Care. The findings include: Review of the facility policy titled, Recognizing Signs and Symptoms of Abuse/Neglect, revised 1/2011, showed, .Our facility will not condone any form of resident abuse or neglect .'Neglect' is defined as failure to provide .services necessary to avoid .mental anguish .Signs of Actual .Neglect .Poor hygiene .Inadequate .care . Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, undated, showed .Policy Statement .Residents will be provided with care .to maintain or improve their ability to carry out .(ADLs) .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including .assistance with .elimination (toileting) . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Comprehensive Care Plan dated 4/11/2022, showed .ADL [Activity of Daily Living] Care Plan .TOILET USE .The resident requires assistance by 1 staff for toileting .The resident is on diuretic therapy .At risk for altered bladder elimination related to impaired mobility .Check and change monitor for incontinence . Review of an admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The resident required extensive assistance of 1 person for bed mobility, was totally dependent on 1 person for toilet use, was always incontinent of bladder, and frequently incontinent of bowel. Review of the April 2022 Grievance Log showed Resident #1 had filed a grievance on 4/28/2022 related to nurse staffing and call lights. Review of a Resident Grievance/Complaint form dated 4/28/2022, showed .Resident [Resident #1] states call light wait time was 2 hrs [hours] .nurse came in room .stated CNA [Certified Nursing Assistant] would be in and never came .She initially pressed her call light at 4 [4:00 PM] .She says she wasn't changed until 11pm . During an interview on 5/23/2022 at 11:10 AM, CNA #1 stated she worked the 6AM (6:00 AM)-6PM (6:00PM) day shift. She stated the night shift (6:00 PM-6:00 AM) staff .leave the residents in a mess . The CNA stated there had been multiple times when she arrived and would find multiple residents soaked with urine and required a complete bed linen change. CNA #1 stated approximately 2 weeks ago (exact date unknown), Resident #1 had her call light on, and she responded to the call light. The CNA stated Resident #1 was crying because she had not been assisted by the night shift staff for toileting needs. The resident was .soaked with urine . and required a full bed linen change. During an interview on 5/23/2022 at 11:23 AM, CNA #2 stated she worked day shift on the 100-hall where Resident #1 resided at the facility. She stated she cared for Resident #1 and was present when the resident became upset a couple of weeks ago (exact date unknown). CNA #2 had assisted CNA #1 with Resident #1, and Resident #1 was crying and stated her toileting needs had not been met on the night shift. Resident #1 was soaked with urine and had to have a complete bed linen change. Resident #1 was alert and oriented and able to make her needs known to staff. The CNA stated Resident #1 had urinated on herself because night shift staff could not answer the resident's call light timely. CNA #2 stated night shift staff had not been answering call lights timely, not assisting continent (able to control bladder and bowel) residents to the bathroom, and not changing the incontinent residents timely. CNA #2 stated she was responsible for 34 residents at times on her day shift. On the days she was responsible for 34 residents, CNA #2 was unable to meet all the resident needs and Resident #1 had urinated on herself because she (CNA #2) had not answered the resident's call light timely (on day shift, exact date unknown). During a telephone interview on 5/23/2022 at 3:17 PM, Resident #1 stated she had been a resident at the facility, had multiple fractures, was non-weight bearing on the left side, and received therapy services. The resident stated she was discharged from the facility on 5/17/2022 to her home. Resident #1 stated the facility had call lights in the rooms for residents to use when they needed assistance. She stated nurses and CNAs were supposed to respond to the residents' needs, but she had to wait 1 to 1 1/2 hours before staff would respond to her call light on night shift. She stated the facility had 1 CNA on night shift to care for the residents and she had to lay in her .own waste [urine and feces] . on night shift multiple times (exact dates unknown). She stated most of the nurses on night shift would not help the CNAs, .problem is the nurses want to sit around and the CNAs are over worked . The resident stated she made the Director of Nursing (DON) aware of her concerns and the DON informed the resident the facility was shorthanded and couldn't get anyone to work. She stated there were normally 2 CNAs on day shift. Resident #1 had problems with staff responding to her call light timely on day shift, depending on who was working, and she had been left in urine multiple times. Resident #1 stated .you can only hold your urine and bowels for so long when you are told you have to wait your turn. Lying in my pee and poop is definitely something I had never done before and don't want to experience it again. It made me cry and I felt totally degraded . During an interview on 5/23/2022 at 9:10 PM, Licensed Practical Nurse (LPN) #1 stated she was familiar with Resident #1 and had cared for the resident routinely. The LPN stated the resident was continent of her bowel and bladder. Resident #1 had complained about her call light not being answered timely and she had to urinate and have a BM (bowel movement) on herself because staff had not responded timely to assist her with her toileting needs (exact date unknown). During an interview on 5/24/2022 at 9:56 AM, the Social Services Director stated Resident #1 had made a grievance (exact date unknown) regarding her call light not being answered timely and had to wait for an hour. Staff came in and said they would be back, staff did not come back to assist the resident, and it took several hours for the resident to get help. The Social Services Director reported the grievance to the DON on 4/28/2022. During an interview on 5/24/2022 at 10:36 AM, CNA #4 stated she worked day shift on the 100-hallway. She stated multiple residents had complained of having to lay in urine for hours at a time on night shift. CNA #4 was unable to name the residents .they come and go on the rehabilitation floor . but did recall Resident #1 complained staff would not answer her call light timely and provide toileting needs on night shift. CNA #4 stated she had arrived on shift multiple times and observed multiple residents on the 100-hallway saturated with urine and had to do a complete bed linen change because the linens were saturated. The CNA stated she reported the concerns to the DON (exact date unknown). During an interview on 5/24/2022 at 6:48 PM, CNA #10 stated he worked night shift on the 100-hallway. The CNA stated he had worked as the only CNA a hand full of times recently (exact dates unknown). He stated he witnessed residents saturated with urine and the residents required a complete bed linen change when he arrived on his shift. CNA #10 stated he cared for Resident #1 routinely, as the only CNA present in the facility on night shift. Resident #1 urinated on herself a couple of times because he was unable to answer her call light timely. During a telephone interview on 5/25/2022 at 10:28 AM, Registered Nurse (RN) #5 stated she worked day shift. She stated CNA staff reported multiple residents on multiple days (exact dates unknown) were observed saturated with urine. RN #5 had witnessed multiple residents saturated with urine and an odor that required a complete bed linen change. She stated CNA #2 reported a concern when Resident #1 (exact date unknown) was saturated with urine when she arrived on first shift. The DON was made aware of Resident #1's concerns. RN #5 stated night shift had been staffed with only 1 CNA multiple times recently and the residents had not received adequate care when only 1 CNA worked the shift. During an interview on 5/25/2022 at 10:48 AM, the Licensed Clinical Social Worker (Talk Therapist) stated multiple residents had complained during therapy sessions of inadequate care. Resident #1 informed the Talk Therapist she would turn her call light on, there would be no response from staff for hours, it happened multiple times, and the resident had to lay in urine and feces on night shift. The Talk Therapist stated it made Resident #1 feel inhuman, she felt degraded, and it caused her mental distress and psychosocial harm. During an interview on 5/25/2022 at 11:45 AM, the Nurse Practitioner (NP) stated Resident #1 had informed her the resident would use her call bell for assistance, the staff would either not answer the call bell for hours, or come in, turn the light off, say they would return, and staff would not return to assist the resident. The NP stated the resident required assistance with toileting needs. Resident #1 informed the NP she had to lay in a urine saturated brief, and sometimes feces, for hours before staff assisted her with toileting needs. The NP stated it happened more on the night shift but had happened on day shift as well. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Comprehensive Care Plan showed .bladder/bowel incontinence r/t [related to] impaired mobility . Further review showed .Check q [every] 2 hours and prn [as needed] as required for incontinence .revision .11/11/2021 . Review of a quarterly MDS assessment dated [DATE] showed Resident #2 had a BIMS score of 15, indicating the resident was cognitively intact. The resident required extensive assistance of 2 persons for bed mobility, extensive assistance of 1 person for toilet use, was occasionally incontinent of urine, and was frequently incontinent of bowel. During an interview on 5/23/2022 at 1:05 PM, Resident #2 stated night shift was not good, and the staff complained of being short staffed. The resident stated when she pushed her call light for assistance with the bedpan, she had to wait a long time for her call light to be answered .It happens on both shifts but worse on night shift. Six PM to midnight is bad and waited up to 2 hours for assistance .at times the CNAs will come in, turn the call light off, say they will come back, and do not return for several hours . Resident #2 stated she required a bedpan for urinating and having a BM (bowel movement) at times, and she was not always aware when her bowels moved. The resident stated she had been saturated with urine and feces on both shifts because staff had not answered her call light timely. The resident stated, .I hold it as long as I can. It makes me feel horrible, not human, and it is degrading to lay in urine and poop because I'm not receiving the care I need . During an observation on 5/23/2022 at 8:07 PM, the following staff were observed on night shift: RN #1, RN #2, LPN #1, LPN #2, and CNA #3. All staff were at the nurse's station and 12 call lights were observed sounding. CNA #3 immediately went to the 100 hallway and the 2 RNs and 2 LPNs remained at the nursing station eating until 8:35 PM. During an observation on 5/23/2022 at 8:07 PM, Resident #2's call light was sounding. During an observation and interview on 5/23/2022 at 8:17 PM, the call light to Resident #2's room was still sounding from when it was observed at 8:07 PM. Resident #2 stated her roommate, Resident #7, had called for assistance at 6:15 PM and staff had not responded to the call light. Resident #2 stated she needed assistance with the bedpan. During an interview on 5/23/2022 at 8:40 PM, Resident #2 stated RN #1 responded to her call light around 8:35 PM (1 hour and 20 minutes after the resident's roommate pressed the call light at 6:15 PM on 5/23/2022). The RN turned the call light off, informed the resident the facility was short staffed with only 1 CNA on the shift, and the CNA would get to her as soon as possible. Resident #2 stated, .why could the nurse not put me on the bed pan . During an interview on 5/23/2022 at 10:00 PM, Resident #2 stated RN #1 assisted her with toileting needs at 9:00 PM (2 hours and 45 minutes later), and the resident had urinated on herself. The resident stated she was very upset about having to urinate on herself. During an interview on 5/23/2022 at 10:08 PM, Licensed Practical Nurse (LPN) #2 stated Resident #2 had complained of laying in urine and feces for hours (exact dates unknown). LPN #2 stated she had observed multiple residents soaked in urine and feces in the past 3 months, .the residents are not cared for . During an interview on 5/24/2022 at 12:43 PM, CNA #8 stated she worked day shift on the 200-hallway. She stated she had multiple observations and multiple days of residents for the past couple of months (exact dates unknown) on the 200-hallway saturated with urine and/or feces which required a full bed linen change. She stated multiple alert residents had informed her night shift staff would not answer the call lights timely. The CNA stated it would take up to 2 hours for the staff to respond. The staff would turn the call light off, inform the residents they would return, and the residents would fall asleep waiting for assistance. The residents would wake up saturated with urine and sometimes feces. She also stated Resident #2 had incontinence of her bowels at times but would hold her urine as long as she could, and the resident would urinate on herself if the call light was not answered timely. She stated Resident #2 informed her .she feels dirty when she pees on herself . CNA #8 reported Resident #2's concerns and the CNAs concerns to several nurses and the DON (exact dates unknown). During an interview on 5/26/2022 at 3:16 PM, the Assistant Director of Nursing (ADON) stated he was made aware of concerns with multiple residents being left saturated in urine for hours. He stated staff had him do observations on several of the residents and he observed multiple residents in bed saturated with urine and requiring a full bed linen change (exact dates unknown). The ADON stated he did not think the residents had received the proper care needed for the past couple of months. He stated Resident #2 had complained of her call light not being answered timely when she needed the bedpan and the resident had urinated on herself. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Comprehensive Care Plan dated 4/19/2022, showed .has an ADL self-care performance deficit r/t Fall .fracture of distal end of right femur . Further review showed .TOILET USE .incontinent and wears briefs. Check and change prn .uses the bedpan for bowel movements .Encourage the resident to use call bell for assistance .Date Initiated 04/20/2022 . Review of an admission MDS assessment dated [DATE], showed Resident #3 had a BIMS score of 15, indicating the resident was cognitively intact. The resident was total dependence of 2 persons for bed mobility, total dependence of 1 person for toilet use, occasionally incontinent of urine, and always incontinent of bowel. During an interview on 5/23/2022 at 11:23 AM, CNA #2 stated Resident #3 complained .not long ago . of night shift not answering her call light (exact date unknown). CNA #2 stated the resident told her the call light was on for hours and the staff had not changed her soiled brief. CNA #2 arrived on dayshift and observed Resident #3 saturated with urine and reported it to RN #5 (exact date unknown). During an interview on 5/23/2022 at 12:00 PM, Resident #3 stated she was non-weight bearing and required assistance with toileting needs. The resident stated the night shift staff did not respond to her call light timely to be assisted with the bedpan. The resident stated .peed and pooped . on herself multiple times (exact dates unknown). The last time was on 5/22/2022 night shift. Resident #3 stated .there is not enough help at night to help us . Night shift is short staffed a lot of times with 1 CNA to care for all the residents. She stated when the staff did assist her with the bedpan, they left the room, waited for her to call for assistance to be removed from the bedpan, and she was left on the bedpan for a .long time . because staff do not respond to the call light. Resident #3 stated .pooped and peed .on myself it did not make me feel too good about myself . During an interview on 5/24/2022 at 4:50 PM, CNA #9 stated she worked day shift on the 100-hallway. She stated Resident #3 was incontinent of urine but could alert staff when her brief needed to be changed. CNA #9 stated she witnessed the resident soaked in urine on multiple occasions and had to change Resident #3's bed linens. During an interview on 5/25/2022 at 3:37 PM, RN #6 stated she worked day shift on the 100-hallway. She stated she has had complaints from day shift CNAs of multiple residents left saturated with urine when they arrived on shift at 6 AM. She stated she observed Resident #3 saturated with urine and required a full bed linen change (exact date unknown). The RN also stated she observed multiple other residents soaked with urine and reported the concerns to the DON. RN #6 stated night shift had worked with only 1 CNA multiple times. The residents were soaked with urine when only 1 CNA worked alone in the facility, and it would be impossible to meet the care needs of the residents with only 1 CNA on night shift. Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Comprehensive Care Plan dated 2/10/2022, showed .resident has bladder/bowel incontinence r/t impaired mobility r/t .[CONDITION(S)] [Cerebral Vascular Accident] .[CONDITION(S)] .INCONTINENT .Check .Q [every] 2 [hours] and prn required for incontinence . Review of a quarterly MDS assessment dated [DATE], showed Resident #4 had a BIMS score of 15, indicating the resident was cognitively intact. The resident required extensive assistance of 1 person for bed mobility and toilet use and was always incontinent of urine and bowel. During an interview on 5/23/2022 at 2:10 PM, Resident #4 stated staff on both shifts did not respond to her call light, but it was worse on night shift. She stated she was supposed to be changed (brief changed) every 2 hours and has had to wait up to 4 to 6 hours to be changed. The resident stated night shift would answer her call light, turn the light off, say they would return, and then did not return to the room. The resident stated when she would wake up, day shift was on duty, and she had gone all night without assistance (brief changed). Resident #4 stated she had to wear briefs because she has had 2 strokes and had minimum movement in her hips and legs. She stated she had informed the head nurse on day shift with brown hair and wears glasses about her concerns. The resident stated .it is hard enough to have to have someone care for me and when I don't get the care I need, it is very upsetting. When I am left in urine and poop for hours, I don't feel human . During an interview on 5/23/2022 at 10:08 PM, LPN #2 stated Resident #4 complained of laying in urine and feces for hours (exact dates unknown). During an interview on 5/24/2022 at 12:11 PM, CNA #7 stated she worked day shift on the 200-hallway. She stated the facility .had a big problem . She stated night shift CNAs would come in late or never show up at all. Nurses sat at the desk, except for LPN #4. LPN #4 helped the CNAs, but the other nurses did not help answer call lights or assist with resident care needs. She stated Resident #4 was saturated with urine this morning from the middle of her back to below her knees. The resident informed CNA #7 she had been checked and changed one time last night on 5/23/2022 because there had been only 1 CNA on the shift. She stated the night shift had worked with only 1 CNA multiple times recently and CNA #7 had observed residents saturated with urine and/or feces and requiring a complete bed linen change. During an interview on 5/25/2022 at 10:48 AM, the Licensed Clinical Social Worker (Talk Therapist) stated Resident #4 was very distressed last week. She stated the resident was very frustrated and angry, and the resident stated she could get better care at home. She stated the resident laid for several hours in urine and feces because her call light had not been answered timely on night shift. The Talk Therapist stated the incident caused Resident #4 mental distress. She reported the incident to the charge nurse, the DON, and the ADON. During an interview on 5/25/2022 at 11:45 AM, the NP stated Resident #4 had complained staff did not answer her call light timely (exact date unknown), and she would lay for long periods of time in a urine-soaked brief before she received assistance from staff. Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission/Readmission Nursing Evaluation dated 5/19/2022, showed the resident was always continent of urine. Review of a Speech Language Pathologist (SLP) Screen/MDS Worksheet undated, showed Resident #5 had a BIMS of 13, indicating the resident was cognitively intact. Resident #5's 5-Day MDS assessment was in progress and had not been completed. Review of Resident #5's Interim Care Plan dated 5/23/2022, showed .broken left hip and broken left wrist .Be sure .resident's call light is within reach and encourage the resident to use it .The resident needs prompt response to all requests for assistance . During an interview on 5/24/2022 at 9:20 AM, Resident #5 stated she was a new resident at the facility (admitted [DATE]). She stated she was continent of bladder and bowel, and she had not received toileting needs at the facility. She stated staff did not answer her call light timely on both shifts, but especially at night. Resident #5 stated the staff came in her room, turned the call light off, say they will return, and then did not return for hours. The resident stated she used her call light at 7:15 PM on 5/23/2022, for toileting assistance. Someone came in, (staff member unknown), turned her call light off, and informed her there was only 1 CNA working and the CNA would get to her as soon as they could. Resident #5 stated she did not receive toileting needs until approximately 10:00 PM (2 hours and 45 mins later). The resident stated she needed assistance with the bedpan, did not receive assistance timely, and she urinated on herself. She stated since her admission to the facility on [DATE], she had urinated on herself 3-4 times because staff had not responded to her call light timely. Resident #5 stated there had been 1 time a staff member told her to use her diaper and they would clean her up (exact date and staff member unknown). The resident stated, .it didn't make me feel good to sit in my own urine for a long time . During an interview on 5/24/2022 at 4:50 PM, CNA #9 stated Resident #5 was a new resident at the facility, was continent of her urine and bowels, and the resident requested a bedpan for her toileting needs. CNA #9 stated she had observed multiple residents soaked in urine multiple times after she arrived on her shift, and it happened a lot (exact dates unknown). Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Comprehensive Care Plan dated 4/22/2022, showed .Incontinence Care Plan .At risk for altered bladder/bowel elimination related to [CONDITION(S)] .Check and Change monitor for incontinence .Provide pericare after each episode of incontinence . Review of an admission MDS assessment dated [DATE], showed Resident #6 had a BIMS score of 12, indicating the resident had moderate cognitive impairment. The resident was total dependence of 1 person for bed mobility and toilet use and was always incontinent of urine and bowel. During an observation and interview on 5/24/2022 at 4:33 PM, Resident #6 yelled out for someone to help him. The resident stated he needed to be changed. He stated he had his call light on for a long time and staff turned off the call light. He informed the staff he needed to be changed and he was informed a CNA would be with him shortly. Resident #6 stated he had been laying in a urine-soaked brief for over 2 hours. CNA #4 and CNA #9 then entered the room to provide care and the resident's brief and under pad was soaked with urine with a strong urine odor present. Resident #6 stated he had not been checked or changed since 10:00 AM on 5/24/2022. During an interview on 5/24/2022 at 4:45 PM, CNA #4 confirmed Resident #4 had not been changed since 10:00 AM (the resident's brief was changed 6 hours and 33 minutes later at 4:33 PM) and stated, .it has been hectic today . During an interview on 5/24/2022 at 5:32 PM, Resident #6 stated he had been at the facility for about 2 weeks. He was incontinent of urine and bowel and had been for some time. He stated since his admission to the facility, he had been left laying a lot of times in a wet brief for long periods of time. He was unable to recall the exact dates and times of each episode. Resident #6 yelled .I don't like laying in my pee During an interview on 5/25/2022 at 11:45 AM, the NP stated Resident #6 had complained staff had not answered his call light timely (exact date unknown). He would lay for long periods of time in a brief soaked in urine and/or feces before he received assistance from the staff. The NP stated she had multiple other residents complain at the facility as well, and she made the nurses and DON aware of the residents' complaints (exact dates unknown). Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Comprehensive Care Plan dated 4/21/2022, showed .has an ADL self-care performance deficit r/t Bilateral AKA [Above the Knee Amputation] .TOILET USE .The resident requires assistance by 1 staff for toileting .Encourage the resident to use bell to call for assistance . Review of an admission MDS assessment dated [DATE], showed Resident #7 had a BIMS score of 15, indicating the resident was cognitively intact. The resident required limited assistance of 1 person for bed mobility and toilet use, was always continent of urine, and was occasionally incontinent of bowel. During an observation on 5/23/2022 at 8:07 PM, the following staff were observed working on night shift: RN #1, RN #2, LPN #1, LPN #2, and CNA #3. All staff were at the nurse's station and 12 call lights were observed sounding. CNA #3 immediately went to the 100 hallway and the 2 RNs and 2 LPNs remained at the nursing station eating until 8:35 PM. During an observation on 5/23/2022 at 8:07 PM, Resident #7's call light was sounding. During an observation and interview on 5/23/2022 at 8:17 PM, Resident #7's call light was still sounding (since 8:07 PM). The resident stated she needed assistance with incontinence care. During an observation and interview on 5/23/2022 at 8:25 PM, Resident #7 stated she had pushed her call light for assistance around 6:00 PM and staff had not responded yet. The resident stated she had a BM, was wet with urine, and needed her .diaper [incontinent brief] . changed. The call light remained sounding at 8:25 PM (first observed at 8:07 PM). During an interview on 5/23/2022 at 10:05 PM, Resident #7 stated she called for assistance for incontinence care around 6:00 PM and was not changed until approximately 9:15 PM (3 hours and 15 minutes after requesting assistance). She stated, .I don't like sitting in my pee and poop . Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's Interim Care Plan dated 5/20/2022, showed .Poor Balance .Unsteady Gait .call light .is within reach and encourage the resident to use it for assistance .resident needs prompt response to all requests for assistance . Review of a SLP Screen/MDS Worksheet undated, showed Resident #8 had a BIMS of 13, indicating the resident was cognitively intact. Resident #8's 5-Day MDS assessment was in progress and had not been completed. During an observation and interview on 5/23/2022 at 8:46 PM, Resident #8 stated her call light had been on for a long time. She had a BM and could not get assistance from the staff. Resident #8's room had a foul odor of feces upon entrance into the room. During an observation with the DON on 5/23/2022 at 9:00 PM, Resident #8, whose call light was initially observed sounding at 8:07 PM, was observed to have a brief in place with a large amount of loose feces. The brief was saturated, and the feces was dried around the edges of the resident's buttocks. During an interview on 5/23/2022 at 9:41 PM, CNA #3 stated she usually worked night shift. She stated multiple residents had complained to her in the past (exact dates unknown) of not being .changed timely . and had to sit in urine and feces because the call light had not been answered timely. She stated, .not good with names . and don't remember all of them (residents who complained). CNA #3 stated she had observed multiple residents wet at different times with urine from day shift when she arrived on shift at 6 PM (exact dates unknown). She stated in a 12-hour shift, if the facility was staffed with 3 CNAs on night shift, 3 dry rounds (check and provide residents with incontinence care and turn and reposition residents every 2 hours) could be completed to ensure residents were clean and dry. CNA #3 stated staff were unable to complete an adequate number of dry rounds when only 1 CNA worked the night shift and staff were unable to meet the residents' needs. The CNA stated she had not been able to complete a full dry round on 5/23/2022 as of 9:41 PM because there was only 1 CNA to care for 78 residents in the facility. During an interview on 5/23/2022 at 10:40 PM, RN #2 stated she worked night shift. She stated she had multiple residents complain day shift staff had not answered the

Based on facility policy review, medical record review, interview, and observation, the facility failed to promote care that maintained residents' dignity by not providing timely assistance with toileting needs for 8 dependent residents (#1, #2, #3, #4, #5, #6, #7, and #8) of 10 dependent residents reviewed. The facility's failure resulted in psychosocial harm for Residents #1, #2, #3, #4, and #6. The facility was cited F-550 at a scope and severity of H, which constitutes Substandard Quality of Care. The findings include: Review of the facility policy titled, Dignity revised 2/2021, showed, .Each resident shall be cared for in a manner that promotes and enhances his or her sense .of self-worth and self-esteem .Residents are treated with dignity .at all times .Demeaning practices and standards of care that compromise dignity are prohibited .Staff are expected to promote dignity and assist residents .promptly .for toileting assistance . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #1 required extensive assistance of 1 person for bed mobility, was totally dependent on 1 person for toilet use, was always incontinent of urine, and was frequently incontinent of bowel. During an interview on 5/23/2022 at 11:10 AM, Certified Nursing Assistant (CNA) #1 stated she worked the 6AM (6:00 AM)-6PM (6:00 PM) dayshift. She stated the night shift (6PM-6AM shift) staff .leave the residents in a mess . The CNA stated there had been multiple times when she arrived and would find multiple residents soaked with urine, requiring a complete bed linen change. CNA #1 stated approximately 2 weeks ago (exact date unknown), Resident #1 had her call light on, and she responded to the call light. The CNA stated Resident #1 was crying because she had not been assisted by the night staff for toileting needs. The resident was .soaked with urine . and required a full bed linen change because of the large amount of saturation of urine on the linens. During an interview on 5/23/2022 at 11:23 AM, CNA #2 stated she worked day shift on the 100-hallway where Resident #1 resided in the facility. She stated she cared for Resident #1 and was present when the resident became upset a couple of weeks ago (exact date unknown). CNA #2 had assisted CNA #1 with Resident #1, and the resident was crying and stated her toileting needs had not been met on the night shift. The CNA stated Resident #1 was soaked with urine and had to have a complete bed linen change. Resident #1 was alert and oriented and able to make her needs known to staff. The CNA stated Resident #1 had urinated on herself because night shift staff could not answer the resident's call light timely. CNA #2 stated night shift staff had not been assisting continent (able to control bladder and bowel) residents to the bathroom and not changing the incontinent residents timely. During a telephone interview on 5/23/2022 at 3:17 PM, Resident #1 stated she had been a resident at the facility, had multiple fractures, was non-weight bearing on the left side, and received therapy services. The resident stated nurses were supposed to respond to the residents' needs, but she had to wait 1 to 1 1/2 hours before staff would respond to her requests on night shift. The resident stated she had to lay in her .own waste [urine and feces (stool)] . on night shift multiple times. Resident #1 stated she had problems with the staff responding to her timely on day shift and she had been left in urine multiple times on day shift as well. Resident #1 stated .you can only hold your urine and bowels for so long when you are told you have to wait your turn. Lying in my pee and poop is definitely something I had never done before and don't want to experience it again. It made me cry and I felt totally degraded . During an interview on 5/24/2022 at 6:48 PM, CNA #10 stated he worked night shift on the 100-hallway. CNA #10 stated he cared for Resident #1 routinely. He stated on days when he was the only CNA present in the facility on night shift, he could not respond to Resident #1's call light timely, and the resident had to urinate on herself a couple of times (exact dates unknown). During an interview on 5/25/2022 at 10:48 AM, the Licensed Clinical Social Worker (Talk Therapist) stated multiple residents had complained during therapy sessions of inadequate care. She stated Resident #1 informed the Talk Therapist she would turn her call light on with no response from staff for hours multiple times, and the resident had to lay in urine and feces on night shift. The Talk Therapist stated it made Resident #1 feel inhuman, degraded, and it caused Resident #1 mental distress and psychosocial harm. During an interview on 5/25/2022 at 11:45 AM, the Nurse Practitioner (NP) stated Resident #1 informed the NP she had to lay in a urine saturated brief, and sometimes feces, for hours before staff assisted her with toileting needs. The NP stated the resident informed her it happened more on the night shift but had happened on day shift as well. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS assessment dated [DATE], showed Resident #2 had a BIMS score of 15, indicating the resident was cognitively intact. The resident required extensive assistance of 2 persons for bed mobility, extensive assistance of 1 person for toilet use, was occasionally incontinent of urine, and was frequently incontinent of bowel. During an interview on 5/23/2022 at 1:05 PM, Resident #2 stated night shift was not good, and the staff complained of being short staffed. The resident stated when she pushed her call light for assistance with the bedpan, she had to wait a long time for her call light to be answered. Resident #2 stated .it happens on both shifts but worse on night shift. Six PM to midnight is bad and waited up to 2 hours for assistance .at times the CNAs will come in, turn the call light off, say they will come back, and they do not return for several hours . The resident stated she had been saturated with urine and feces on both shifts because staff had not answered her call light timely. The resident stated, .I hold it as long as I can. It makes me feel horrible, not human, and it is degrading to lay in urine and poop because I'm not receiving the care I need . During an interview on 5/23/2022 at 10:08 PM, Licensed Practical Nurse (LPN) #2 stated Resident #2 had complained of laying in urine and feces for hours (exact dates unknown). LPN #2 stated she had observed multiple residents soaked in urine and feces in the past 3 months. During an interview on 5/24/2022 at 12:43 PM, CNA #8 stated she worked day shift on the 200-hallway. She stated Resident #2 informed CNA #8 .she [Resident #2] feels dirty when she pees on herself . During an interview on 5/26/2022 at 3:16 PM, the Assistant Director of Nursing (ADON) stated he was made aware of concerns of multiple residents left saturated in urine for hours. He stated Resident #2 had complained of her call light not being answered timely when she needed the bedpan and the resident urinated on herself. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS assessment dated [DATE], showed Resident #3 had a BIMS score of 15, indicating the resident was cognitively intact. The resident required total dependence of 2 persons for bed mobility, total dependence of 1 person for toilet use, was occasionally incontinent of urine, and was always incontinent of bowel. During an interview on 5/23/2022 at 12:00 PM, Resident #3 stated she was non-weight bearing and required assistance with toileting needs. The resident stated the night shift staff did not respond to her call light timely to be assisted with the bedpan. The resident stated .peed and pooped . on herself multiple times (exact dates unknown) and the last time was on 5/22/2022 (night shift). Resident #3 stated when she .pooped and peed .it did not make me feel good about myself . During an interview on 5/24/2022 at 4:50 PM, CNA #9 stated she worked day shift on the 100-hallway. She stated she observed Resident #3 soaked in urine on multiple occasions (exact dates unknown) and had to change bed linens due to saturation. Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS assessment dated [DATE] showed Resident #4 had a BIMS score of 15, indicating the resident was cognitively intact. The resident required extensive assistance of 1 person for bed mobility and toilet use and was always incontinent of urine and bowel. During an interview on 5/23/2022 at 2:10 PM, Resident #4 stated staff on both shifts do not respond to her call light, but it was worse on night shift. She stated she was supposed to be changed (brief changed) every 2 hours and has had to wait up to 4 to 6 hours to be changed. The resident stated night shift would answer her call light, turn the light off, say they would return, and then did not return to the room. The resident stated when she would wake up, day shift was on duty, and she had gone all night without assistance (brief changed). Resident #4 stated she would be saturated with urine, sometimes feces, and it had happened multiple times recently (exact dates unknown). Resident #4 stated, .it is hard enough to have to have someone care for me and when I don't get the care I need, it is very upsetting. When I am left in urine and poop for hours, I don't feel human . During an interview on 5/23/2022 at 10:08 PM, LPN #2 stated Resident #4 had complained of laying in urine and feces for hours (exact dates unknown). During an interview on 5/24/2022 at 12:11 PM, CNA #7 stated she worked day shift on the 200-hallway. She stated the facility .had a big problem . The CNA stated she had observed residents saturated with urine and/or feces who required a complete bed linen change. She stated Resident #4 was saturated with urine this morning from the middle of her back to below her knees. The resident informed CNA #7 she had been checked and changed 1 time last night on 5/23/2022. During an interview on 5/25/2022 at 10:48 AM, the Licensed Clinical Social Worker (Talk Therapist) stated Resident #4 was very distressed last week. She stated the resident was very frustrated, angry, and the resident stated she could get better care at home. The Talk Therapist stated the resident informed her she laid for several hours in urine and feces because her call light had not been answered timely on night shift. The Talk Therapist stated the incident caused Resident #4 mental distress. During an interview on 5/25/2022 at 11:45 AM, the Nurse Practitioner (NP) stated Resident #4 had complained staff did not answer her call light timely (exact shift unknown), and she would lay for long periods of time in a urine-soaked brief before getting assistance. Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission/Readmission Nursing Evaluation dated 5/19/2022, showed the resident was always continent of urine. Review of a Speech Language Pathologist (SLP) Screen/MDS Worksheet undated, showed Resident #5 had a BIMS of 13, indicating the resident was cognitively intact. Resident #5's 5-Day MDS assessment was in progress and had not been completed. During an interview on 5/24/2022 at 9:20 AM, Resident #5 stated she was a new resident at the facility (admitted [DATE]). She stated she was continent of bladder and bowel, and she had not received toileting needs at the facility. She stated staff did not answer her call light timely on both shifts, but especially at night. Resident #5 stated the staff came in her room, turned the call light off, say they will return, and did not return for hours. The resident stated she used her call light at 7:15 PM on 5/23/2022, for toileting assistance. Someone came in (staff member unknown), turned her call light off, informed the resident there was only 1 CNA working, and the CNA would get to her as soon as they could. Resident #5 stated she did not receive toileting needs until approximately 10:00 PM (2 hours and 45 mins later). The resident stated she needed assistance with the bedpan and had to urinate on herself because she did not receive assistance timely. She also stated since her admission to the facility on [DATE], she had urinated on herself 3-4 times because staff had not responded to her call light timely. Resident #5 stated there had been 1 time a staff member told her to use her diaper and they would clean her up (exact date and staff member unknown). The resident stated, .it didn't make me feel good to sit in my own urine for a long time . Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS assessment dated [DATE], showed Resident #6 had a BIMS score of 12, indicating the resident had moderate cognitive impairment. The resident was total dependence of 1 person for bed mobility and toilet use, and always incontinent of urine and bowel. During an observation and interview on 5/24/2022 at 4:33 PM, Resident #6 yelled out for someone to help him. The resident stated he needed to be .changed . He stated he had his call light on for a long time, staff turned it off, the resident informed the staff he needed to be changed, and he was informed a CNA would be with him shortly. Resident #6 stated he had been laying in a urine-soaked brief for over 2 hours. The resident appeared upset and frustrated. CNA #4 and CNA #9 entered the room to provide assistance, and the resident's brief and under pad were soaked with urine with a strong urine odor present. Resident #6 stated he had not been checked or changed since 10:00 AM on 5/24/2022. During an interview on 5/24/2022 at 4:45 PM, CNA #4 confirmed Resident #6 had not been changed since 10:00 AM (the resident's brief was changed at 4:33 PM, 6 hours and 33 minutes later). During an interview on 5/24/2022 at 5:32 PM, Resident #6 stated he had been at the facility for about 2 weeks and was incontinent of urine and bowel prior to admission to the facility. He stated since his admission to the facility he had been left laying multiple times in a wet brief for long periods of time (exact dates unknown). Resident #6 stated .I don't like laying in my pee . During an interview on 5/25/2022 at 11:45 AM, the NP stated Resident #6 had complained of staff not answering his call light timely (exact shift unknown), and he would lay for long periods of time in a brief soaked in urine and/or feces before he received assistance. Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS assessment dated [DATE], showed Resident #7 had a BIMS score of 15, indicating the resident was cognitively intact. The resident required limited assistance of 1 person for bed mobility and toilet use, was always continent of urine, and was occasionally incontinent of bowel. During an interview on 5/23/2022 at 10:05 PM, Resident #7 stated she had her .diaper . changed around 9:15 PM (5/23/2022), after she initially called for assistance with incontinence care around 6:00 PM. She stated, .I don't like sitting in my pee and poop . Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission/Readmission Nursing Evaluation dated 5/19/2022, showed the resident was occasionally incontinent of urine, frequently incontinent of bowel, and was alert to person, place, and time. Review of a SLP Screen/MDS Worksheet undated, showed Resident #8 had a BIMS of 13, indicating the resident was cognitively intact. Resident #8's 5-Day MDS assessment was in progress and had not been completed. During an observation and interview on 5/23/2022 at 8:46 PM, Resident #8 stated her call light had been on for a long time. She had a BM (bowel movement) and could not get assistance from the staff. Resident #8's room had a foul odor of feces upon entrance into the room. During an interview on 5/24/2022 at 6:36 PM, LPN #4 stated she worked day shift on the 200-hallway. She stated she had witnessed multiple residents laying in urine for long periods of time and the residents required a complete bed linen change on her shift due to saturated linen. During an interview on 6/1/2022 at 9:40 AM, the NP confirmed residents at the facility were not treated with dignity and respect when their toileting needs were not met. During an interview on 6/1/2022 at 9:55 AM, the ADON confirmed the residents had not been treated with dignity and respect if the residents felt inhuman, degraded, and horrible because they had to lay in urine and/or feces for hours. During an interview on 6/1/2022 at 10:20 AM, the Talk Therapist confirmed when the residents laid in urine and/or feces for hours, they had not been treated with dignity and respect. During a telephone interview on 6/1/2022 at 11:30 AM, the Medical Director confirmed residents at the facility were not treated with dignity and respect. The Medical Director confirmed the facility's dignity policy was not followed.

Based on facility policy review, review of the facility's Centers for Medicare and Medicaid Services CMS-672 Resident Census And Conditions of Residents form, review of the facility assessment tool, medical record review, interview, observation, and review of staffing schedules and time punches, the facility failed to ensure sufficient nurse staffing to provide toileting needs to 8 dependent residents (#1, #2, #3, #4, #5, #6, #7, and #8) of 10 dependent residents reviewed for toileting needs. The facility's failure resulted in psychosocial harm for Residents #1, #2, #3, #4, and #6. The findings include: Review of the facility policy titled, Staffing, revised 10/2017, showed, .facility provides sufficient numbers of staff .to provide care and services for all residents in accordance with .the facility assessment .Staffing numbers .are determined by the needs of the residents . Review of the facility's document titled, CMS-672 Resident Census and Conditions of Residents dated 5/23/2022, showed the facility had a census of 78 residents, 40 residents with occasional or frequent incontinence of bladder, and 27 residents with occasional or frequent incontinence of bowel. Three residents were independent with toilet use, 48 required assistance of one or two staff for toilet use, and 27 were dependent for toilet use. Review of the Facility Assessment Tool dated 11/2021 showed .Resident Level of Independence to Dependence .Toileting .Independent .7% .Assist of 1-2 .79% .Dependent .14% .Staffing Plan .Direct care staffing needs .are evaluated prior to or at the beginning of each shift and adjusted as needed to meet the care needs and acuity of the resident population .Position .CNA [Certified Nursing Assistant] .Daily Hrs [hours] .106.00 . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. During an interview on 5/23/2022 at 11:23 AM, CNA #2 stated she worked the 6 AM (6:00 AM)-6 PM (6:00 PM) dayshift on the 100-hallway where Resident #1 resided while at the facility. Resident #1 had complained a couple of weeks ago night shift (6:00 PM-6:00 AM) staff had not answered her call light timely (unsure of the exact date). The resident stated her call light was on for hours and the staff had not changed her soiled brief. CNA #2 arrived on dayshift and observed Resident #1 saturated with urine. CNA #2 stated at times she had been responsible for 34 residents on dayshift, and she had been unable to meet all the resident needs. During a telephone interview on 5/23/2022 at 3:17 PM, Resident #1 stated she had been a resident at the facility and was discharged to home on 5/17/2022. The resident had to wait 1 to 1 1/2 hours before staff would respond to her call light on night shift since her admission on 4/11/2022. The facility worked with 1 CNA on night shift to care for the residents and Resident #1 had to lay in her own waste (urine and feces) on night shift multiple times. The resident made the Director of Nursing (DON) aware of her concerns and the DON informed the resident the facility was shorthanded and couldn't get anyone to work. There were normally 2 CNAs on day shift, and the resident had problems with staff responding to her call light timely on day shift, depending on who was working, and she had been left in urine multiple times. During an interview on 5/24/2022 at 10:36 AM, CNA #4 stated she worked day shift on the 100-hallway. The CNA stated Resident #1 had complained staff would not answer her call light timely and provide toileting needs on night shift. CNA #4 stated she had arrived on shift multiple times and found multiple residents on the 100-hallway saturated with urine and had to do a complete bed linen change because the linens were saturated. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS assessment dated [DATE], showed Resident #2 had a BIMS score of 15, indicating the resident was cognitively intact. During an interview on 5/23/2022 at 1:05 PM, Resident #2 stated night shift was not good, and the staff complained of being short staffed. When the resident pushed her call light for assistance with the bedpan, she had to wait for up to 2 hours for her call light to be answered. The resident stated it happened on both shifts but was worse on night shift, from 6 PM to midnight. The resident stated she had been saturated with urine and feces on both shifts because staff had not answered her call light timely. During an interview on 5/23/2022 at 8:17 PM, Resident #2 stated her roommate, Resident #7, had called for assistance at 6:15 PM (call light was observed sounding since 8:07 PM and remained sounding during the interview) and staff had not responded to the call light. Resident #2 stated she needed assistance with the bedpan. During an interview on 5/23/2022 at 8:40 PM, Resident #2 stated Registered Nurse (RN) #1 responded to her call light around 8:35 PM (2 hours and 20 minutes later). The RN turned the call light off, informed the resident the facility was short staffed and only had 1 CNA on the shift, and the CNA would get to her as soon as possible. During an interview on 5/23/2022 at 10:08 PM, Licensed Practical Nurse (LPN) #2 stated she worked night shift routinely. She stated approximately 25% of the time there were 3 CNAs on shift. There had been multiple times the facility only had 1 CNA on the shift because of staff call ins. LPN #2 stated she received multiple complaints from residents about call lights not being answered timely. She stated multiple residents had complained of laying in urine and feces for hours including Resident #2. LPN #2 stated she had observed multiple residents soaked in urine and feces in the past 3 months, and the residents were not cared for properly in the facility. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS assessment dated [DATE], showed Resident #3 had a BIMS score of 15, indicating the resident was cognitively intact. During an interview on 5/23/2022 at 12:00 PM, Resident #3 stated she had peed and pooped on herself multiple times (not sure of the exact dates) but the last time was on 5/22/2022 on night shift. Resident #3 stated .there is not enough help at night to help us .1 CNA to take care of all of us . Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS assessment dated [DATE], showed the Resident #4 had a BIMS score of 15, indicating the resident was cognitively intact. During an interview on 5/24/2022 at 12:11 PM, CNA #7 stated she worked day shift on the 200-hallway. She stated the facility .had a big problem . Night shift CNAs would come in late or never show up at all. The CNA stated night shift had worked with only 1 CNA multiple times recently and CNA #7 had observed residents saturated with urine and/or feces (unsure of the exact dates), requiring a complete bed linen change. She stated Resident #4 was saturated with urine this morning from the middle of her back to below her knees. The resident informed CNA #7 she had been checked and changed 1 time last night on 5/23/2022 because there had been only 1 CNA on the shift. Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Speech Language Pathologist (SLP) Screen/MDS Worksheet undated, showed Resident #5 had a BIMS of 13, indicating the resident was cognitively intact. Resident #5's 5-Day MDS assessment was in progress and had not been completed. During an interview on 5/24/2022 at 9:20 AM, Resident #5 stated she used her call light at 7:15 PM on 5/23/2022, for toileting assistance. Someone came in (unknown staff member), turned her call light off, informed her there was only 1 CNA working, and the CNA would get to her as soon as they could. Resident #5 stated she did not receive toileting assistance until approximately 10:00 PM (2 hours and 45 mins later). The resident stated she needed assistance with the bedpan, and she had urinated on herself because she had not received assistance. Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS assessment dated [DATE], showed Resident #6 had a BIMS score of 12, indicating the resident had moderate cognitive impairment. During an observation and interview on 5/24/2022 at 4:33 PM, Resident #6 yelled out for someone to help him. Resident #6 stated he had been laying in a urine-soaked brief for over 2 hours. CNA #4 and CNA #9 assisted the resident and the resident's brief and under pad was soaked with urine and had a strong urine odor. The resident stated he had not been checked or changed since 10:00 AM on 5/24/2022. During an interview on 5/24/2022 at 4:45 PM, CNA #4 confirmed Resident #6 had not been changed since 10:00 AM, (6 hours and 33 minutes) and stated, .it has been hectic today . Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS assessment dated [DATE], showed Resident #7 had a BIMS score of 15, indicating the resident was cognitively intact. During an observation and interview on 5/23/2022 at 8:25 PM, Resident #7 stated she had pushed her call light for assistance around 6:00 PM (on 5/23/2022) and staff had not responded. The resident stated she had a BM (bowel movement), was currently wet with urine, and needed her .diaper [incontinence brief] . changed. Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a SLP Screen/MDS Worksheet undated, showed Resident #8 had a BIMS of 13, indicating the resident was cognitively intact. Resident #8's 5-Day MDS assessment was in progress and had not been completed. During an interview on 5/23/2022 at 8:46 PM, Resident #8 stated her call light had been on for a long time, and she had a BM and could not get assistance from the staff. Resident #8's room had a foul odor of BM upon entrance into the room. During an observation on 5/23/2022 at 8:07 PM, there was 2 RNs, 2 LPNs, and 1 CNA working. All the staff were at the nurse's station and there were 12 call lights sounding. During an interview on 5/23/2022 at 9:41 PM, CNA #3 stated she worked the night shift. CNA #3 stated staff were unable to complete an adequate number of rounds (check and provide residents with incontinence care and turn and reposition residents every 2 hours) to meet the residents' needs when only 1 CNA worked the night shift. She stated she had not been able to complete a full round on 5/23/2022 as of 9:41 PM (she arrived at 6:00 PM) because there was only 1 CNA to care for 78 residents. During an interview on 5/23/2022 at 10:23 PM, RN #1 confirmed there was 1 CNA was on night shift (5/23/2022) for 78 residents on the census. During an interview on 5/24/2022 at 12:43 PM, CNA #8 stated she worked day shift on the 200-hallway. She stated multiple alert and oriented residents had informed her night shift staff would not answer the call lights timely and it would take up to 2 hours for the staff to respond to the resident's needs. During an interview on 5/24/2022 at 4:50 PM, CNA #9 stated she worked the day shift on the 100-hallway. She stated she observed multiple residents soaked in urine multiple times after she arrived on her shift, and it happened 2-3 times a week at least. During an interview on 5/24/2022 at 6:21 PM, RN #4 stated she worked the night shift and .lucky to have 2 [CNAs] and lot of times have 1 [CNA] . She stated the staff were unable to keep the residents clean and dry when only 1 CNA was on the shift. RN #4 confirmed she had witnessed incontinent residents lay in urine for up to an hour and not receive the care they needed because call lights had not been answered timely to assist the residents with their needs because there was not enough staff. During an interview on 5/24/2022 at 6:36 PM, LPN #4 stated she worked night shift on the 200-hallway and most of the time there were 1 to 2 CNAs on the shift. She stated when there was only 1 to 2 CNAs on the shift, it was impossible to complete rounds every 2 hours. LPN #4 stated she witnessed multiple residents lay in urine for long periods of time and required a complete bed linen change. During an interview on 5/24/2022 at 7:04 PM, CNA #11 stated she worked night shift on the 200-hallway. She stated night shift was staffed with only 1 CNA multiple times. The CNA stated she had worked multiple times by herself on night shift and had been unable to meet the care needs of the residents. She stated the residents laid in urine and/or feces up to 2 hours before she could provide incontinence care due to staffing. During a telephone interview on 5/25/2022 at 10:28 AM, RN #5 stated night shift had been staffed with only 1 CNA multiple times recently and the residents had not received adequate care when only 1 CNA worked the shift (6 PM - 6 AM). During an interview on 5/25/2022 at 3:37 PM, RN #6 stated she worked day shift on the 100-hallway. She stated night shift had worked with only 1 CNA multiple times. The residents were soaked with urine when only 1 CNA had worked alone, and it was impossible to meet the care needs of the residents with only 1 CNA on night shift. During an interview on 5/26/2022 at 3:16 PM, the Assistant Director of Nursing (ADON) stated the facility had worked short staffed, night shift had worked with only 1 CNA multiple times, and it was not feasible for rounds to be completed every 2 hours. During an interview on 5/26/2022 at 5:57 PM, the DON stated the complaints started about 3-4 weeks ago when the facility census .grew . and the acuity of the patients changed. The DON was responsible for staffing in the facility. During observation and interview on 5/26/2022 at 6:05 PM, the DON reviewed the staffing schedules and compared the punch detail report. The DON confirmed the facility's assessment showed the daily hours for CNAs were 106.00 hours daily and the facility failed to maintain 106.00 hours on 5/9, 5/11, 5/17, and 5/21/2022. Interview revealed the facility assessment for resident care needs from CNAs was not followed. During an interview on 5/26/2022 at 6:29 PM, the Administrator stated he was not aware some of the residents had concerns because the residents had not complained in the resident council meetings. He stated concerns could have been reported as a grievance but . nursing takes care of the grievances . He stated the DON or ADON had not made him aware of any concerns regarding call lights not being answered, resident care issues, or staff complaints. The Administrator was aware night shift worked with only 1 CNA multiple times recently. He stated the facility currently had a high acuity on the 100-hallway, and the plan was for the rehabilitation residents on the 100-hallway to be mixed with the long-term care residents on the 200 hallway to .balance things out . Refer to F-550 and F-600

Based on review of facility policy, medical record review, review of facility documentation, review of the Quality Assurance Performance Improvement (QAPI) meeting documentation, and interview, the facility's QAPI committee failed to take effective action aimed at performance improvement, measure the success of the intervention, and track performance to ensure improvements were realized and sustained after identifying a problem with POST forms. The QAPI committee failed to take effective corrective action which resulted in the facility failing to honor end of life decisions for 3 residents (Resident #3, Resident #2, and Resident #1), and the facility failing to have end of life decisions available in the medical record for 1 resident (Resident #4) of 23 residents reviewed, and had the potential to affect all 68 residents in the facility. The facility's failure placed Residents #3, #2, and #1 in Immediate Jeopardy (IJ) (A situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) and had the potential to affect all 68 residents in the facility. The Administrator, the Director of Nursing (DON), and Regional Nurse were informed of the Immediate Jeopardy (IJ) on [DATE] at 8:02 PM. The facility was cited an Immediate Jeopardy (IJ) at F-578(K), F-657(K), F-678(K), F-835 (K), and F-868 (K). The facility was cited Substandard Quality of Care at F-678 (K). The IJ was removed onsite [DATE] and was effective [DATE] - [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 3:46 PM and the corrective actions were validated onsite by surveyors on [DATE]. The findings include: Review of the facility policy, Quality Assurance and Performance Improvement (QAPI) Plan dated ,[DATE], stated, .This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems .The objectives of the QAPI Plan are to: Provide a means to identify and resolve present and potential negative outcomes related to resident care and services .Reinforce and build effective systems and processes related to the delivery of quality care and services .Provide structure and processes to correct identified quality and/or safety deficiencies .Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcomes . Medical record review revealed Resident #3 was admitted to the facility on [DATE]. On [DATE], the Resident's Power of Attorney (POA) stated Resident #3 had an Advance Directive and the resident wished to not be resuscitated (DNR) if found unresponsive. The POA verbally requested the resident be a DNR status and the POA would provide the Advance Directive. The Advance Directive was scanned into the facility EHR on [DATE]. Medical record review revealed on [DATE], Resident #3 was found unresponsive, Cardiopulmonary Resuscitation (CPR) was started, Emergency Medical Services (EMS) was called, and EMS attempted to revive the resident. The resident was pronounced deceased on [DATE], after resuscitative efforts were unsuccessful. Medical record review showed Resident #1 was re-admitted to the facility on [DATE] following a hospital admission. The admission orders [REDACTED]. On [DATE], the resident was found in respiratory distress, CPR was started, EMS was called, the resident was intubated (placement of a tube into the windpipe to maintain an open airway), and the resident was transferred to the hospital Emergency Department (ED). At the hospital, the family chose to remove all life-sustaining measures and the resident died on [DATE]. Medical record review showed Resident #2 was admitted to the facility on [DATE]. The resident was placed on hospice services on [DATE] and an order for [REDACTED]. The facility informed the ED staff after the transfer and after the resident had been intubated, that the resident was supposed to be a DNR. The resident was extubated (breathing tube removed) after consultation with family and died . Review of facility documentation titled, (Name of Facility) Post-Acute & Rehabilitation Center Annual Assessment for 2021, showed .QAPI Program feedback, data systems, and monitoring. The policies and procedures must include, at a minimum, the following .Facility maintenance of effective systems to identify, collect, and use data and information .and including how such information will be used to develop and monitor performance indicators . Review of the QAPI meeting documentation, .Quality Assurance and Performance Improvement Meeting Summary . dated XXX[DATE] .problem idetentified (identified) XXX[DATE] .Plan of Action/Correction .Update remaining POST forms (and) add to (EHR) (electronic health record) .Audit completed [DATE] .Dept (department) assigned .nursing .person responsible .DON (Director of Nursing)/RM (Risk Manager) .Expected Date of Completion XXX[DATE] .Follow Up Action .(yes was checked to indicate resolved) .Completed on [DATE] . Review of facility in-service documentation titled, Staff Meeting [DATE] showed the facility had educated staff regarding POST form completion and process on [DATE]. During a telephone interview on [DATE] at 1:59 PM, Licensed Practical Nurse (LPN) #6 stated if a resident wished to change their code status, a new POST form would be completed by a nurse at the facility and the MDS (Minimum Data Set) Coordinator would be responsible for obtaining the new physician's order. During an interview on [DATE] at 2:47 PM, LPN #2 indicated when a resident elected hospice services, the hospice nurse was responsible for both completing a new POST form and obtaining the corresponding physician's order for code status from the hospice physician. The LPN indicated her understanding of the process was the hospice nurse would leave a copy of the new POST form and physician's orders with a nurse at the facility, and the facility nurse was responsible for placing the new orders in the EHR (Electronic Health Record). During an interview on [DATE] at 3:29 PM, Registered Nurse (RN) #4 stated when a resident wished to change their code status, the hospice nurse notified the facility, and the facility nurse was to complete a new POST form, then obtain an order from the facility Nurse Practitioner (NP). RN #4 stated if the facility received a new order from the hospice physician for a hospice resident, a hospice nurse would also call the facility to notify the nurse supervisor, and the supervisor was responsible for putting the new order into the EHR. During a telephone interview on [DATE] at 10:00 AM, LPN #7 stated she was unsure of the process for who completed a new POST form, or how it was relayed to the facility when a resident transitioned to hospice or desired a change in code status. During an interview on [DATE] at 10:45 AM, the DON confirmed the facility did not have a process in place to integrate the hospice care plan with the facility's care plan to ensure comprehensive, collaborative care. During an interview on [DATE] at 11:41 AM, the Administrator stated she was unsure of the process or who was responsible for obtaining a new POST form if a hospice resident wanted to change their code status. She confirmed when a new POST form was completed for a hospice resident, that information would need to be communicated between the facility and the hospice agency. Medical record review showed Resident #4 was admitted to the facility on [DATE]. The resident's admission orders [REDACTED]. The resident's EHR did not indicate the resident's code status. During an interview on [DATE] at 3:54 PM, RN #1 stated she normally looked in the EHR for code status, and if it was not there, she referred to the POST book (binder with hard copies of residents' POST forms). The RN stated the POST book was kept at the nurse's station, and if there were 2 POST forms in the code book she, would go to her supervisor for clarification. During an interview on [DATE] at 4:14 PM, LPN #5 stated she usually checked code status in the EHR. The LPN stated there was a POST book at the nurse's station .we were looking for it the other day . but could not find it. The nurse stated if she could not find the resident's code status in the EHR or in the code book .Well, I'd probably start doing CPR . During an interview on [DATE] at 4:30 PM, RN #3 stated .The computer is more accurate than the paperwork . and if there was no code status in the EHR, the nurse should go to the POST book. In an emergency, the RN stated if we cannot prove they are DNR, we would initiate CPR. The RN stated maintaining the POST book was ultimately the responsibility of the Assistant Director of Nursing (ADON), and whoever completed the POST form entered the status into the EHR. Whenever a resident goes from full code to DNR (such as often occurs when a resident enrolls in hospice services) the facility nurse reviewed hospital discharge orders, and if the resident was alert and oriented, we would discuss the POST form with the resident. Usually the charge nurse, or if there was not a charge nurse, the floor nurse would change the resident's code status in the EHR and would take the paper copy to the ADON. During an interview on [DATE] at 4:00 PM, RN #1 confirmed the RN Supervisors entered resident admission orders [REDACTED]. She stated she felt there was a need for more communication in the facility. RN #1 stated if she knew a resident may be started on hospice care, she would watch for any code status change. She stated if there was no code status documented in the EHR, she would look at the POST book. RN #1 confirmed the POST book was not always kept at the nurse's station. During an interview on [DATE] at 7:40 PM, RN #1 and RN #3 (Nursing Supervisors) stated the supervisors did not have access to the ADON's office to obtain the POST form book after the ADON's shift ended and on weekends. RN #3 stated the nursing supervisor's keys did not unlock the ADON's door for access to the POST book. During an interview on [DATE] at 4:23 PM, the DON stated the Nursing Supervisors or the nurse working on the hall were responsible for obtaining POST forms and physician's orders for a code status upon admission or readmission to the facility. The DON stated if a code status was not readily available in the EHR, the staff were to check the POST book. The POST book was to be kept at the nurse's station. The DON stated the ADON was responsible to keep the POST book updated and currently there was not a process of how she obtained the information to keep it updated. The DON was unsure if the POST book was located at the nurse's station or in the ADON's office. The DON confirmed if a code status was updated, the old POST form should be taken out of the POST book. The DON confirmed the POST book was not currently updated. The DON stated he was unsure if the ADON knew her responsibilities pertaining to the POST book. The DON confirmed the facility did not have a good process or system in place for obtaining and updating POST forms and code status changes. During an interview on [DATE] at 6:35 PM, the Social Services Director (SSD) stated the facility did not have a designated place for hospice staff to leave paperwork for facility staff, and did not have a staff person at the facility designated to receive hospice information. He stated he was unsure who in the facility received the care plans and care plan updates from hospice. The SSD stated to his knowledge, he was not the responsible party for receiving hospice care plans. During an interview on [DATE] at 6:50 PM, the MDS Coordinator stated the process was for the hospice nurse to take the updated hospice care plan to the SSD. During an interview on [DATE] at 7:32 PM and on [DATE] at 3:48 PM, the Administrator stated she began employment at the facility [DATE] and worked 1 week overlapping with the previous Administrator. The Administrator stated she was not aware of concerns identified by the previous Administrator. The Administrator confirmed she had the information about previously identified concerns from past PIPs (Performance Improvement Projects) completed by the facility that were in the facility QAPI book. The Administrator stated since she began employment at the facility, in morning stand-up meeting they checked the chart of new admissions to ensure they had a code status order and a POST form. Per her experience as a social worker, she was aware of the importance of POST forms and the Administrator stated she decided, unprompted, to conduct a POST audit in February 2021.It's very important to make sure your (resident POST) info (information) is correct . The Administrator explained her POST audit process was going through the resident list, ensuring each resident had a code status documented in the EHR, and verifying the resident had a POST form uploaded in the EHR. The Administrator confirmed the POST form book available for facility staff use as an alternative to, or as backup to the EHR, was not included in the audit conducted. The Administrator confirmed the POST form book was not updated and contained multiple POST forms for residents with conflicting information, .the potential is there (for a resident to receive CPR when they were DNR) . The Administrator agreed staff would go by the first POST form they saw, and a resident may not get the treatment they wanted. The Administrator stated she was not aware of a problem with the resident code status's in the EHR not matching the POST forms prior to [DATE](1 day prior to Resident #2 receiving life sustaining treatment against his wishes), the day she began the EHR code status and POST form audit. The Administrator confirmed on [DATE], a Performance Improvement Project (PIP) on POST forms was created, without the input of the Medical Director. Per the PIP, POST forms in the EHR were updated using a separate file of resident POST forms the Administrator kept in her office, and the residents' code status was updated in the EHR. The PIP started on [DATE] and was completed on [DATE]. The Administrator stated she brought the concern to QAPI at the [DATE] meeting. The Administrator confirmed POST forms were discussed, and the Medical Director .did not give much input . The Administrator stated all staff received a mandatory in-service on [DATE] about POST forms. The Administrator stated afterwards, she .looked at some (POST forms) . indicating she performed sporadic random audits of POST forms. The Administrator confirmed she did not document her random follow-up audits and there was no further action taken on this PIP prior to this survey. The Administrator confirmed a root cause analysis had not yet been done. The Administrator stated she was not aware 3 residents (Resident #3, Resident #1, and Resident #2) received life sustaining treatment against their wishes, prior to this survey. The Administrator stated a total of 2 facility-wide POST form audits had been completed: one by her on [DATE]-[DATE], and one by the DON on [DATE]-[DATE]. The Administrator stated .We need continuous audits on things . The Administrator stated she was unaware of the outcome of the DON's [DATE] - [DATE] audit. During an interview on [DATE] at 3:49 PM, The Administrator stated when a new or updated POST form was received or obtained, the facility nurse should put the new or updated POST information into the EHR and place the form in Medical Records. The Administrator stated the Medical Records Clerk had a difficult time keeping up with her job duties in medical records and central supply with the onset of COVID-19. The Administrator stated she expected the POST form book to be alphabetized by the resident's last name for ease of accessibility. As of [DATE], the Administrator stated she did not know who was responsible for updating the POST book. During a telephone interview on [DATE] at 1:01 PM, the Medical Director confirmed it was his expectation for the discharge orders from the hospital for code status and the order for code status on the facility's Admission Order form to be entered into the EHR system physician's orders for staff availability. The Medical Director was newly hired and had attended one QAPI meeting, in February 2021. He stated he wasn't aware POST forms were a problem. The Medical Director did not recall any discussion of POST forms and did not recall a PIP on POST forms being discussed. The Medical Director confirmed if a resident chose to be DNR, .I'd expect that request be honored . Facility corrective actions include: An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received [DATE] at 3:46 PM, and the corrective actions were validated on-site by the surveyors on [DATE] through review of documents, observations, review of facility policies, and staff interviews. The Removal Plan presented to the survey team by the facility documented the following immediate corrective actions implemented: On [DATE], the Regional Nurse Consultant provided training to the Administrator, Director of Nursing, Assistant Director of Nursing, and Social Services Director. The training included: 1. Obtaining and completing a TN POST and/or Advanced Directive upon admission. 2. Review quarterly to ensure the resident's end of life wishes are known. On [DATE], the DON and ADON completed re-education with all licensed nursing staff and contracted licensed nursing staff, Social Services, Medical Director, and Admissions Director. The training included: 1. Review of the facility policy and procedures for obtaining and completing the Tennessee (TN) POST form and/or Advanced Directives. 2. Obtaining a physician order for [REDACTED]. 3. Initiating and updating care plans immediately upon admission, re-admission, resident's or responsible parties' request, and/or change of status. All facility licensed staff including contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. On [DATE], all 68 residents were reassessed by the DON, ADON, and/or Social Services to ensure each resident has a TN POST form and/or Advanced Directive and the Physician Order matched the POST form and/or Advanced Directive, in the resident's medical record, and that the resident's care plan has been updated to match the TN POST and/or advanced directive in the medical record. This was validated by survey team on [DATE], after an audit of 68 medical records. On [DATE], the DON and ADON completed re-education with all licensed nursing staff and contracted licensed nursing staff. The training included: 1. The process for verifying a resident's code status before performing CPR, which includes viewing the POST form and the physician's order in PCC (facility EHR). All facility licensed staff including contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. On [DATE], the DON and ADON provided re-education to all licensed nursing staff. The training included: 1. Step by Step POST form process 2. Changing existing POST forms 3. Hospice POST form changes 4. The location of POST Form Binder 5. Baseline and updating of Care Plans and orders related to code status. All facility licensed staff including contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. Daily audits will be conducted by the DON, ADON or designee utilizing the F835 Audit Tool of every new admission, re-admission, and on the date the resident's Quarterly MDS/Care Plan review is scheduled to ensure the TN POST and/or Advanced Directive is obtained and completed, a Physician Order is obtained and documented, and the resident's Care Plan had been created and/or updated to reflect the resident's end of life wishes expressed on the TN POST and/or Advanced Directive for 3 months and then on-going as determined by the QAPI. The audits will be reviewed and signed daily by the Administrator. Admissions Team meetings are held during regular business hours Monday-Friday led by the Admissions Director and attended by department managers including DON, ADON, Social Services, Administrator, and MDS Coordinator, for clinical review of new admissions, re-admissions, and changes to POST. The QAPI committee will meet weekly beginning [DATE], until compliance is sustained as deemed by the QAPI Committee. The Administrator is responsible to oversee the QAPI committee and ensure compliance is achieved. The surveyors reviewed the Removal Plan and verified 68 current resident medical records were complete and accurate and included a completed POST form with a physician's signature, a physician's order had been obtained for the code status, and the care plan had been updated to include code status. The surveyors review of the facility's Removal Plan, facility training materials, EHR, POST Form Book, Care Plans, facility policy, and staff interviews verified training on maintaining accurate Advanced Directives, POST forms, code status changes, physician's orders, and baseline care plans. All facility licensed nursing staff to include contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. The surveyors interviewed 4 Registered Nurses (RN's), 2 Licensed Practical Nurses (LPN'S) on all shifts, the Social Services Director, and the Admissions Coordinator on [DATE]. These interviews revealed they had received new training on the facility's policy and procedures for Advance Directives to include the new process to identify code status and how to transcribe Physician orders. Continued interview revealed they had received new education on Baseline Care Plans and how to maintain its accuracy in the medical record. These interviews confirmed the staff was knowledgeable and able to verbalize the facility's policy and procedures for Advance Directives to include the new process to identify code status, hospice POST form status changes, how to transcribe Physician orders, Baseline Care Plans, updating the comprehensive care plan, and how to maintain an accurate and complete medical record, and there were no identified concerns. Noncompliance at F867 continues at a scope and severity of E for monitoring of the effectiveness of corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on medical record review, review of hospice documentation, review of facility documentation, review of the Quality Assurance Performance Improvement (QAPI) committee monthly meetings and sign in sheets, and interview, the facility's Administrator failed to take effective systemic action after being made aware of a widespread problem related to resident's code status in the EHR (Electric Health Record) not corresponding to the resident's code status on the paper POST (Physician Orders for Scope of Treatment) form. This failure resulted in 3 residents' (Resident #3, Resident #1, and Resident #2) end of life wishes not being honored and 1 resident's (Resident #4) end of life wishes not being readily available in the medical record. The facility's failure placed the residents in Immediate Jeopardy (IJ) (A situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) and had the potential to affect all 68 residents in the facility. The Administrator, the Director of Nursing (DON), and Regional Nurse were informed of the IJ on [DATE] at 8:02 PM. The facility was cited an Immediate Jeopardy at F-578(K), F-657(K), F-678(K), F-835 (K), and F-867 (K). The facility was cited Substandard Quality of Care at F-678 (K). The Immediate Jeopardy was removed onsite [DATE] and was effective [DATE] - [DATE]. An acceptable Removal Plan which removed the immediacy of the jeopardy, was received on [DATE] at 3:46 PM and the corrective actions were validated onsite by surveyors on [DATE]. The findings include: Medical record review revealed Resident #3 was admitted to the facility on [DATE]. On [DATE], the Resident's Power of Attorney (POA) stated Resident #3 had an Advance Directive and the resident wished to not be resuscitated (DNR) if found unresponsive. The POA verbally requested the resident be a DNR status and the POA would provide the Advance Directive. The Advance Directive was scanned into the facility EHR on [DATE]. Medical record review revealed on [DATE], Resident #3 was found unresponsive, Cardiopulmonary Resuscitation (CPR - Cardiopulmonary Resuscitation) was started, Emergency Medical Services (EMS) was called, and EMS attempted to revive the resident. The resident was pronounced deceased on [DATE], after resuscitative efforts were unsuccessful. Medical record review showed Resident #1 was re-admitted to the facility on [DATE] following a hospital admission. The admission orders [REDACTED]. On [DATE], the resident was found in respiratory distress, CPR was started, EMS was called, the resident was intubated (placement of a tube into the windpipe to maintain an open airway), and the resident was transferred to the hospital Emergency Department (ED). At the hospital, the family chose to remove all life-sustaining measures and the resident died on [DATE]. Medical record review showed Resident #2 was admitted to the facility on [DATE]. The resident was placed on hospice services on [DATE] and an order for [REDACTED]. The facility informed the ED staff after the transfer and after the resident had been intubated, that the resident was supposed to be a DNR. The resident was extubated (breathing tube removed) after consultation with family and died . Review of facility in-service documentation titled, Staff Meeting [DATE] showed the facility had educated staff regarding POST form completion and process on [DATE]. During an interview on [DATE] at 11:41 AM, the Administrator stated she was unsure of who was responsible for completing or updating a POST form when a resident transitioned to hospice services. The Administrator stated the facility staff, or the hospice agency staff could complete the form and the updated information should be communicated between the 2 entities. The Administrator stated she was unsure who was responsible for the comparison of the facility's care plan and the hospice care plan. The Administrator confirmed she was aware of a communication break down between the 2 entities. Medical record review showed Resident #4 was admitted to the facility on [DATE]. The resident's admission orders [REDACTED]. The resident's EHR did not indicate the resident's code status. During an interview on [DATE] at 3:48 PM, the Administrator stated she began employment at the facility [DATE]th, 2021 and worked 1 week overlapping with the previous Administrator. The Administrator stated since she began employment at the facility, in the morning stand up meetings they checked the charts of new admissions to ensure they had a code status order and a POST form. Per her experience as a social worker, she was aware of the importance of POST forms and the Administrator stated she decided, unprompted, to conduct a POST form audit in February.It's very important to make sure your (resident POST) info (information) is correct . The Administrator explained her POST audit process was going through the resident list, ensuring each resident had a code status documented in the electronic health record (EHR), and verifying the resident had a POST form uploaded in the EHR. The Administrator confirmed the physical book of resident POST forms which was supposed to be available for facility staff use as an alternative to, or as backup to the EHR, was not included in the audit. The Administrator confirmed she was not aware of a problem with the resident code status in the EHR not matching the POST forms prior to [DATE], the day she began the EHR code status and POST form audit. On [DATE], a Performance Improvement Project (PIP) on POST forms was created, without the input of the Medical Director. Per the PIP, POST forms in the EHR were updated using a separate file of resident POST forms the Administrator kept in her office, and the resident's code status was updated in the EHR, starting on [DATE], and was completed on [DATE]. The Administrator stated she brought the concern of the residents' code status in the EHR not matching the POST forms to QAPI at the [DATE] meeting. The Administrator stated all staff received a mandatory in-service on [DATE] about POST forms. The Administrator stated afterwards, she .looked at some (POST forms) . indicating she performed sporadic random audits of POSTs and confirmed she did not document her random follow-up audits and there was no further monitoring or follow-up. The Administrator confirmed she was not aware 3 residents (Resident #3, Resident #1, Resident #2) received life sustaining treatment against their wishes, prior to this survey. The DON completed a POST audit over the course of [DATE] and [DATE]. The Administrator confirmed a total of 2 facility-wide POST form audits were completed: one by her and one by the DON. The Administrator confirmed .We need continuous audits on things . The Administrator confirmed she was unaware of the outcome of the DON's [DATE] - [DATE] audit. The Administrator further stated during her audit, she had not compared the POST book to the Residents' EHR to determine the code status accuracy and had not completed a root cause analysis after she became aware of the concerns with residents' code status and POST forms. Refer to F-578(K), F-657 (K), F-678 (K), F-867(K). An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received [DATE] at 3:46 PM, and the corrective actions were validated on-site by the surveyors on [DATE] through review of documents, observations, review of facility policies, and staff interviews. The Removal Plan presented to the survey team by the facility documented the following immediate corrective actions implemented. On [DATE], the Regional Nurse Consultant provided training to the Administrator, Director of Nursing, Assistant Director of Nursing, and Social Services Director. The training included: 1. Obtaining and completing a Tennessee (TN) POST and/or Advanced Directive upon admission 2. Review quarterly to ensure the residents' end of life wishes are known. On [DATE], the DON and ADON completed re-education with all licensed nursing staff and (contracted licensed nursing staff, Social Services, Medical Director, and Admissions Director. The training included: 1. Review of the facility policy and procedures for obtaining and completing the TN POST form and/or advanced Directives, 2. Obtaining a physician order for [REDACTED]. 3. Initiating and updating care plans immediately upon admission, re-admission, resident's or responsible parties' request, and/or change of status. All facility licensed staff including contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. On [DATE], all 68 residents were reassessed by the DON, ADON, and/or Social Services to ensure each resident had a TN POST form and/or Advanced Directive in the resident's medical record, and the Physician Order matched the POST form and/or Advanced Directive, and that the resident's care plan has been updated to match the TN POST and/or Advanced Directive in the medical record. This was validated by survey team on [DATE], after an audit of 68 medical records. On [DATE], the DON and ADON completed re-education with all licensed nursing staff and contracted licensed nursing staff. The training included: 1. The process for verifying a resident's code status before performing CPR, which includes viewing the POST form and the physician's order in PCC (facility's EHR). All facility licensed staff including contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. On [DATE], the DON and ADON provided re-education to all licensed nursing staff. The training included: 1. Step by Step POST form process 2. Changing existing POST forms 3. Hospice POST form changes 4. The location of POST Form Binder 5. Baseline and updating of Care Plans and orders related to code status. All facility licensed staff including contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. Daily audits will be conducted by the DON, the ADON, or designee utilizing the F835 Audit Tool of every new admission, re-admission, and on the date the resident's Quarterly MDS/Care Plan review is scheduled to ensure the TN POST and/or Advanced Directive are obtained and completed, a Physician Order is obtained and documented and the resident's Care Plan had been created and/or updated to reflect the resident's end of life wishes expressed on the TN POST and/or Advanced Directive for 3 months and then on-going as determined by the QAPI (Quality Assurance and Performance Improvement). The audits will be reviewed and signed daily by the Administrator. Admissions Team meetings are held during regular business hours Monday-Friday led by the Admissions Director and attended by department managers including DON, ADON, SSD, Administrator, and MDS Coordinator, for clinical review of new admissions, re-admissions, and changes to POST. New admission, re-admission, and changes to POST forms obtained over the weekend or holidays will be reviewed the next business day. The QAPI committee will meet weekly beginning [DATE], until compliance is sustained as deemed by the QAPI Committee. The Administrator is responsible to oversee the QAPI committee and ensure compliance is achieved. The surveyors reviewed the Removal Plan and verified 68 current resident medical records were complete and accurate and included a completed POST form with a physician's signature, a physician's order had been obtained for the code status, and the care plan had been updated to include code status. The surveyors review of the facility's AOC, facility training materials, EHR, POST Form Book, Care Plans, facility policy and staff interviews verified training on maintaining accurate Advanced Directives, POST forms, code status changes, physician's orders, and baseline and comprehensive Care Plans. All facility licensed nursing staff to included contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. The surveyors interviewed 4 RN's, 2 LPN'S on all shifts, the Social Services Director, and the Admissions Coordinator on [DATE]. These interviews revealed they had received new training on the facility's policy and procedures for Advance Directives to include the new process to identify code status and how to transcribe Physician orders. Continued interview revealed they had received new education on baseline and comprehensive Care Plans and how to maintain its accuracy in the medical record. These interviews confirmed the staff was knowledgeable and able to verbalize the facility's policy and procedures for Advance Directives to include the new process to identify code status, hospice POST form status changes, how to transcribe Physician orders, baseline Care Plans, updating the comprehensive care plan, and how to maintain an accurate and complete medical record, and there were no identified concerns. Noncompliance at F835 continues at a scope and severity of E for monitoring of the effectiveness of corrective actions to ensure sustained compliance. The facility is required to submit a Plan of Correction.

Based on review of facility policy, medical record review, review of hospital records, review of Emergency Medical Services (EMS) records, interview, and review of hospice documentation, the facility failed to ensure a process was in place to ensure residents end of life wishes were honored for 4 residents (Resident #3, Resident #1, Resident #2 and Resident #4) of 23 residents reviewed for code status. The facility failed to make readily available a physician's orders [REDACTED].#1, failed to obtain an updated physician's orders [REDACTED].#3 and #2, and failed to make readily available a physician's orders [REDACTED].#4. The facility's failure to ensure a system was in place to ensure end-of-life wishes were honored placed the residents in Immediate Jeopardy (IJ) (A situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The facility's failure had the potential to affect all 68 residents in the facility. The Administrator, Regional Nurse Consultant, and the Director of Nursing (DON) were informed of the IJ on [DATE] at 8:02 PM in the conference room. The facility was cited F-678 at a scope and severity of K which constitutes Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective [DATE] - [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 3:46 PM. The corrective actions were verified onsite by the surveyors on [DATE]. The findings include: Review of the facility's policy titled, Do Not Resuscitate Order (DNR), revised ,[DATE], showed .Our facility will not use cardiopulmonary resuscitation (CPR) and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order (DNR) in effect .Inquiries concerning do not resuscitate orders/request should be referred to the Administrator, Director of Nursing (DON) Services, or to the Social Services Director . Review of the facility's undated policy titled, ADVANCE DIRECTIVE POLICY AND PROCEDURE showed the facility's policy was to provide basic life support, including CPR .subject to physician order [REDACTED].Nurses .are educated to initiate CPR .unless .A valid Do Not Resuscitate order is in place . Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a baseline care plan dated [DATE] showed Resident #3's representative was Family Member #1. A question on the baseline care plan .Does the resident have Advanced Directives (a written statement of a person's wishes regarding medical treatment) . was marked as No. Review of a hospital discharge order dated [DATE] showed Resident #3 was a Full Code (full life-sustaining treatment including CPR, intubation, and ventilator use). Review of a Nursing Note dated [DATE] showed .(Family Member #1) at facility .stated that he had paperwork at home that stated that resident wished to be a DNR .refused to sign POST (physician's orders [REDACTED].#2) that he would return tomorrow evening with POA (Power of Attorney) and advance directive paperwork and sign in (it) (POST) then . Review of the physician's orders [REDACTED].#3's active orders were for CPR with the start date of [DATE]. Review of the DURABLE POWER OF ATTORNEY .ADVANCE CARE PLAN, dated [DATE] showed Resident #3 had marked .No . on the form for .CPR .Life Support (continuous use of breathing machine and other equipment that helps the lungs, heart, kidneys, and other organs to continue to work) . indicating the resident did not want CPR or life support. Review of a Nursing Note dated [DATE] at 12:58 AM showed .Resident noted to be unresponsive with no pulse or breathing. EMS notified. CPR initiated . Review of a Nursing Note dated [DATE] at 1:18 AM for Resident #3 showed .Care of resident turned over to EMS at this time. Code continues . Review of the EMS record dated [DATE] showed Resident #3 had a [MEDICAL CONDITION]. The record showed .Dispatched emergency to the listed facility for (Resident #3), [MEDICAL CONDITION] .CPR being performed by staff. They (facility staff) state that they have been performing CPR between ,[DATE] minutes .pt (patient) shown in Asystole (absent heart beat). CPR immediately resumed and ACLS (Advanced Cardiac Life Support) protocols initiated .IO (Intraosseous) access (the process of injecting fluids and/or medications directly into the bone) obtained in pts (patient's) right .tibia (the inner and typically larger of the 2 bones between the knee and the ankle) .ventilations .provided with good compliance .pt. was defibrillated (delivers a dose of electric current to the heart) and CPR immediately resumed. After rhythm check after defibrillation, pt (patient) shown back in asystole. ACLS protocol started again .(local hospital) contacted via (by) radio .(name of emergency room physician) .gave orders for CPR and other lifesaving interventions to discontinue. Facility staff notified of stopped efforts . The EMS record showed IO fluids and medications administered included [MEDICATION NAME], Sodium [MEDICATION NAME], and [MEDICATION NAME]. Resident #3 was found .Dead on Scene - Resuscitation Attempted (Without Transport) .[MEDICAL CONDITION]/Death . Review of a Nursing Note dated [DATE] showed .Resident (Resident #3) pronounced dead at 0206 (2:06 AM) . During an interview on [DATE] at 5:44 PM, the Director of Nursing (DON) said a nurse's note on [DATE] stated Resident #3's son was at the facility and refused to sign the POST form and stated he would be at the facility the next day with the Advanced Directive paperwork. The DON stated the Advance Directive was scanned into the EHR (electronic health record) on [DATE] which indicated a DNR status. On [DATE] Resident #3 was found unresponsive by the nursing staff with no pulse or breathing, EMS was notified, and CPR was initiated. The DON confirmed CPR should not have been initiated according to the Advanced Directive on file in the EHR and Resident #3's wishes for end of life care were not honored. During an interview on [DATE] at 6:28 PM, Registered Nurse (RN) #2 stated Resident #3 was admitted on [DATE] around 11:29 PM. RN #2 stated the son refused to sign a POST form, had durable POA and an Advance Directive at home which stated Resident #3 was a DNR, and the son would bring the Advance Directive to the facility later. RN #2 stated she did not follow up with the son regarding Resident #3's DNR code status. On [DATE] at 12:58 AM, Resident #3 was found unresponsive. RN #2 checked his code status on the EHR and saw it indicated CPR. CPR was initiated by RN #2 and EMS was notified. Once EMS arrived, they took over life sustaining treatment. EMS notified the ER physician and was given the order to stop CPR. RN #2 stated CPR should not have been initiated on Resident #3 and Resident #3's end of life wishes was not followed. During a telephone interview on [DATE] at 1:04 PM, the Medical Director of the facility stated if Resident #3's Advanced Directive indicated a DNR status and CPR was performed, Resident #3's wishes for end of life care were not honored. Medical record review showed Resident #1 was admitted to the facility on [DATE], was transferred to the hospital on [DATE], and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's medical record showed no documentation a POST form had been completed. Review of Resident #1's Order Recap Report showed an order for [REDACTED]. with an order date of [DATE] and an end date of [DATE]. Review of Resident #1's hospital Discharge to Outside Facility Form dated [DATE], showed .Current code Status .Allow Natural Death (Do Not Attempt Resuscitation) . Review of Resident #1's admission orders [REDACTED].DNR . Review of Resident #1's Order Summary Report dated [DATE], showed no documentation of a physician's orders [REDACTED]. Review of Resident #1's Nursing Note dated [DATE], showed .Called to resident room, noted resident to be in respiratory distress, provider notified via (by) telephone of condition, instructed LPN to call 911, Resident #1 appeared to have restricted airway, attempted to clear airway via [MEDICATION NAME] maneuver (procedure used to assist a person who is choking), head of bed lowered, CPR strap pulled to gain hard surface, resident loss pulse, CPR initiated, EMS arrived, resident taken to (name of hospital) via ems, family notified via phone call . Review of Resident #1's EMS documentation dated [DATE], showed .arrived to find nursing home staff attending to the patient. The patient was unconscious with agonal respirations (gasping that people do when they are struggling to breathe), lying supine (on her back) in her bed inside room .Nursing home staff stated they performed CPR for four minutes and got pulses (heart rate) back on the patient .The patient had radial pulses (heart rate felt at the wrist) .The patient did not have immediately visible venous access (access of the blood stream through a vein). A successful Blue needle IO was obtained .in the patient's left Tibia access point .at that time the patient's oropharynx (throat) was suctioned due to copious (large) amounts of blood, food, mucus, and vomitus being present .the patient was intubated (placement of a tube into the windpipe to maintain an open airway) orotracheal (through the mouth and into the trachea/windpipe) . Review of Resident #1's Emergency Department documentation dated [DATE], showed .Patient presents with .Post [MEDICAL CONDITION] (sudden loss of heart function) .Apparently she was eating today, when she likely aspirated (when something enters the airway or lungs by accident) according to EMS. Nursing home staff stated she became unresponsive and started CPR. She was intubated when the EMS arrived .Spoke with patient's family at length who stated that she (Resident #1) did not want to have any invasive procedures done, and that she had wished to be DNR .Plan for now is to not accelerate care in any way. Family is discussing possible withdrawal as patient likely has very poor prognosis . Review of Resident #1's hospital discharge summary dated [DATE], showed .her (family members) requested palliative care (care focused on relief of pain and other symptoms of a serious illness) and removal of ventilator (a machine used to deliver breaths to a patient who is physically unable to breathe). She was extubated (airway tube removed) with the expectation of dying over the next several minutes to hours .she persisted until today ([DATE]) She died with her children present . During an interview on [DATE] at 4:23 PM, the DON stated he assessed Resident #1, he got a stethoscope (medical device used to listen to sounds in the body), checked the resident, and observed she was not breathing. The DON stated he instructed LPN #3 to call 911. The DON stated Resident #1 lost a pulse/heart rate around 9:00 AM. The DON started CPR and LPN #3 brought the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) to the room. The DON stated he could see something in the resident's throat, it appeared she had pureed eggs or something yellow gummed up in her mouth. He thought her airway was restricted but continued CPR as he was trying to thrust (abdominal thrusts- procedure to assist with clearing the airway) to clear the airway. The DON stated he was able to get the airway cleared and the pulse had resumed before EMS arrived. The DON stated CPR was performed for probably ,[DATE] minutes. During review of the emergency department report, the DON confirmed Resident #1 had wished to be DNR. The DON confirmed the facility had not provided care per Resident #1's wishes. Resident #1 had received CPR, mechanical ventilation, and intubation against her wishes for DNR code status. During a telephone interview on [DATE] at 10:10 AM, Licensed Practical Nurse (LPN) #3 confirmed she was Resident #1's nurse on [DATE]. LPN #3 stated she entered Resident #1's room to administer her medication after breakfast and observed her face was beet red and she just couldn't breathe. LPN #3 stated she notified the DON and checked the EHR which indicated Resident #1 was a full code status. LPN #3 stated the DON started chest compressions while she called 911 and retrieved the crash cart. Upon arrival to Resident #1's room, LPN #3 initiated the Ambu bag (hand held device used to provide breaths to someone who is not breathing). LPN #3 stated Resident #1 regained a pulse and CPR had been stopped by the facility staff by the time EMS arrived. During a phone interview on [DATE] at 12:52 PM, Resident #1's Family Member stated the facility had called her on [DATE] and the DON had informed her that Resident #1 had possibly gotten choked and went into [MEDICAL CONDITION]. He told her Resident #1 did have a pulse when EMS took her to the hospital. The Family Member stated she went to the hospital and was informed Resident #1 had been put on a ventilator on the way to the hospital by EMS, .which she (Resident #1) had never wanted and we (the resident's family) had never wanted that . The Family Member confirmed the family had made the decision to have Resident #1 taken off the ventilator and she died on [DATE]. The Family Member stated the facility had not discussed the resident's/family's wishes for DNR code status with the resident's family. She stated .we (the family) just didn't want that (CPR, intubation, and mechanical ventilation) and neither did she (Resident #1). We (the family) had talked to her (Resident #1) about that before her (Resident #1) dementia had gotten so bad . During an interview on [DATE] at 11:43 AM, Nurse Practitioner (NP) #1 stated the facility's Admission Order form contains the resident's code status. She stated the NP's will sign the bottom of the form during the admission process indicating they are approving those orders for that resident's admission. She was unsure of the process the staff would take to ensure those orders were entered into the EHR. NP #1 confirmed Resident #1's admission orders [REDACTED]. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a POST form dated [DATE], showed .Resuscitate .CPR . Review of a Hospice Comprehensive Assessment and Plan of Care Update report, showed .SOC (Start Of Care) XXX[DATE] .Advance Directive .DO NOT RESUSCITATE . Review of a POST form dated [DATE] (after the resident was admitted to hospice services), showed .Do Not Attempt Resuscitation .(DNR) .no CPR . Review of Resident #2's Active Physician order [REDACTED].CPR .order date [DATE] . Review of the Electronic Medication Administration Record (E-MAR) dated [DATE]-[DATE], showed .Advance Directive .CPR . Review of a nursing note dated [DATE], documented by LPN #1, showed .0740 (7:40 AM) resident unresponsive, eyes are fixed and dilated, skin cold to the touch, irregular heart rate and labored breathing noted . (NP #2) made aware of residents condition around 0743 (7:43 AM) Resident is hospice, full code. New order from NP to call EMS and hospice . Review of EMS records dated [DATE], showed .EMS dispatched to (name of facility) for (Resident #2) unresponsive .responded immediate and upon arrival found patient unresponsive in his room .Airway was open and clear, breathing was weak and slow ,[DATE] times a minute (normal is ,[DATE]) .absent radial pulses and very weak carotid pulses .patient .moved to the ambulance .vitals (vital signs) were obtained showing a low but normal blood pressure. HR (Heart Rate) was only obtainable via auscultation (the action of listening to sounds). ECG (Electrocardiography, a method of graphic tracing of the electric current generated by the heart muscle) showed Asystole (cessation of electrical and mechanical activity of the heart) only in all leads. Patient continued to have a physical Heart Beat with absence of waveform activity shown on the monitor . Saturations (amount of oxygen in the bloodstream) were low and patient was placed on a NRB (non-rebreather, a device used to assist in the delivery of oxygen therapy) at 15 LPM (Liters Per Minute). IV (intravenous-within a vein) was attempted in his arms and both external jugular (neck veins) without success. An IO was put in place in patients (patient's) left Tibia .Due to the patient still moving and breathing on his own but unable to control his airway and respirations (breathing) being low and quality poor the decision to intubate was made. Patient was given 200 mg (milligrams) of [MEDICATION NAME] (medication used for sedation and starting and maintaining anesthesia) IV push and intubated with a 7.5 mm (millimeter) ETT (Endotracheal Tube, an airway catheter) secured at 22 cm (centimeter) at the teeth .confirmed tube placement . Review of ER records dated [DATE], showed .Chief Complaint .Altered Mental Status .pt (patient) (Resident #2) found unresponsive at nursing home. Intubated by ems .[MEDICATION NAME] for intubation .The patient presents here due to [MEDICAL CONDITION] .shortly after the patient's arrival his facility called and reported that he was DNR and should not have been intubated .did discuss the case with his listed emergency contact .She feels strongly that he would not have wanted to be intubated and at this point he would like to be taken off the ventilator and allowed to die naturally. He does have [MEDICAL CONDITION] .Patient was given [MEDICATION NAME] (drug used for severe pain) for comfort and was extubated. He died shortly thereafter . During a telephone interview on [DATE] at 12:23 PM, LPN #1 stated she worked day shift on [DATE]. Resident #2 was observed around 7:15 AM to be unresponsive, oxygen saturation was in the 80's (normal oxygen saturation greater than 92 %), his blood pressure (B/P) was low, and she was unable to get his oxygen saturation and B/P stable. She notified NP #2 of the resident's change in condition, and informed her the resident was on hospice and had a full code status. NP #2 instructed LPN #1 to send the resident to the ER if he was a full code and to notify hospice. LPN #1 stated she later learned Resident #2 had a DNR code status, after he was transferred to the hospital, and should not have been transferred to the hospital and intubated. During a telephone interview on [DATE] at 3:18 PM, Hospice Registered Nurse (RN) #1 with Hospice Agency #1 stated the facility had contacted the triage nurse on [DATE], reported Resident #2 was not breathing good, and was being transported to the hospital. The triage nurse contacted Hospice RN #1, who called the facility and spoke with the Assistant Director of Nursing (ADON) and informed the ADON the resident was DNR/Comfort measures. Hospice RN #1 instructed the ADON not to send the resident to the ER. During an interview on [DATE] at 10:10 AM, NP #1 stated she was not aware Resident #2 had a DNR status. NP #1 stated Resident #2's POST form dated [DATE] showed he was a full code status and she was unaware Resident #2' had an updated POST form for a DNR dated [DATE]. NP #1 stated it was her expectation if a resident had a DNR code status, the resident should not be transferred to the ER or receive life sustaining treatment. During an interview on [DATE] at 10:45 AM, the DON confirmed Resident #2 was transferred to the ER and received life sustaining treatment against Resident #2's wishes. During a telephone interview on [DATE] at 3:00 PM, Resident #2's Family Member stated the resident's wishes were to be a DNR/Comfort status and he would not have wanted to receive life sustaining measures. During an interview on [DATE] at 3:49 PM, the Administrator stated when a new or updated POST form was received or obtained, the facility nurse should put the new or updated POST information into the EHR and place the form in Medical Records. During an interview on [DATE] at 12:45 PM, the Medical Records Clerk stated she had not received an updated POST form to scan into the EHR for Resident #2 to reflect a DNR status until [DATE] (2 days after Resident #2 expired). During a telephone interview on [DATE] at 1:02 PM, the Medical Director stated it was his expectation if Resident #2 had a POST form with a DNR status, the resident should not have had life sustaining treatment. Medical record review showed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's hospital's Discharge to Outside Facility Form showed an order dated [DATE] for .Code status .Full Code (indicating the resident wished to receive full treatment including Cardiopulmonary resuscitation in the event the resident had stopped breathing and had no pulse) . Review of Resident #4's admission orders [REDACTED]. Review of Resident #4's POST form dated [DATE], showed .Resuscitate (CPR) .Full Treatment .use intubation, advanced airway interventions, and mechanical ventilation as indicated . Review of Resident #4's baseline care plan dated [DATE], showed .Does the resident have Advanced Directives .yes . During an interview on [DATE] at 9:02 AM, RN #1 confirmed there was no code status order in Resident #4's current physician's orders [REDACTED].#1 confirmed Resident #4 had been admitted to the facility on [DATE]. RN #1 stated if Resident #4 became unresponsive, she would .go grab the book (POST book) and see if it (POST) was in there and if it wasn't there, we would code (provide life sustaining treatment) her . RN #1 stated it was the responsibility of the RN Supervisor who completed the admission for Resident #4 to ensure the resident's code status had been entered into the EHR physician's orders [REDACTED]. During an interview on [DATE] at 9:20 AM, the DON confirmed Resident #4 did not have a code status entered in the physician's orders [REDACTED]. The DON stated LPN #7 had completed the resident's admission in the EHR and was responsible to ensure the physician's orders [REDACTED]. The DON stated LPN #7 had access to both the POST form and the admission orders [REDACTED]. Review of Resident #4's Order Summary Report, showed a physician's orders [REDACTED].#4 was admitted to the facility) for .CPR- Full Code . The order had been entered into the EHR after the interviews with RN #1 and the DON. During an interview on [DATE] at 3:48 PM, the Administrator stated since she had begun employment at the facility on [DATE], the new admissions charts were reviewed in the morning stand-up meetings for accuracy. She stated if upon review of the chart, a resident did not have a physician's orders [REDACTED]. The Administrator confirmed Resident #4 had been admitted after she had begun the process of reviewing the new admissions charts in the morning stand-up meetings. The Administrator confirmed Resident #4 did not have a physician's orders [REDACTED]. She stated she did not remember if the chart had been reviewed after Resident #4's admission on [DATE]. During an interview on [DATE] at 11:43 AM, NP #1 confirmed Resident #4's Admission Order sheet dated [DATE] stated full code. NP #1 stated it was her expectation for those orders to be entered into the EHR. During a telephone interview on [DATE] at 1:02 PM, the Medical Director stated it was his expectation for the discharge orders from the hospital for code status, and the order for code status on the facility's Admission Order form, to be entered into the EHR system physician's orders [REDACTED]. During a telephone interview on [DATE] at 2:17 PM, RN #6 stated all residents' code statuses were in the EHR. RN #6 stated she would follow the information in the EHR. If a resident was a DNR/Hospice status and had a decline in health, she would notify the hospice nurse and would not transport the resident to the ER for life sustaining treatment. RN #6 stated if a resident transitioned to hospice care, the nursing supervisor at the facility was responsible for completing a new POST form and obtaining a new physician's orders [REDACTED]. She also stated if a resident had a DNR status, life sustaining treatment should not be initiated. During an interview on [DATE] at 2:47 PM, LPN #2 stated each resident's code status was placed on the E-MAR under the resident's name. If a resident was a DNR status, the expectation was the resident was to be kept comfortable and no life sustaining treatment would be initiated. If a resident transitioned to hospice service, the hospice nurse was responsible for completing a new POST form and obtaining a new physician's orders [REDACTED]. The hospice nurse would leave a copy of the new POST form and physician's orders [REDACTED]. During an interview on [DATE] at 3:29 PM, RN #4 stated a resident's code status was identified on the resident's E-MAR. If a resident was a DNR status, the resident was not to be transported to the ER for life sustaining treatment. RN #4 stated if a resident transitioned to hospice services and wished to change their code status, the hospice nurse notified a nurse at the facility. The facility nurse completed a new POST form and would obtain a new physician's orders [REDACTED]. During a telephone interview on [DATE] at 10:00 AM, LPN #7 stated the resident's code status is on the E-MAR and a copy of the POST form was scanned into the EHR. LPN #7 stated if a hospice resident had a decline in health condition and was DNR, the resident would not be transferred to the ER, CPR would not be initiated, the resident would not be intubated, and would be allowed to die naturally. If a resident transitioned to hospice services, LPN #7 stated she was not sure who completed a new post form or how the information was relayed to the facility. During an interview on [DATE] at 4:00 PM, RN #1 stated the RN Supervisors completed admissions and entered the admission orders [REDACTED]. She stated she felt there was a need for more communication in the facility. RN #1 stated if she knew a resident may be started on hospice care, she would watch for any code status change. She stated if there was no code status documented in the EHR, she would look at the POST book (a copy of all Residents' POST forms in a notebook) at the nurse's station. RN #1 confirmed the POST book may not always be kept at the nurse's station. During an interview on [DATE] at 4:18 PM, the Administrator stated a copy of the completed POST form should be given to the ADON, who was responsible for placing the POST form in the POST book. The ADON was responsible for maintaining and updating the POST form book. The Administrator stated the POST book was sometimes located at the nurse's station or in the ADON's office. The Administrator stated the RN nursing supervisors had a key to gain access to the ADON's office for the POST book after hours and on weekends. During an interview on [DATE] at 4:23 PM, the DON confirmed the Nursing Supervisors or the nurse working on the hall were responsible for obtaining POST forms and physician's orders [REDACTED]. The DON stated if a code status was not readily available in the EHR, the staff were to check the POST book. The DON stated the ADON was responsible to keep the POST book updated and currently there was not a process of how she obtained the information to keep it updated. The DON was unsure if the POST book was located at the nurse's station or in the ADON's office. He stated if a code status was updated, the old POST form should be taken out of the POST book. The DON stated he was unsure if the ADON knew her responsibilities pertaining to the POST book. The DON confirmed the facility failed to have a good process or system in place for obtaining and updating POST forms and code status changes. During an interview on [DATE] at 4:50 PM, the DON confirmed a problem with POST forms was identified by the previous facility Administrator, who left at the end of [DATE]. The DON clarified the problem identified was POST forms were not scanned into the EHR, and missing POST forms.I don't have a good process in place; I'm getting ready to put a new process in place because things are falling through the cracks . The DON discussed the complexity of the facility-wide problem and stated .It's an impossible problem for 1 person to fix and (running the facility) is largely a 1 man show . The DON confirmed he was unaware 3 residents (#1, #2, and #3) received life sustaining treatment against their wishes prior to this survey. During an interview on [DATE] at 7:40 PM, RN #1 and RN #3 (Nursing Supervisors) stated the supervisors do not have access to the ADON's office to obtain the POST form book after the ADON's shift ends and on weekends. RN #3 confirmed the nursing supervisor's keys did not unlock the ADON's door for access to the POST book. During an interview on [DATE] at 3:49 PM, the Administrator stated when a new or updated POST form was received or obtained, the facility nurse should put the new or updated POST information into the EHR and place the form in Medical Records. The Administrator stated the Medical Records Clerk had a difficult time keeping up with her job duties in medical records and central supply with the onset of COVID-19. As of [DATE], the Administrator stated she did not know who the DON would delegate to be responsible for updating the POST book. Refer to F-578(K), F-657(K), F-835 (K), F-867 (K) An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received [DATE] at 3:46 PM, and the corrective actions were validated on-site by the surveyors on [DATE] through review of documents, observations, review of facility policies, and staff interviews. The Removal Plan pr(TRUNCATED)

Based on review of facility policy, medical record review, review of Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, EMS (Emergency Medical Service) documentation review, Hospital documentation review, observation, and interview, the facility failed to revise a comprehensive care plan to include code status, Advance Directive, and/or Physician's Order for Scope of Treatment (POST) form for 3 residents (Resident #3, Resident #1, and Resident #2) of 20 residents reviewed for care plans. The facility's failure to revise the care plan resulted in Residents' #3, #1, and #2 receiving Cardiopulmonary Resuscitation (CPR) and/or Life-Sustaining Treatment against the residents' or the resident representatives' wishes and placed the residents in Immediate Jeopardy (A situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The facility's failure had the potential to affect all 68 residents in the facility. The Administrator, Regional Nurse Consultant, and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 8:02 PM in the conference room The facility was cited an Immediate Jeopardy at F-657 (K). The Immediate Jeopardy was removed onsite and was effective [DATE] - [DATE]. An acceptable Removal Plan which removed the immediacy of the jeopardy, was received on [DATE] at 3:46 PM. The corrective actions were verified onsite by the surveyors on [DATE]. The findings include: Review of the facility's undated policy titled, ADVANCE DIRECTIVE POLICY AND PROCEDURE, showed .The resident will be assessed periodically for decision-making ability capacity and for changes in resident preferences and choices .Advance care planning is an integral aspect of the facility's comprehensive care planning process and assures re-evaluation of the resident's desires on a routine basis and when there is a significant change in the resident's condition. The process can help the resident, family and interdisciplinary team prepare for the time when a resident becomes unable to make decisions or is actively dying .The interdisciplinary team will identify, clarify, and review, as part of the comprehensive care planning process, the existing care instructions along with resident's .wishes as the resident's medical condition changes . Review of the Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, dated ,[DATE], showed .The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care .The care plan should be revised on an ongoing basis to reflect changes in the resident and the care the resident is receiving .A well developed .care plan .Reflects the resident's/resident representative's input, goals, and desired outcomes .Review and revise the current care plan, as needed .The overall care plan should be oriented towards .Respecting the resident's right to decline treatment . Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a baseline care plan dated [DATE] showed Resident #3's representative was Family Member #1. The care plan showed Resident #3 communicated easily and understood staff. A question on the baseline care plan .Does the resident have Advanced Directives (a written statement of a person's wishes regarding medical treatment . was marked as No. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #3 was cognitively intact. The MDS showed Resident #3 participated in the MDS assessment. Review of the hospital discharge orders dated [DATE] showed Resident #3 had a Full Code status. Review of a comprehensive care plan initiated [DATE] showed Resident #3 had a full code status (Cardiopulmonary Resuscitation/CPR) with the goal .Resident's advance directive wishes will be honored . and .If code status changes update medical record . Continued review showed the care plan was not revised to indicate a DNR (do not resuscitate) code status after the Advanced Directive was scanned into the EHR on [DATE]. Review of the DURABLE POWER OF ATTORNEY .ADVANCE CARE PLAN, dated [DATE] showed Resident #3 had marked .No . on the form for .CPR .Life Support . Review of the electronic health record (EHR) showed the document was scanned into the EHR on [DATE] and was available for staff review. Continued review showed the physician's order, care plan, and EHR were not updated to reflect the DNR code status. Review of a Nursing Note dated [DATE] at 12:58 AM showed Resident #3 was found unresponsive, did not have a pulse and was not breathing. EMS was notified and CPR was initiated at the facility. Review of a Nursing Note dated [DATE] at 1:18 AM for Resident #3 showed EMS arrived and continued with life sustaining treatment. Review of the EMS record dated [DATE] showed Resident #3 had a [MEDICAL CONDITION] and EMS was dispatched to the facility for Resident #3. Upon EMS' arrival to the facility, CPR was being performed by the staff. Facility staff stated they had been performing CPR between 15 and 20 minutes. Advanced Cardiac Life Support (ACLS) protocols were initiated by EMS. An IO (Intraosseous) (the process of injecting fluids and/or medications directly into the bone) was placed in Resident #3's left Tibia (the inner and typically larger of the two bones between the knee and the ankle. After defibrillation (the administration of electric shocks to the heart in order to reset normal heart rhythm in persons who are experiencing [MEDICAL CONDITION]), Resident #3 was shown to be in asystole (no heartbeat). ACLS protocol were started again. EMS notified the local emergency room (ER) physician and orders were obtained to discontinue CPR and life sustaining treatment. Review of a Nursing Note dated [DATE] at 2:06 AM showed .Resident (Resident #3) pronounced dead at 0206 (2:06 AM) . During an interview on [DATE] at 5:44 PM, the Director of Nursing (DON) stated Resident #3's Advance Directive was scanned into the EHR on [DATE] which indicated a DNR status and the care plan was not updated to reflect the change. During an interview on [DATE] at 6:28 PM, Registered Nurse (RN) #2 stated on [DATE] she had spoken with Resident #3's Family Member #1 (Resident #3's representative) regarding the POST form (Tennessee Physician Orders for Scope of Treatment) and Resident #3's wishes. RN #2 stated the resident's son had requested Resident #3 have a DNR status and refused to sign the POST form at that time. RN #2 stated the son indicated he was Power of Attorney (POA) and had Advance Directive paperwork at home which indicated Resident #3 was a DNR and the son would bring it to the facility later. RN #2 stated she was unsure if the son had ever brought the POA and Advanced Directive paperwork to the facility and did not follow up with facility staff after the conversation with Resident #3's Family Member #1. During an interview on [DATE] at 4:55 PM, the Minimum Data Set (MDS) Coordinator stated she updated the care plans by reviewing medical documents in the EHR and talking with staff. The MDS coordinator stated she recalled Resident #3 having a Full Code status when he was admitted to the facility. The MDS Coordinator stated she did not always review the baseline care plans and had not reviewed the baseline care plan or Advanced Directive for Resident #3. The MDS Coordinator stated she had not reviewed or knew the Advance Directive paperwork existed until [DATE]. The MDS coordinator confirmed Resident #3's care plan had not been updated to reflect the DNR code status. Medical record review showed Resident #1 was admitted to the facility on [DATE], was transferred to the hospital on [DATE], and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's medical record showed no documentation a POST form had been completed. Review of Resident #1's comprehensive care plan dated [DATE], showed .(Resident #1) is a full code .If code status changes update the medical record .Review code status quarterly to ensure preferences are honored . Review of Resident #1's Order Recap (Recapitulation) Report showed an order for [REDACTED]. Review of Resident #1's admission MDS assessment dated [DATE], showed the resident had severe cognitive impairment. Review of Resident #1's hospital Discharge to Outside Facility Form dated [DATE], showed when the resident was readmitted to the facility after a hospital stay .Current code Status .Allow Natural Death ( Do Not Attempt Resuscitation) . Review of Resident #1's admission orders [REDACTED].Code status: DNR . Review of Resident #1's Order Summary Report dated [DATE], showed no documentation of a physician's order for the resident's code status. Review of Resident #1's Nursing Note dated [DATE], showed .Called to resident room, noted resident to be in respiratory distress, provider notified via telephone of condition, instructed LPN (Licensed Practical Nurse) to call 911 .CPR strap pulled to gain hard surface, resident loss pulse, CPR initiated, EMS arrived, resident taken to (name of hospital) via ems, family notified via phone call . During an interview on [DATE] at 4:23 PM, the DON confirmed Resident #1 had been admitted to the facility on [DATE]. She had an order for [REDACTED].#1 had been transferred to the hospital on [DATE] and returned to the facility on [DATE]. The DON confirmed the admission orders [REDACTED]. The DON confirmed the CPR/full code status physician's order from the [DATE] admission had been discontinued on [DATE] by the ADON from the EHR system. During an interview on [DATE] at 6:50 PM, The MDS Coordinator confirmed Resident #1 did not have a code status in the EHR. She confirmed Resident #1's hospital discharge orders and facility admission orders [REDACTED]. The MDS Coordinator confirmed she was to review the hospital discharge orders and the facility admission orders [REDACTED]. She confirmed Resident #1's care plan had not been updated to reflect Resident #1's code status to DNR. During a phone interview on [DATE] at 12:52 PM, Resident #1's Family Member stated the facility had called her on [DATE] to inform her Resident #1 had been transferred to the hospital. The Family Member stated she went to the hospital and was informed Resident #1 had been put on a ventilator on the way to the hospital by EMS, .which she (Resident #1) had never wanted that and we (the resident's family) had never wanted that . The Family Member confirmed the family had made the decision to have Resident #1 taken off the ventilator and she died on [DATE]. The Family Member stated the facility had not discussed the resident's/family's wishes for DNR code status with the resident's family. She stated .we (the family) just didn't want that (CPR, intubation, and mechanical ventilation) and neither did she (Resident #1). We (the family) had talked to her (Resident #1) about that before her (Resident #1) dementia had gotten so bad . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Order Summary Report, showed a physician's order for CPR dated [DATE]. Review of a comprehensive care plan showed .full code . with the date initiated [DATE].If code status changes update medical record .Review code status quarterly to ensure preferences are honored . Review of a POST form dated [DATE], showed .Resuscitate .CPR . Further review showed Resident #2 had signed the form. Review of a Hospice Comprehensive Assessment and Plan of Care Update report, showed the resident had started hospice services on [DATE] and had updated the POST form with a DNR code status. Review of a POST form dated [DATE] showed Resident #2 had signed a POST form which indicated DNR and to Allow Natural Death. Review of a nursing note dated [DATE], documented by LPN #1, showed at 7:40 AM Resident #2 was found unresponsive. The resident was under hospice services and had full code status. LPN #1 notified NP #2 and NP #2 gave orders to call EMS and notify hospice. Review of EMS records dated [DATE], showed EMS was dispatched to the facility for Resident #2 and upon arrival the resident was found unresponsive in his room. Resident #2's airway was open and clear, breathing was weak and slow ,[DATE] times (normal is ,[DATE] breaths per minute) a minute and had absent radial pulses (heart rate felt at the wrist) and very weak carotid pulses (heart rate felt at the neck). The resident was moved to the ambulance. Resident #2's heart rate was only obtainable via auscultation (the action of listening to sounds) and an ECG (Electrocardiography, a method of graphic tracing of the electric current generated by the heart muscle) showed asystole (cessation of electrical and mechanical activity of the heart). Resident #2's oxygen saturations (amount of oxygen in the bloodstream) was low and he was placed on a NRB (non-rebreather, a device used to assist in the delivery of oxygen therapy). An IV (intravenous-within a vein) was attempted in his arms and both external jugular (neck veins) without success. An IO was placed in Resident #2's left Tibia. The resident was unable to control his airway and breathing and the resident was intubated. Review of emergency room (ER) records dated [DATE], showed Resident #2 was found unresponsive at the nursing home. EMS intubated the resident due to [MEDICAL CONDITION]. Shortly, after the resident's arrival to the ER, the facility called the hospital and reported Resident #2 was a DNR and should not have been intubated. The ER spoke with Resident #2's Family Member and the decision was made to take Resident #2 off the ventilator and be allowed to die naturally. During an interview on [DATE] at 6:50 PM, the MDS Coordinator stated when a resident elected to receive hospice services, she reviewed the care plan and revised as needed. The MDS Coordinator confirmed Resident #2 had been admitted to hospice care on [DATE] and had been changed to a DNR code status and she had not revised Resident #2's care plan. Refer to tags F-578 (K), F-678 (K), F-835 (K), and F-867 (K). An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received [DATE] at 3:46 PM, and the corrective actions were validated on-site by the surveyors on [DATE] through review of documents, observations, review of facility policies, and staff interviews. The Removal Plan presented to the survey team by the facility documented the following immediate corrective actions implemented. On [DATE], the Regional Nurse Consultant provided training to the Administrator, Director of Nursing, Assistant Director of Nursing, and Social Services Director. The training included: 1. Obtaining and completing a Tennessee (TN) POST and/or Advanced Directive upon admission 2. Review quarterly to ensure the residents' end of life wishes are known. On [DATE], the DON and ADON completed re-education with all licensed nursing staff and (contracted licensed nursing staff, Social Services, Medical Director, and Admissions Director. The training included: 1. Review of the facility policy and procedures for obtaining and completing the TN POST form and/or advanced Directives, 2. Obtaining a physician order for [REDACTED]. 3. Initiating and updating care plans immediately upon admission, re-admission, resident's or responsible parties' request, and/or change of status. All facility licensed staff including contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. On [DATE], all 68 residents were reassessed by the DON, ADON, and/or Social Services to ensure each resident had a TN POST form and/or Advanced Directive in the resident's medical record, and the Physician Order matched the POST form and/or Advanced Directive, and that the resident's care plan has been updated to match the TN POST and/or Advanced Directive in the medical record. This was validated by survey team on [DATE], after an audit of 68 medical records. On [DATE], the DON and ADON completed re-education with all licensed nursing staff and contracted licensed nursing staff. The training included: 1. The process for verifying a resident's code status before performing CPR, which includes viewing the POST form and the physician's order in PCC (facility's EHR). All facility licensed staff including contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. On [DATE], the DON and ADON provided re-education to all licensed nursing staff. The training included: 1. Step by Step POST form process 2. Changing existing POST forms 3. Hospice POST form changes 4. The location of POST Form Binder 5. Baseline and updating of Care Plans and orders related to code status. All facility licensed staff including contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. Daily audits will be conducted by the DON, the ADON, or designee utilizing the F835 Audit Tool of every new admission, re-admission, and on the date the resident's Quarterly MDS/Care Plan review is scheduled to ensure the TN POST and/or Advanced Directive are obtained and completed, a Physician Order is obtained and documented and the resident's Care Plan had been created and/or updated to reflect the resident's end of life wishes expressed on the TN POST and/or Advanced Directive for 3 months and then on-going as determined by the QAPI (Quality Assurance and Performance Improvement). The audits will be reviewed and signed daily by the Administrator. Admissions Team meetings are held during regular business hours Monday-Friday led by the Admissions Director and attended by department managers including DON, ADON, SSD, Administrator, and MDS Coordinator, for clinical review of new admissions, re-admissions, and changes to POST. New admission, re-admission, and changes to POST forms obtained over the weekend or holidays will be reviewed the next business day. The QAPI committee will meet weekly beginning [DATE], until compliance is sustained as deemed by the QAPI Committee. The Administrator is responsible to oversee the QAPI committee and ensure compliance is achieved. The surveyors reviewed the Removal Plan and verified 68 current resident medical records were complete and accurate and included a completed POST form with a physician's signature, a physician's order had been obtained for the code status, and the care plan had been updated to include code status. The surveyors review of the facility's Removal Plan, facility training materials, EHR, POST Form Book, Care Plans, facility policy and staff interviews verified training on maintaining accurate Advanced Directives, POST forms, code status changes, physician's orders, and baseline and comprehensive Care Plans. All facility licensed nursing staff to included contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. The surveyors interviewed 4 RN's, 2 LPN'S on all shifts, the Social Services Director, and the Admissions Coordinator on [DATE]. These interviews revealed they had received new training on the facility's policy and procedures for Advance Directives to include the new process to identify code status and how to transcribe Physician orders. Continued interview revealed they had received new education on baseline and comprehensive Care Plans and how to maintain its accuracy in the medical record. These interviews confirmed the staff was knowledgeable and able to verbalize the facility's policy and procedures for Advance Directives to include the new process to identify code status, hospice POST form status changes, how to transcribe Physician orders, baseline Care Plans, updating the comprehensive care plan, and how to maintain an accurate and complete medical record, and there were no identified concerns. Noncompliance at F657 continues at a scope and severity of E for monitoring of the effectiveness of corrective actions to ensure sustained compliance. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review, review of hospital records, review of Emergency Medical Services (EMS) documentation, interview, and review of hospice documentation, the facility failed to establish mechanisms for documenting and communicating the resident's wishes for end of life care to staff responsible for the resident's care and failed to honor those wishes for 3 of 23 residents (Resident #3, Resident #1, Resident #2) reviewed. The facility's failure to honor the residents' and/or representative(s) wishes to refuse resuscitative measures and life sustaining treatment for [REDACTED].#1, and #2 placed the residents in Immediate Jeopardy (IJ) (A situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The facility's failure had the potential to affect all 68 residents in the facility. The Administrator, Regional Nurse Consultant, and the Director of Nursing (DON) were informed of the IJ on [DATE] at 8:02 PM in the conference room. The Immediate Jeopardy was removed onsite and was effective [DATE] - [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 3:46 PM. The corrective actions were verified onsite by the surveyors on [DATE]. The findings include: Review of the facility's undated policy titled, ADVANCE DIRECTIVE POLICY AND PROCEDURE, showed .The resident has the right and the facility will assist the resident to formulate an advance directive .Resident has the right .Advance directive .a written instruction, such as .durable power of attorney .relating to the provision of health care when the individual is incapacitated .Cardiopulmonary resuscitation .refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased .Durable Power of Attorney for Health Care .document delegating to an agent the authority to make health care decisions in case the individual delegating that authority subsequently becomes incapable of doing so .Life-sustaining treatment .treatment that .sustains an individual's life and without which the individual will die .The term includes both life-sustaining medications and interventions such as mechanical ventilation .All advance directive document copies will be obtained and located in the computerized documentation system (point click care) .Resident wishes will be communicated to the staff via (by way of) the care plan . Review of the facility's policy titled, Do Not Resuscitate Order (DNR), revised ,[DATE], showed .Our facility will not use cardiopulmonary resuscitation .and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect .Do not resuscitate orders .maintained in the resident's medical record .Inquiries concerning do not resuscitate orders/request should be referred to the Administrator, Director of Nursing Services, or to the Social Services Director (SSD) . Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #3 was cognitively intact. The MDS showed Resident #3 participated in the MDS assessment. Review of Resident #3's medical record showed no documentation a Physician's Order for Scope of Treatment (POST) form (a form describes health care wishes for someone facing a life-threatening medical condition) had been completed upon admission to the facility. Review of the hospital discharge orders dated [DATE] showed Resident #3 was a Full Code (full life-sustaining treatment including CPR, intubation, and ventilator use). Review of a baseline care plan dated [DATE] showed Family Member #1 was Resident #3's representative. The care plan showed Resident #3 communicated easily and understood staff. A question on the Baseline Care Plan .Does the resident have Advanced Directives (a written statement of a person's wishes regarding medical treatment) . was marked as No. Review of a comprehensive care plan dated [DATE] showed Resident #3 had a full code status (Cardiopulmonary Resuscitation/CPR). The care plan showed Resident #3's advance directive wishes would be honored and if the code status changed the medical record would be updated. Review of the Physician's Order Summary Reports (Recapitulation Orders) dated [DATE] and [DATE] showed Resident #3's active orders were for CPR with the start date of [DATE]. Review of a Nursing Note dated [DATE] showed Registered Nurse (RN) #2 had spoken to Family Member #1 at the facility regarding the resident's code status. The note showed the resident's son had Durable Power of Attorney (POA) and Advance Care Plan paperwork at home that stated the resident wished to be a DNR. The resident's son refused to sign a POST form and instructed RN #2 he would return the next day with the paperwork. Review of the DURABLE POWER OF ATTORNEY .ADVANCE CARE PLAN, dated [DATE] showed Resident #3 had indicated he did not want CPR or Life Support (continuous use of breathing machine and other equipment that helps the lungs, heart, kidneys, and other organs to continue to work). Review of the electronic health record (EHR) showed the document was available for staff review on [DATE] in Resident #3's electronic health record. Review of a Nursing Note dated [DATE] at 12:58 AM, showed Licensed Practical Nurse (LPN) #10 found Resident #3 unresponsive, she notified RN #2, and CPR was initiated. Review of the EMS record dated [DATE] showed Resident #3 had a [MEDICAL CONDITION] (sudden loss of heart function). The record showed EMS was dispatched to the facility for Resident #3. Upon EMS arrival to the facility, CPR was being performed by the facility staff. EMS assumed care and initiated Advanced Cardiac Life Support (ACLS) protocols which included an Intraosseous (IO) access (the process of injecting fluids and/or medications directly into the bone) being placed in Resident #3's left tibia (the inner and typically larger of the two bones between the knee and the ankle). EMS defibrillated (administering a controlled electric shock to allow restoration of the normal heart rhythm) Resident #3 and CPR was immediately resumed. The EMS record showed Resident #3 was found to be in asystole (no heartbeat). ACLS protocol was restarted, the local hospital emergency room (ER) physician was contacted by EMS, and orders were received for CPR and other lifesaving interventions to be discontinued. During an interview on [DATE] at 2:04 PM, Nurse Practitioner (NP) #1 stated if there was not an Advance Directive or POST form in place and there was paperwork in the chart or the EHR which identified the resident's POA, the facility nursing staff should accept the verbal or telephone request from the resident's POA for the code status. NP #1 stated the verbal request for the code status should be witnessed by 2 licensed nurses. NP #1 stated when the facility received an Advanced Directive form for a resident, the facility should update the EHR and obtain a physician order immediately. NP #1 stated the Advance Care Directive and the representative's verbal request for the DNR status for Resident #3 was not honored. During an interview on [DATE] at 6:28 PM, RN #2 stated Resident #3 was admitted on [DATE] around 11:29 PM and was too sleepy to sign a POST form. RN #2 stated on [DATE] she spoke with Family Member #1 outside the front doors of the facility and asked him about the POST form. RN #2 stated Member #1 refused to sign a POST form at that time and indicated he had POA and Advance Directive paperwork at home which stated Resident #3 was a DNR and Family Member #1 requested Resident #3 remain a DNR. RN #2 stated Family Member #1 stated he would bring the paperwork to the facility later. RN #2 stated due to the hospital admission orders [REDACTED]. On [DATE] at 12:58 AM, according to the nurse's notes, Resident #3 was found unresponsive by an LPN. RN #2 stated she was told Resident #3 was unresponsive, checked his code status on the EHR and saw it indicated CPR. RN #2 stated she initiated CPR and EMS was notified. Once EMS arrived, they took over life sustaining treatment/CPR. EMS notified the emergency room physician and was given an order to stop CPR. RN #2 stated based on Resident #3's Advance Directive of a DNR status, CPR should not have been initiated and Resident #3's end of life wishes were not honored. During a telephone interview on [DATE] at 1:04 PM, the Medical Director of the facility confirmed if Resident #3's Advanced Directive indicated a DNR status and CPR was performed, Resident #3's wishes for end of life care were not followed. The Medical Director confirmed a verbal request by a resident or a resident's POA/Representative(s) for a code status or a change in code status should be honored. Medical record review showed Resident #1 was admitted to the facility on [DATE], was transferred to the hospital on [DATE], and was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's medical record showed no documentation a POST form had been completed. Review of Resident #1's Comprehensive Care Plan dated [DATE], showed .(Resident #1) is a full code . Review of Resident #1's Physician's Recap Orders showed an order for [REDACTED]. Review of Resident #1's hospital Discharge to Outside Facility Form dated [DATE], showed .Current code Status .Allow Natural Death (Do Not Attempt Resuscitation) . Review of Resident #1's admission orders [REDACTED]. Review of Resident #1's Order Summary Report dated [DATE], showed no documentation of a physician's order for the resident's code status. Review of Resident #1's Nursing Note dated [DATE], showed .Called to resident room, noted resident to be in respiratory distress, provider notified via telephone of condition, instructed LPN to call 911 .CPR initiated, EMS arrived, resident taken to (name of hospital) via ems, family notified via phone call . Review of Resident #1's EMS documentation dated [DATE], showed EMS .arrived .The patient was unconscious .Nursing home staff stated they performed CPR for four minutes and got pulses (heart rate) back on the patient . EMS .intubated (placement of a tube into the windpipe to maintain an open airway) . Review of Resident #1's Emergency Department documentation dated [DATE], showed .Patient presents with .Post [MEDICAL CONDITION] .Nursing home staff stated she became unresponsive and started CPR. She was intubated when EMS arrived .Spoke with patient's family .she (Resident #1) had wished to be DNR . During an interview on [DATE] at 4:43 PM, the DON confirmed Resident #1's Admission Order form dated [DATE] showed an order for [REDACTED].#1 became unresponsive, the EHR said CPR. The DON confirmed the facility did not have a POST form completed from Resident #1's admission on [DATE] or the readmission on [DATE]. During an interview on [DATE] at 4:23 PM, the DON confirmed Resident #1 had been admitted to the facility on [DATE] with an order for [REDACTED].#1 was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. The hospital admission orders [REDACTED]. The DON stated RN #2 completed the [DATE] admission for Resident #1 and did not enter the DNR code status order in the EHR. The DON confirmed the CPR/full code physician's order dated [DATE] had been discontinued on [DATE] from the EHR system and the updated DNR code status had not been entered into the EHR Physician's Orders. The DON stated on [DATE], Resident #1 was not breathing well, the DON checked the resident's EHR and saw the resident had a CPR/full code status. Resident #1 lost a pulse/heart rate and the DON initiated CPR. The DON confirmed a physician's order for [DATE] for a DNR code status was not readily available/accessible in the EHR. The DON confirmed the facility failed to complete a POST form on [DATE] to reflect a DNR code status for Resident #1, which resulted in initiation of CPR against Resident #1's wishes. During a phone interview on [DATE] at 12:52 PM, Resident #1's Family Member stated the facility had called her on [DATE] to inform her Resident #1 had been transferred to the hospital. The Family Member stated she went to the hospital and was informed Resident #1 had been put on a ventilator on the way to the hospital by EMS, .which she (Resident #1) had never wanted that and we (the resident's family) had never wanted that . The Family Member confirmed the family had made the decision to have Resident #1 taken off the ventilator and she died on [DATE]. The Family Member stated the facility had not discussed the resident's/family's wishes for DNR code status with the resident's family. She stated .we (the family) just didn't want that (CPR, intubation, and mechanical ventilation) and neither did she (Resident #1). We (the family) had talked to her (Resident #1) about that before her (Resident #1) dementia had gotten so bad . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Physician's Order Summary Report dated [DATE], showed .CPR .order date [DATE] . Review of an undated Comprehensive Care Plan showed .full code .Date Initiated: [DATE] . Review of a POST form dated [DATE], showed .Resuscitate .CPR . and Resident #2 had signed the POST form. Review of a Hospice Comprehensive Assessment and Plan of Care Update report, showed .SOC (Start Of Care) XXX[DATE] .Advance Directive .DO NOT RESUSCITATE . Review of the medical record showed the document had not been scanned into the resident's EHR on [DATE]. Review of a POST form dated [DATE] (after the resident was admitted to hospice services), showed .Do Not Attempt Resuscitation .DNR .no CPR .Allow Natural Death .Comfort Measures .Do not transfer to hospital for life-sustaining treatment . Resident #2 had signed the POST form. Review of the Electronic Medication Administration Record [REDACTED].Advance Directive .CPR . Review of a nursing note dated [DATE], documented by LPN #1, showed .0740 (7:40 AM) resident (Resident #2) unresponsive .Resident is hospice, full code. New order from NP to call EMS and hospice . Review of EMS records dated [DATE], showed .EMS dispatched to (name of facility) .found patient (Resident #2) unresponsive in his room .the decision to intubate was made . by EMS. Review of ER records dated [DATE], showed .Chief Complaint .Altered Mental Status .(Resident #2) found unresponsive at nursing home. Intubated by ems .shortly after the patient's arrival his facility called and reported that he was DNR and should not have been intubated .do not have paperwork that corroborates this . During a telephone interview on [DATE] at 12:23 PM, LPN #1 stated she worked day shift on [DATE]. She also stated she observed Resident #2 around 7:15 AM to be unresponsive. LPN #1 notified NP #2 and informed her of Resident #2's change in condition, was on hospice, and had a full code status. LPN #1 stated she was informed the Assistant Director of Nursing (ADON) had found a new POST form, which indicated Resident #2 was a DNR Status, after the resident had been transferred to the hospital. LPN #1 confirmed Resident #2 was DNR and was transferred to the hospital and intubated against his wishes. During a telephone interview on [DATE] at 1:59 PM, LPN #6 stated if a resident was a DNR and receiving Hospice services and became unresponsive, hospice would be notified of the decline, but the resident would not be transported to the hospital for life sustaining treatment, such as CPR or intubation, unless directed by hospice. LPN #6 stated the normal process for verifying a resident's code status was to check the E-MAR or admission notes, and the POST form was to be scanned into the EHR. During a telephone interview on [DATE] at 3:18 PM, Hospice RN #1 stated the facility had contacted the hospice triage nurse on [DATE]. Resident #2 was not breathing good and was being transported to the hospital. The triage nurse contacted Hospice RN #1. Hospice RN #1 called the facility and spoke with the ADON and informed the ADON Resident #2 was a DNR/Comfort measures. Hospice RN #1 also stated the ADON informed her the facility records identified the resident as a full code status and the facility would need the updated POST form which indicated the DNR status. Hospice RN #1 informed the ADON she would fax the POST and instructed the facility not to send Resident #2 to the hospital. The ADON informed Hospice RN #1 she would let Resident #2's nurse know about the DNR status. Hospice RN #1 stated she had not received a telephone call back from the facility to let her know they had received the POST form which indicated the DNR status (which was signed by Resident #2 on [DATE]). Hospice RN #1 stated she called the facility's Administrator and the Administrator informed her the POST form, which indicated the DNR status, had not been received and the facility's POST form on file indicated Resident #2's code status was as a full code. Hospice RN #1 informed the Administrator she would refax the form and again instructed the facility not to send Resident #2 to the emergency room (ER). The Administrator informed Hospice RN #1 Resident #2 had already been transported to the ER. Hospice RN #1 stated she obtained a new POST form for DNR status for Resident #2 on [DATE] and had provided a copy of the POST form to the facility at that time. During an interview on [DATE] at 4:19 PM, RN #5 stated the residents' code status was in the EHR and the E-Mar under the resident's name. She also stated if a resident had DNR/Hospice status, the resident would not be transferred to the ER for life sustaining treatment. RN #5 stated if a resident transitioned to hospice services and wished to change their code status, the hospice nurse was responsible for completing a new POST form and obtaining a new physician's order for the code status change. The hospice nurse would give the facility nurse a copy of the POST form and new physician's order with the status change. The facility nurse was responsible for ensuring the new order was placed in the EHR. During an interview on [DATE] at 7:49 AM, LPN #5 stated the facility's policy was if a resident had a DNR/Hospice status, the resident remained in the facility, was not to be transferred to the hospital unless the family requested, and no life sustaining treatment should be initiated, including CPR or intubation. LPN #5 stated in an emergency situation, she would follow the code status in the EHR. LPN #5 stated if a resident transitioned to hospice care and decided to change their code status, the hospice nurse was responsible for completing the new POST form and obtaining a new physician's order. After the new POST form and physician's order was signed by the hospice physician, the forms were faxed to the facility. During an interview on [DATE] at 10:10 AM, NP #1 stated she was not aware Resident #2 had a DNR status. NP #1 stated Resident #2's POST form dated [DATE] showed he was a full code and she was unaware Resident #2 had an updated POST form dated [DATE] indicating a DNR status. NP #1 stated it was her expectation if a resident had a DNR code status, the resident should not be transferred to the ER or receive life sustaining treatment. During an interview on [DATE] at 10:45 AM, the DON confirmed the facility failed to obtain the updated POST form dated [DATE] from the hospice agency indicating Resident #2 wished to be a DNR, which resulted in Resident #2 being transferred to the ER and receiving life sustaining treatment. The DON confirmed the facility failed to follow the facility's policy for DNR status and failed to honor Resident #2's end of life wishes. During an interview on [DATE] at 11:28 AM, the ADON stated she was working on [DATE] when Resident #2 had a significant decline and was transferred to the hospital. The ADON stated she had received a call from a hospice nurse regarding Resident #2, but did not recall the specifics of the conversation. During an interview on [DATE] at 11:41 AM, the Administrator confirmed the facility failed to provide care according to Resident #2's end of life wishes as stated on the POST form completed by hospice on [DATE]. During a telephone interview on [DATE] at 1:02 PM, the Medical Director confirmed it was his expectation if a resident had a POST form with a DNR status, the resident should not receive life sustaining treatment. The Medical Director confirmed the POST form indicating DNR status for Resident #2 was not honored and the residents received life sustaining treatment against their end of life wishes. Refer to tags F-657 (K), F-678 (K), F-835 (K), and F-867 (K) An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received [DATE] at 3:46 PM, and the corrective actions were validated on-site by the surveyors on [DATE] through review of documents, observations, review of facility policies, and staff interviews. The Removal Plan presented to the survey team by the facility documented the following immediate corrective actions implemented. On [DATE], the Regional Nurse Consultant provided training to the Administrator, Director of Nursing, Assistant Director of Nursing, and Social Services Director. The training included: 1. Obtaining and completing a TN POST and/or Advanced Directive upon admission. 2. Review quarterly to ensure the resident's end of life wishes are known. On [DATE], the DON and ADON completed re-education with all licensed nursing staff and contracted licensed nursing staff, Social Services, Medical Director, and Admissions Director. The training included: 1. Review of the facility policy and procedures for obtaining and completing the TN POST form and/or advanced Directives. 2. Obtaining a physician order for [REDACTED]. 3. Initiating and updating care plans immediately upon admission, re-admission, resident's or responsible parties' request, and/or change of status. All facility licensed staff including contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. On [DATE], all 68 residents were reassessed by the DON, ADON, and/or Social Services to ensure each resident had a Tennessee (TN) POST form and/or Advanced Directive in the resident's medical record, and the Physician Order matched the POST form and/or Advanced Directive, and that the resident's care plan had been updated to match the TN POST and/or Advanced Directive in the medical record. This was validated by survey team on [DATE], after an audit of 68 medical records. On [DATE], the DON and ADON completed re-education with all licensed nursing staff and contracted licensed nursing staff. The training included: 1. The process for verifying a resident's code status before performing CPR, which includes viewing the POST form and the physician's order in PCC (facility's EHR). All facility licensed staff including contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. On [DATE], the DON and ADON provided re-education to all licensed nursing staff. The training included: 1. Step by Step POST form process 2. Changing existing POST forms 3. Hospice POST form changes 4. The location of POST Form Binder (POST form book) 5. Baseline and updating of Care Plans and orders related to code status. All facility licensed staff including contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. Daily audits will be conducted by the DON, the ADON, or designee utilizing the F835 Audit Tool of every new admission, re-admission, and on the date the resident's Quarterly MDS/Care Plan review is scheduled to ensure the TN POST and/or Advanced Directive are obtained and completed, a Physician Order is obtained and documented, and the resident's Care Plan had been created and/or updated to reflect the resident's end of life wishes expressed on the TN POST and/or Advanced Directive for 3 months and then on-going as determined by the QAPI (Quality Assurance and Performance Improvement). The audits will be reviewed and signed daily by the Administrator. Admissions Team meetings are held during regular business hours Monday-Friday led by the Admissions Director and attended by department managers including DON, ADON, SSD, Administrator, and MDS Coordinator, for clinical review of new admissions, re-admissions, and changes to POST. New admission, re-admission, and changes to POST forms obtained over the weekend or holidays will be reviewed the next business day. The QAPI committee will meet weekly beginning [DATE], until compliance is sustained as deemed by the QAPI Committee. The Administrator is responsible to oversee the QAPI committee and ensure compliance is achieved. The surveyors reviewed the Removal Plan and verified 68 current resident medical records were complete and accurate and included a completed POST form with a physician's signature, a physician's order had been obtained for the code status, and the care plan had been updated to include code status. The surveyors review of the facility's Removal Plan, facility training materials, EHR, POST Form Book, Care Plans, facility policy and staff interviews verified training on maintaining accurate Advanced Directives, POST forms, code status changes, physician's orders, and baseline and comprehensive care plans. All facility licensed nursing staff to include contracted staff who were not working on [DATE] will be re-educated on the date of their return to work. The surveyors interviewed 4 Registered Nurses (RN's), 2 Licensed Practical Nurses (LPN'S) on all shifts, the SSD, and the Admissions Coordinator on [DATE]. These interviews revealed they had received new training on the facility's policy and procedures for Advance Directives to include the new process to identify code status and how to transcribe physician orders. Continued interview revealed they had received new education on baseline and comprehensive care plans and how to maintain its accuracy in the medical record. These interviews confirmed the staff were knowledgeable and able to verbalize the facility's policy and procedures for Advance Directives to include the new process to identify code status, hospice POST form status changes, how to transcribe Physician orders, Baseline and comprehensive care plans, updating the comprehensive care plan, and how to maintain an accurate and complete medical record, and there were no identified concerns. Noncompliance at F578 continues at a scope and severity of E for monitoring of the effectiveness of corrective actions to ensure sustained compliance. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review, and interview, the facility failed to investigate an allegation of abuse timely for 1 resident (Resident #5) of 9 residents reviewed for abuse. The facility's failure to investigate an allegation of abuse resulted in psychosocial harm for Resident #5. The findings include: Review of the facility's policy titled, Abuse Prohibition/Investigative Policy, revised 11/2016, showed .All reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by abuse coordinator and involve facility management as needed .Should an incident or suspected incident of resident abuse, mistreatment .be reported, the Administrator will immediately assign a person to be in charge of abuse investigation .The abuse Coordinator will, as a minimum .Review the resident's medical record to determine events leading up to the incident .Obtain Statements from persons involved in incident .Interview the person(s) reporting the incident .Interview the resident .Interview the resident's Attending Physician as needed to determine the resident's current level of function and medical condition .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate, family members, and visitors .Interview other residents to whom the accused employee provides care .Employees of this facility who have been accused of resident abuse will be immediately suspended from duty until the results of the investigation have been reviewed by the Administrator . Medical record review showed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's care plan dated 4/27/2020, showed .(Resident #5) has anxiety, depression, with complaints of feeling tired and having little energy. Hx (history) of Verbal altercation with another resident no longer in the facility .Attention seeking behavior-uses call light, the (then) doesn't want anything .(Resident #5) has bowel/bladder incontinence (lack of voluntary control of bowels or bladder) .Check resident every two hours and assist with toileting as needed .(Resident #5) has anxiety, depression .Observe for signs and symptoms [MEDICAL CONDITION] hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or [MEDICAL CONDITION] . Review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact. Further review showed the resident required extensive assistance of 1 staff member for toileting and was always incontinent. During an interview on 3/8/2021 at 3:29 PM, Registered Nurse (RN) #4 stated she had been aware of an incident in which a staff member had talked inappropriately to a resident. RN #4 stated a Certified Nurse Aide (CNA) told her Resident #5 was crying and RN #4 went to the resident's room to see what was wrong. Resident #5 told her a night shift CNA had told Resident #5 nobody liked her, nobody wanted to help her, and Resident #5 was a .pee pee pants . RN #4 stated she had interviewed Resident #5's roommate about the incident and the roommate (Resident #51) had reported the same occurrence. RN #4 stated she had reassured the resident and informed her she would take care of her. RN #4 stated she had reported the incident to the Director of Nursing (DON). RN #4 was unsure of the date of the incident and stated it was maybe one day last week. RN #4 was unable to recall the name of the CNA, but she had worked the night shift and RN #4 had seen her leave the facility this morning (3/8/2021). During an interview on 3/8/2021 at 4:38 PM, the DON stated he had not been made aware of an incident between a night shift CNA and Resident #5. During an interview on 3/8/2021 at 4:47 PM, RN #4 stated she may have reported the incident to the Administrator and not to the DON. During an interview on 3/8/2021 at 5:16 PM, the DON revealed Resident #5 was interviewed on 3/8/2021 and had stated the incident had occurred last week. The DON stated he had checked the schedule and CNA #5 had worked on Tuesday (3/2/2021). During an interview on 3/8/2021 at 5:18 PM, the Administrator stated she had not been made aware Resident #5 had reported CNA #5 had spoken inappropriately to her. During an interview on 3/9/2021 at 9:00 AM, Resident #5 stated the incident occurred at about 2:00 AM. She was unable to remember the date but thought it was last Tuesday or Wednesday (3/2/2021 or 3/3/2021). Resident #5 stated she was cold and wanted a blanket. Resident #5 stated the CNA had told her she was inconsiderate and mean to other people and had called Resident #5 a brat. The resident was unable to remember the staff member's name but stated she was a CNA. Resident #5 stated she had been very upset and had reported the incident to RN #7. During an interview on 3/9/2021 at 9:05 AM, Resident #5's roommate, Resident #51, stated the incident had occurred at about 4:00 AM. She stated she had been sleeping and had been awakened by yelling. Resident #51 stated the CNA told Resident #5 that none of the nurses liked her, and Resident #5 kept it too cold in the room. Resident #51 stated the incident occurred a couple of weeks ago. She was unable to remember the CNA's name. Resident #51 stated Resident #5 had reported the incident to the night shift supervisor who had told Resident #5 that the CNA would not be allowed to come back into the room. Resident #51 confirmed the CNA had not been back into the room. During a phone interview on 3/9/2021 at 3:33 PM, CNA #7 stated she did remember CNA #5 had .upset . Resident #5 but was unsure of what day it had occurred. CNA #7 stated she was assisting CNA #5 to provide incontinence care to Resident #5 and CNA #5 had told Resident #5 she should be able to roll herself in the bed. CNA #7 stated CNA #5 had been .a little hateful . and .could tell by looking at (Resident #5) it had hurt her feelings . CNA #7 stated she had reported this to the Licensed Practical Nurse (LPN) and was told .there was already something being looked into . CNA #7 stated the night shift supervisor, RN #7, had told CNA #7 she had to provide care to Resident #5 because CNA #5 was not allowed back into that room because CNA #5 had made Resident #5 cry. During an interview on 3/9/2021 at 4:55 PM, the DON stated CNA #5 had previously reported Resident #5 had yelled at her about the air conditioner. The DON stated he had talked to Resident #5 and she had admitted she had yelled at CNA #5, but Resident #5 had not made any complaints about CNA #5 at the time of that interview. The DON confirmed he had told CNA #5 to not go back into Resident #5's room, but he was unable to remember the date. Review of a Psychiatric Progress Note dated 3/9/2021, showed .I was told by staff that she had a problem with one of the night shift CNAs that had apparently said some pretty negative things to (Resident #5) and that she had made a complaint about the incident. I asked her if anything had happened, she said no. I asked her multiple times and telling her that I was there to talk about what happened and she still declined to speak to me about any of the issues, which was very unusual for her . During an interview on 3/9/2021 at 5:06 PM, the Psychiatric Nurse Practitioner (NP) stated she had been asked to interview Resident #5 on this date (3/9/2021) to talk to her about the incident between Resident #5 and CNA #5. She stated Resident #5 had told her everything was fine and had not discussed the incident with her. The Psychiatric NP stated Resident #5 usually would tell her about incidents, even if it had occurred weeks ago. She stated Resident #5 had denied the incident, which she felt was unusual for the resident. During a phone interview on 3/10/2021 at 12:09 PM, CNA #5 stated she had gone into Resident #5's room to answer the call light and found both residents were asleep. She stated she had turned the call light off and left the room. CNA #5 stated this had happened twice. CNA #5 stated the call light came back on for the third time and she went back into the room and asked Resident #51 if she needed anything. Resident #51 had said she had not turned the call light on and did not need anything. CNA #5 stated she then tapped Resident #5 on her shoulder to wake her up and asked what she needed. CNA #5 stated Resident #5 had begun to yell at the CNA. CNA #5 stated Resident #5 had yelled things like .I hate you .I want a CNA to be nice to me .I want a nice CNA . but stated she had not called the resident any names or talked mean to her. CNA #5 stated the RN Supervisor, RN #7, had gone into the room and spoke with Resident #5. CNA #5 stated the DON had told her to not go back into Resident #5's room, and she had not been in the room since that date. CNA #5 was unable to remember the date but thought it had been about 2 weeks ago. During a phone interview on 3/11/2021 at 5:47 AM, RN #8 confirmed she had been told that CNA #5 was not allowed to go back into Resident #5's room. RN #8 stated she had been told Resident #5 had become upset and yelled at CNA #5, and CNA #5 was no longer allowed in the resident's room. RN #8 stated RN #7 had reported the incident to day shift. During a phone interview on 3/11/2021 at 6:07 AM, RN #7 confirmed she was the night shift supervisor. She confirmed Resident #5 did make a complaint, but she could not remember the date, and stated .maybe last week . RN #7 stated CNA #5 had come to her to report Resident #5 had yelled at her. RN #7 stated she went to the resident's room and the resident was crying and, at first, was unable to tell her what was wrong. RN #7 stated she had not seen the resident that upset before and she tried to calm her. RN #7 stated the resident reported CNA #5 had asked her to turn her TV down. Resident #5 told RN #7 she had turned her call light on, and CNA #5 had entered the room and turned the call light off. The resident had turned the call light back on and CNA #5 reentered the room and again turned the call light off without assisting her. Resident #5 reported the third time she had turned the call light on, CNA #5 entered the room, and with a loud voice had told Resident #5 to turn her TV down. RN #7 stated the resident had reported CNA #5 was .hateful . RN #7 stated she had assured the resident CNA #5 would not be allowed back into the room. RN #7 stated she spoke to CNA #5 and CNA #5 did report she had turned the call light off because she thought the resident was sleeping, and the third time she entered the room she had rubbed the resident's leg to wake her up and ask what she needed, when the resident began to yell at her. RN #7 stated she had instructed CNA #5 not to go back into that room and the other CNAs would care for Resident #5. RN #7 stated she believed this occurred at about 5:37 AM but was unable to remember the date. She stated she thought it was about 2 weeks ago. RN #7 stated she had reported it to the day shift nurses, LPN #2 and RN #4. RN #7 stated she had also reported to the DON that CNA #5 had hurt Resident #5's feelings when she asked her to turn the TV down, and Resident #5 said the CNA was hateful to her. During an interview on 3/11/2021 at 2:18 PM, LPN #2 stated Resident #5 had turned her call light on and told a CNA that she wanted to speak to LPN #2. LPN #2 went into the room and Resident #5 was .sobbing . Resident #5 reported CNA #5 had told the resident she was spoiled and selfish, nobody liked her, nobody wanted to take care of her, and if she didn't pee her pants, people would come in her room more often. LPN #2 stated she immediately reported the incident to RN #4 who then reported it to the Administrator. LPN #2 stated she had not known of Resident #5 crying and upset before that day. LPN #2 was unable to remember the date this occurred. During an interview on 3/11/2021 at 2:43 PM, the DON confirmed he was unsure of the date the incident occurred. He stated it had been a couple weeks ago when he had told CNA #5 to not go back into Resident #5's room. He confirmed the facility had not investigated the allegation of abuse timely.

Based on facility policy review, medical record review, and interview, the facility failed to report an allegation of abuse timely for 1 Resident (Resident #5) of 7 residents reviewed for abuse, which resulted in psychosocial harm for Resident #5. The findings include: Review of the facility's policy titled, Abuse Prohibition/Investigative Policy, revised 11/2016, showed .All reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by abuse coordinator and involve facility management as needed .Should an incident or suspected incident of resident abuse, mistreatment .be reported, the Administrator will immediately assign a person to be in charge of abuse investigation .The abuse Coordinator will call the 1-800-96-Abuse line immediately .no later than 24 hours from allegation) and provide the necessary information to the Hot Line Operator .The Federal Immediate Report will be completed and sent immediately (No later than 24 hours) from initiation of investigation .The Federal 5 day Report which will be sent within 5 working Days, as well as to other state survey and certification agencies as requested/required . Medical record review showed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's care plan dated 4/27/2020, showed .(Resident #5) has anxiety, depression, with complaints of feeling tired and having little energy. Hx (history) of Verbal altercation with another resident no longer in the facility .Attention seeking behavior-uses call light, the (then) doesn't want anything .(Resident #5) has bowel/bladder incontinence (lack of voluntary control of bowels or bladder) .Check resident every two hours and assist with toileting as needed .(Resident #5) has anxiety, depression .Observe for signs and symptoms [MEDICAL CONDITION] hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or [MEDICAL CONDITION] . Review of resident #5's quarterly Minimum data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact. Further review showed the resident required extensive assist of 1 staff member for toileting and was always incontinent. Review of a Psychiatric Progress Note dated 3/9/2021, showed .I (Psychiatric Nurse Practitioner (NP)) was told by staff that she had a problem with one of the night shift CNAs (Certified Nurse Aide) that had apparently said some pretty negative things to (Resident #5) and that she (Resident #5) had made a complaint about the incident. I (Psychiatric NP) asked her (Resident #5) if anything had happened, she said no. I (Psychiatric NP) asked her (Resident #5) multiple times and telling her that I was there to talk about what happened and she (Resident #5) still declined to speak to me about any of the issues, which was very unusual for her . During an interview on 3/8/2021 at 3:29 PM, Registered Nurse (RN) #4 stated she was aware of an incident in which a staff member had talked inappropriately to a resident. RN #4 stated a CNA told her Resident #5 was crying and RN #4 went to the resident's room to see what was wrong. Resident #5 told her a night shift CNA had told Resident #5 nobody liked her, nobody wanted to help her, and Resident #5 was a .pee pee pants . RN #4 stated she had interviewed Resident #5's roommate (Resident #51) about the incident and the roommate had reported the same occurrence. RN #4 stated she had reported the incident to the Director of Nursing (DON). RN #4 was unsure of the date of the incident and stated it was maybe one day last week. During an interview on 3/8/2021 at 4:38 PM, the DON stated he had not been made aware of an incident between a night shift CNA and Resident #5. The DON stated .that is abuse and is reportable and now I'm going to have to report it because you (the surveyor) just told me about it . During an interview on 3/8/2021 at 4:47 PM, RN #4 stated she may have reported the incident to the Administrator and not to the DON. During an interview on 3/8/2021 at 5:18 PM, the Administrator stated she had not been made aware Resident #5 had reported CNA #5 had spoken inappropriately to her. The Administrator stated if she had been made aware of any staff making statements like that towards any resident, she would have reported it to the state. During an interview on 3/9/2021 at 9:00 AM, Resident #5 stated the incident occurred at about 2:00 AM. She was unable to remember the date but thought it was last Tuesday or Wednesday (3/2/2021 or 3/3/2021). Resident #5 stated she was cold and wanted a blanket. Resident #5 stated the CNA had told her she was inconsiderate and mean to other people and had called the resident a brat. The resident was unable to remember the staff member's name but stated she was a CNA. Resident #5 stated she had been very upset and had reported the incident to RN #7. During an interview on 3/9/2021 at 9:05 AM, Resident #5's roommate, Resident #51, stated the incident had occurred at about 4:00 AM. She stated she had been sleeping and had been awakened by yelling. Resident #51 stated the CNA told Resident #5 that none of the nurses liked her, and Resident #5 kept it too cold in the room. Resident #51 stated the incident occurred a couple of weeks ago. She stated Resident #5 had reported the incident to the night shift supervisor. During a phone interview on 3/10/2021 at 12:09 PM, CNA #5 stated she had gone into resident #5's room to answer the call light and found both residents were asleep. She stated she had turned the call light off and left the room. CNA #5 stated this had happened twice. CNA #5 stated the call light came back on for the third time and she went back into the room and asked roommate if she needed anything. The roommate had said she had not turned the call light on and did not need anything. CNA #5 stated she then tapped Resident #5 on her shoulder to wake her up and asked what she needed. CNA #5 stated Resident #5 had begun to yell at the CNA. CNA #5 stated Resident #5 had yelled things like .I hate you .I want a CNA to be nice to me . I want a nice CNA but stated she had not called the resident any names or talked mean to her. CNA #5 stated the RN Supervisor, RN #7, had gone into the room and spoke with Resident #5. CNA #5 was unable to remember the date but thought it had been about 2 weeks ago. During a phone interview on 3/11/2021 at 6:07 AM, RN #7 confirmed she was the night shift supervisor. She confirmed Resident #5 did make a complaint, but she could not remember the date stated .maybe last week . RN #7 stated CNA #5 had come to her to report Resident #5 had yelled at her. RN #7 stated she went to the resident's room and the resident was crying and, at first, was unable to tell her what was wrong. RN #7 stated she had not seen the resident that upset before and she tried to calm her. RN #7 stated the resident reported CNA #5 had asked her to turn her TV down. Resident #5 told RN #7 she had turned her call light on, and CNA #5 had entered the room and turned the light off. The resident had turned the light back on and CNA #5 reentered the room and again turned the light off without assisting her. Resident #5 reported the third time she had turned the call light on, CNA #5 entered the room and with a loud voice had told Resident #5 to turn her TV down. RN #7 stated the resident had reported CNA #5 was .hateful . RN #7 stated she believed this occurred at about 5:37 AM but was unable to remember the date. She stated she thought it was about 2 weeks ago. RN #7 stated she had reported the incident to the day shift nurses, Licensed Practical Nurse (LPN) #2 and RN #4. RN #7 stated she had also reported to the DON that CNA #5 had hurt Resident #5's feelings when she asked her to turn the TV down and Resident #5 said the CNA was hateful to her. During an interview on 3/11/2021 at 2:18 PM, LPN #2 stated Resident #5 had turned her call light on and told a CNA that she wanted to speak to LPN #2. LPN #2 went into the room and Resident #2 was .sobbing . and reported to LPN #2 that CNA #5 had told the resident she was spoiled and selfish, nobody liked her and nobody wanted to take care of her, and if she didn't pee her pants people would come in her room more often. LPN #2 stated she immediately reported the incident to RN #4 who then reported it to the Administrator. LPN #2 was unable to remember the date this occurred. During an interview on 3/11/2021 at 2:43 PM, the DON confirmed he was unsure of the date the incident occurred. He stated it had been a couple weeks ago when he had told CNA #5 to not go back into Resident #5's room. He confirmed the facility had not reported the allegation of abuse timely.

Based on facility policy review, medical record review, and interview, the facility failed to prevent abuse for 1 resident (Resident #5) of 9 residents reviewed for abuse. The facility's failure to prevent abuse for Resident #5 resulted in psychosocial harm. The findings include: Review of the facility's policy titled, Abuse Prohibition/Investigative Policy, revised 11/2016, showed .Verbal abuse: is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents .Mental abuse: includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation .Actions to prevent abuse .Providing resident .information on how and to whom they may report concerns, incidents, and grievances, without the fear of retribution, and provide feedback regarding the concerns that they have expressed .Identifying, correcting and intervening in situations in which abuse .are more likely to occur .Anyone who witnesses an incident of suspected abuse .tell the abuser to stop immediately and to report it to the nursing supervisor immediately .The employee alleged to have committed the act of abuse will be immediately removed from duty pending investigation of the incident .The Administrator or designee shall place the employee on immediate suspension pending an investigation of the incident .The facility will protect resident from further harm during the investigation and provide the resident with a safe environment .social services director/designee will monitor the resident feelings concerning the incident and document the findings in the resident's medical record . Medical record review showed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's care plan dated 4/27/2020, showed .(Resident #5) has anxiety, depression, with complaints of feeling tired and having little energy. Hx (history) of Verbal altercation with another resident no longer in the facility .Attention seeking behavior-uses call light, the (then) doesn't want anything .(Resident #5) has bowel/bladder incontinence (lack of voluntary control of bowels or bladder) .Check resident every two hours and assist with toileting as needed .(Resident #5) has anxiety, depression .Observe for signs and symptoms [MEDICAL CONDITION] hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or [MEDICAL CONDITION] . Review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact. Further review showed the resident required extensive assistance of 1 staff member for toileting and was always incontinent. During an interview on 3/8/2021 at 3:29 PM, Registered Nurse (RN) #4 stated she had been aware of an incident in which a staff member had talked inappropriately to a resident. RN #4 stated a Certified Nurse Aide (CNA) told her Resident #5 was crying and RN #4 went to the resident's room to see what was wrong. Resident #5 told her a night shift CNA had told Resident #5 nobody liked her, nobody wanted to help her, and Resident #5 was a .pee pee pants . RN #4 stated she had interviewed Resident #5's roommate about the incident and the roommate (Resident #51) had reported the same occurrence. RN #4 stated she had reassured the resident and informed her she would take care of her. RN #4 stated she had reported the incident to the Director of Nursing (DON). RN #4 was unsure of the date of the incident and stated it was maybe one day last week. RN #4 was unable to recall the name of the CNA, but she had worked the night shift and RN #4 had seen her leave the facility this morning (3/8/2021). During an interview on 3/8/2021 at 4:38 PM, the DON stated the alleged abuse had not been reported to him. During an interview on 3/8/2021 at 4:47 PM, RN #4 stated she may have reported the incident to the Administrator and not to the DON. During an interview on 3/8/2021 at 5:16 PM, the DON revealed Resident #5 was interviewed on 3/8/2021 and stated the incident had occurred last week. The DON stated he had checked the schedule and CNA #5 had worked on Tuesday (3/2/2021). The DON stated this may have been the date the incident occurred. During an interview on 3/8/2021 at 5:18 PM, the Administrator stated she had not been informed Resident #5 had reported CNA #5 had spoken inappropriately to her. During an interview on 3/9/2021 at 9:00 AM, Resident #5 stated the incident occurred at about 2:00 AM. She was unable to remember the date but thought it was last Tuesday or Wednesday (3/2/2021 or 3/3/2021). Resident #5 stated she was cold and wanted a blanket. Resident #5 stated the CNA had told her she was inconsiderate and mean to other people and had called Resident #5 a brat. The resident stated the staff member was a CNA, but she was unable to remember the CNA's name. Resident #5 stated she had been very upset and had reported the incident to RN #7. During an interview on 3/9/2021 at 9:05 AM, Resident #5's roommate, Resident #51, stated she did remember the incident that occurred between Resident #5 and a CNA. She was unable to remember the CNA's name. Resident #51 stated the incident had occurred at about 4:00 AM a couple of weeks ago. Resident #51 stated she had been sleeping and had been awakened by yelling. Resident #51 stated the CNA told Resident #5 that none of the nurses liked her, and Resident #5 kept it too cold in the room. Resident #51 stated Resident #5 had reported the incident to the night shift supervisor who had told Resident #5 that the CNA would not be allowed to come back into the room. Resident #51 confirmed the CNA had not been back into the room. During a phone interview on 3/9/2021 at 3:33 PM, CNA #7 stated she did remember CNA #5 had .upset . Resident #5 but was unsure of what day it had occurred. CNA #7 stated she was assisting CNA #5 to provide incontinence care to Resident #5 and CNA #5 had told Resident #5 she should be able to roll herself in the bed. CNA #7 stated CNA #5 had been .a little hateful . and .could tell by looking at (Resident #5) it had hurt her feelings . CNA #7 stated she had reported this to the Licensed Practical Nurse (LPN) and was told .there was already something being looked into . CNA #7 stated the night shift supervisor, RN #7, had told CNA #7 she had to provide care to Resident #5 because CNA #5 was not allowed back into that room because CNA #5 had made Resident #5 cry. During an interview on 3/9/2021 at 4:55 PM, the DON confirmed there was a past incident that had occurred between CNA #5 and Resident #5 and he had told CNA #5 to not go back into Resident #5's room, but he was unable to remember the date. Review of a Psychiatric Progress Note dated 3/9/2021, showed .I was told by staff that she (Resident #5) had a problem with one of the night shift CNAs that had apparently said some pretty negative things to (Resident #5) and that she had made a complaint about the incident. I asked her (Resident #5) if anything had happened, she said no. I asked her multiple times and telling her that I was there to talk about what happened and she still declined to speak to me about any of the issues, which was very unusual for her . During an interview on 3/9/2021 at 5:06 PM, the Psychiatric Nurse Practitioner (NP) stated she had been asked to interview Resident #5 on this date (3/9/2021) about the incident between Resident #5 and CNA #5. She stated Resident #5 had told her everything was fine and had not discussed the incident with her. The Psychiatric NP stated Resident #5 usually would tell her about incidents, even if it had occurred weeks ago. She stated Resident #5 had denied the incident, which she felt was unusual for the resident. During a phone interview on 3/10/2021 at 12:09 PM, CNA #5 stated she had gone into Resident #5's room to answer the call light and found both residents were asleep. She stated she had turned the call light off and left the room. CNA #5 stated this had happened twice. CNA #5 stated the call light came back on for the third time and she went back into the room and asked Resident #51 if she needed anything. Resident #51 had said she had not turned the call light on and did not need anything. CNA #5 stated she then tapped Resident #5 on her shoulder to wake her up and asked what she needed. CNA #5 stated Resident #5 had begun to yell at the CNA. CNA #5 stated she had not called the resident any names or talked mean to her but Resident #5 had yelled things like .I hate you .I want a CNA to be nice to me .I want a nice CNA . CNA #5 stated she reported Resident #5 had yelled at her to the RN Supervisor and the RN Supervisor, RN #7, had gone into the room and spoke with Resident #5. CNA #5 stated the DON had told her to not go back into Resident #5's room, and she had not been in the room since that date. During a phone interview on 3/11/2021 at 5:47 AM, RN #8 confirmed she had been told that CNA #5 was not allowed to go back into Resident #5's room. RN #8 was unsure of when she had been told but stated it had been recent. RN #8 stated she had been told Resident #5 had become upset and yelled at CNA #5, and CNA #5 was no longer allowed in the resident's room. RN #8 stated RN #7 had reported the incident to day shift. During a phone interview on 3/11/2021 at 6:07 AM, RN #7 confirmed she was the facility night shift supervisor. She confirmed Resident #5 did make a complaint, but she could not remember the date, and stated .maybe last week . RN #7 stated CNA #5 had come to her to report Resident #5 had yelled at her. RN #7 stated she went to the resident's room and the resident was crying and, at first, was unable to tell her what was wrong. RN #7 stated she had not seen the resident that upset before and she tried to calm her. RN #7 stated the resident reported CNA #5 had asked her to turn her TV down. Resident #5 told RN #7 she had turned her call light on, and CNA #5 had entered the room and turned the call light off. The resident had turned the call light back on and CNA #5 reentered the room and again turned the call light off without assisting her. Resident #5 reported the third time she had turned the call light on, CNA #5 entered the room, and with a loud voice had told Resident #5 to turn her TV down. RN #7 stated the resident had reported CNA #5 was .hateful . RN #7 stated she had assured the resident CNA #5 would not be allowed back into the room. RN #7 stated she spoke to CNA #5 and CNA #5 did report she had turned the call light off because she thought the resident was sleeping, and the third time she entered the room she had rubbed the resident's leg to wake her up and ask what she needed, when the resident began to yell at her. RN #7 stated she had instructed CNA #5 not to go back into that room and the other CNAs would care for Resident #5. RN #7 stated she believed this occurred at about 5:37 AM but was unable to remember the date. She stated she thought it was about 2 weeks ago. RN #7 stated she had reported it to the day shift nurses, LPN #2 and RN #4. RN #7 stated she had also reported the incident to the DON. RN #7 stated she reported to the DON that CNA #5 had been hateful to the resident and had hurt Resident #5's feelings when she asked her to turn the TV down. During an interview on 3/11/2021 at 2:18 PM, LPN #2 stated Resident #5 had turned her call light on and told a CNA that she wanted to speak to LPN #2. LPN #2 went into the room and Resident #5 was .sobbing . Resident #5 reported CNA #5 had told the resident she was spoiled and selfish, nobody liked her, nobody wanted to take care of her, and if she didn't pee her pants, people would come in her room more often. LPN #2 stated she immediately reported the incident to RN #4 who then reported it to the Administrator. LPN #2 stated she had not known of Resident #5 crying and upset before that day.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure fluids were provided to maintain hydration for 1 resident (#45) of 2 residents reviewed for hydration of 27 sampled residents. The facility's failure resulted in actual Harm to Resident #45. The findings include: Review of facility policy Nutrition and Hydration to Maintain Skin Integrity revised 10/2010, revealed .General Guidelines . Ensure the resident's intake of fluid is sufficient. 'Sufficient fluid' means the amount of fluid needed to prevent dehydration and maintain health .The Dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission .A general guideline for determining baseline daily fluids needs is to multiply the residents body weight in kilograms (kg) times 30 ml (milliliters) .Risk factors for dehydration include .Coma/decreased sensorium .Functional impairments that make it difficult to drink, reach fluids, or communicate fluid needs (e.g.,(example) [MEDICAL CONDITION]) . Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #45 was emergently discharged to an acute care hospital on [DATE] and admitted with Altered Mental Status and Dehydration. Continued review revealed Resident #45 was readmitted to the facility on [DATE]. Medical record review of the facility's Weight Change History document revealed Resident #45's initial weight on 12/8/18 was 156.8 pounds (71.27 kg). According to the facility's policy for determining fluid needs, Resident #45 would have required 2138 ml of fluids daily based on her weight in kilograms (71.27 kg x 30 ml of fluid equals total daily fluid requirement). Medical record review of the Certified Nursing Assistant Activities of Daily Living Flow Record for Resident #45 dated 12/8/18 to 12/17/18 revealed the resident required total dependence for eating. Continued review revealed the following fluid intake was recorded daily for each 24 hour period: 12/8/18 - 295 milliliters (ml) 12/9/18 - 210 ml 12/10/18 - 190 ml 12/11/18 - 200 ml 12/12/18 - 705 ml 12/13/18 - 340 ml 12/14/18 - 50 ml 12/15/18 - 25 ml 12/16/18 - 75 ml 12/17/18 - 0 ml (prior to transfer) Medical record review of Resident #45's Admission Minimum (MDS) data set [DATE] revealed the resident had short and long term memory loss, was rarely understood, totally dependent on staff assistance for bed mobility, transfers, dressing, eating, and had been identified for choking during meals. Continued review revealed cognitive skills for daily decision making were severely impaired. Medical record review of Resident #45's nursing note dated 12/8/18 revealed .CNA (Certified Nursing Assistant) feeding pt (patient) at present, sl (slight) diff. (difficulty) swallowing noted . Medical record review of Physician #2's order for Resident #45 dated 12/10/18 revealed .ST (speech therapist) to eval/tx (evaluate/treat) as indicated .[MEDICAL CONDITION] .dysphagia .Tx (treatment) to include dysphagia management . Medical record review of Resident #45's nursing note dated 12/10/18 revealed .Diff. (difficulty) swallowing noted . Medical record review of Physician #2 order dated 12/10/18 revealed .Diet change to Puree with Nectar Thick liquids . Medical record review of nursing note dated 12/11/18 revealed .continues to have a very difficult time swallowing . Medical record review of Physician #2's History and Physical dated 12/11/18 revealed .transferred here for admission on 12/7/2018 (after hospitalization ) .patient's level of alertness has varied from being lethargic to alert but not verbally responsive .She is minimally responsive. She is very sleepy and unarousable to my aggressive stimuli .Patient is unresponsive to the point that I cannot perform a full neurological exam . Medical record review of Resident #45's Interdisciplinary Team note dated 12/12/18 revealed .Severe deficits-hydration et (and) nutrition risk based on aspiration - may consider TF (tube feeding) option if it is her wish . Medical record review of a physician's orders [REDACTED].Limited Additional Interventions .use medical treatment, antibiotics, IV (intravenous) fluids and cardiac monitoring as indicated .Transfer to hospital if indicated .Artificially Administered Nutrition. Oral fluids & (and) nutrition must be offered if feasible .Long-term artificial nutrition by tube . Medical record review of Resident #45's ST note dated 12/13/18 revealed .Family present at bedside .Education re: (regarding) pt's (patient's) severe deficits-oropharyngeal (part of the throat just behind the mouth) swallow, significant concern for dehydration, malnutrition, inability to swallow medications, aspiration risk .Recommend consideration of alternative means of hydration and nutrition. Consent to pursue alternative means of hydration and nutrition-nursing notified . Medical record review of Physician #2's order dated 12/13/18 revealed .GI (gastrointestinal) consult for alternative means for hydration & nutrition (PEG - Percutaneous Endoscopic Gastrostomy - tube inserted into the stomach to provide nutrition and fluids) . Medical record review of Nurse Practitioner (NP) #2's order dated 12/14/18 revealed .CBC (complete blood count/lab test), CMP (comprehensive metabolic panel/lab test) on 12/15/18 . Medical record review of NP #2's Progress Note dated 12/14/18 revealed .Poor p.o. (by mouth) intake .Nurse reports patient with very little p.o. intake .Family is requesting alternative means of hydration and nutrition. GI appointment for PEG tube evaluation is set for Monday (12/17/18) . Medical record review of Resident #45's nursing note dated 12/14/18 revealed .Resident has been nonverbal and was unable to swallow medications . Medical record review of Resident #45's nursing note dated 12/15/18 revealed .was unable to swallow medications during this shift . Medical record review of Resident #45's nursing note dated 12/17/18 revealed .she is very lethargic .held her medication in fear of her aspirating . Medical record review of Resident #45's ST note dated 12/17/18 revealed .CNA reports that pt had reduced level of alertness over weekend, poor PO (by mouth) intake. This SLP (Speech Language Pathologist) communicated with nursing re (regarding): pt's poor intake, concern for dehydration .Pt has GI consult this morning .concern .of pt's hydration risk .Addendum: Pt was sent to hospital at doctor appointment . Review of the Ambulance Service documentation dated 12/17/18 revealed .8:52 (AM) .Pulse 100, RR (respiratory rate) 26 was dispatched to (name of facility) .to transport (Resident #45) to (GI office) .the patient presented to be unresponsive in the room while attending CNAs and LPN (Licensed Practical Nurse) #3 were getting her ready .poor skin turgor .Per attendant, patient has declined over the weekend with poor oral intake .(LPN #1) nursing supervisor entered the room and quickly assessed the patient's condition. He (LPN #1/Unit Manager) requested .transport would proceed to (GI office) instead of the recommended ER (emergency room ) . Continued review revealed .At destination .Physician (GI office Physician) .refused to consult this patient as she stated that patient should go to the ER based on current conditions .patient was transported to (acute care center) . Review of Resident #45's History and Physical from an acute care hospital dated 12/17/18 revealed .Patient is obtunded (altered level of consciousness), unresponsive and nonverbal to deep noxious (very unpleasant) stimuli. Oral mucosa is very dry, cracked. Skin is generally dry with tenting. A .(indwelling urinary catheter) is in place, draining blood-tinged/purulent (containing pus) urine. Hypertensive (elevated), BP (blood pressure) 167/79. [MEDICAL CONDITION] (elevated heart rate) upon ED (emergency department) arrival, resolved with IV fluid bolus (large amount of fluid) .Meds given in ER .1 L (liter) NS (normal saline/ fluid electrolyte) bolus, IV (Intravenous) .Assessment Principle Problems .Dehydration .Active problems .UTI (urinary tract infection) Acute [MEDICAL CONDITION], Leukocytosis (increased number of white cells in the blood), Altered mental status, [MEDICAL CONDITION] (A rise in serum sodium concentration .caused by a decrease in total body water), Hypertension . Medical record review of Resident #45's facility Physician's Progress Note dated 12/26/18 revealed .returned from the hospital on 12/23 .admitted to (named hospital) with dehydration and dysphagia . Review of the Data Collection/Evaluation Nutritional assessment dated [DATE] revealed the resident was receiving nutritional support through a tube feeding. Continued review revealed Resident #45 was receiving [MEDICATION NAME] 1.2 at 68 ml per hour with 26 ml per hour of water flush for a 22 hour period. Continued review revealed the resident's fluid needs including tube flushes with water before, during, and after medication administration were calculated at 1923 ml. Medical record review of a Physician's Progress Note dated 1/22/19 revealed .she was readmitted here on 12/23/18 after PEG tube placement and an admission for significant dehydration associated with aggressive dysphagia. She is now receiving tube feedings and tolerating them well. She continues to have persistent [MEDICAL CONDITION]. Her weight has gone from the 140s now up to 151.8 pounds . Random observations of Resident #45 during the survey conducted from 1/28/19 to 1/30/19 in the resident's room revealed the resident resting in bed with tube feeding being administered via pump as prescribed. Continued observations revealed Resident #45 was not responsive to conversation and kept her eyes closed during attempts to communicate with her. Interview with the ST on 1/29/19 at 1:45 PM, at the nurse's station, confirmed on 12/17/18 she contacted the Unit Supervisor/LPN #1 regarding concerns for Resident #45's poor PO intake, dehydration, and stated the resident .may need to go to the emergency room instead of the GI consult appointment . Interview with NP #2 on 1/30/19 at 9:30 AM, in the conference room confirmed he was asked to evaluate Resident #45 on 12/14/18 for poor PO intake. Further interview revealed the NP was not aware of Resident #45's decline in PO intake. Continued interview confirmed it was the responsibility of nursing to notify the NP on call if a resident's condition deteriorates. Continued interview confirmed if he had been notified he would have ordered IV fluids. Interview with Physician #2 on 1/30/19 at 11:45 AM, in the conference room, revealed it was nursing's responsibility to notify the on call NP if a resident's condition changes or deteriorates. Further interview revealed Physician #2 was not made aware of the resident's decreased PO fluid intake and if she had been made aware she would have ordered IV fluids, which may have prevented Resident #45's dehydration and subsequent readmission to the hospital on [DATE].

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide adequate supervision to ensure fall interventions were implemented for 1 resident (#39) resulting in a fall with [MEDICAL CONDITION] of 3 residents reviewed for falls of 27 residents sampled. The facility's failure resulted in actual Harm to Resident #39. The findings include: Review of the facility policy Falls and Fall Risk, Managing revised 12/2007, revealed .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Medical record review revealed Resident #39 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 11, indicating the resident had moderate cognitive impairment. Further review revealed the resident required total assistance of 1 staff member for bed mobility and transfers. Medical record review of Resident #39's Care Plan dated 11/9/18 revealed .at risk for falls r/t (related to) [MEDICAL CONDITION], Shy drager syndrome (neurological disorder affecting the body's involuntary functions), difficulty with functional mobility .hx (history) of falls .9/23/18-Fall mats to exit side of bed . Medical record review of Resident #39's Skilled Daily Nurses Note dated 12/8/18 revealed .RESIDENT ON FLOOR @ (at) SIDE OF BED .BED AGAINST WALL, WAIST HIGH, FALL MAT ROLLED UP @ FOOT OF BED . Medical record review of the facility fall investigation dated 12/10/18 revealed Resident #39 had a fall from the bed on 12/8/18 at 11:30 AM. Further review revealed .Resident states that she was trying to turn in the bed and slid out of bed into the floor .Observation noted the bed in its highest position at time of fall . Continued review revealed .Resident was admitted to (named hospital) with [DIAGNOSES REDACTED].staff will adjust bed height to attempt to prevent further falls from bed . Medical record review of an acute care emergency room record dated 12/8/18 revealed .PATIENT (#39) IS BROUGHT IN FROM THE NURSING HOME AFTER SHE SLID OUT OF BED. SHE IS COMPLAINING OF LEFT HIP PAIN . Further review revealed .PATIENT HAS A COMMINUTED LEFT INTERTR[NAME]HANTERIC [MEDICAL CONDITION] (a break of the upper part of the thigh bone into more than two fragments). SHE WILL BE admitted for FURTHER EVALUATION TREATMENT . Medical record review of Resident #39's Orthopedic Surgery consult from the acute care hospital dated 12/8/18 revealed .Obtain consent for left hip Cephalomedullary (treatment of [REDACTED].Will proceed with operative fixation following medical optimization . Medical record review of Resident #39's acute care hospital discharge note dated 12/13/18 revealed .Admission Diagnoses: [REDACTED].Procedures: Intramedullary nail fixation (rod) . Observation of Resident #39 on 1/28/19 at 11:46 AM, in the resident's room, revealed the resident lying on the bed with the electric bed control within reach of the resident. Observation of Resident #39 on 1/29/19 at 1:04 PM, in the resident's room, revealed the resident lying on the bed with the electric bed control by the right side rail within the resident's reach. Interview with Certified Nursing Assistant (CNA) #3 on 1/29/19 at 2:40 PM, at the 400 hallway nurse's station, revealed .I saw her in the floor .the bed was up higher . Further interview with CNA #3 confirmed the fall mat was not in place at the time of the fall. Interview with the Risk Manager on 1/29/19 at 2:48 PM, in the conference room, confirmed the fall mat was not in place at the time of Resident #39's fall. Interview with CNA #4 on 1/30/19 at 8:28 AM at the 400 hall nurse's station, confirmed the fall mat was not in place at the time of the fall. Interview with CNA #5 on 1/30/19 at 1:38 PM, on the 400 hallway, confirmed if a resident has a fall mat ordered it is to be kept at the bedside .no matter what . Telephone interview with Physician #1 on 1/30/19 at 2:06 PM confirmed it is his expectation if the resident had a fall mat care planned to be at the bedside, it would be there at all times. Continued interview confirmed if the fall mat had been in place at the time of Resident 39's fall it would have .decreased the risk for the fracture .

Based on facility policy review, medical record review, observation, and interview, the facility failed to implement a care plan intervention to prevent falls for 1 resident (#39) of 3 residents reviewed for falls of 27 residents sampled. The facility's failure resulted in Harm to Resident #39. The findings include: Review of facility policy Care Plans, Comprehensive Person-Centered revised 12/2016, revealed .A comprehensive, person-centered care plan is developed and implemented for each resident . Medical record review revealed Resident #39 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #39's Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment. Further review revealed the resident required total assistance of 1 staff member for bed mobility and transfers. Medical record review of Resident #39's Care Plan dated 11/9/18 revealed .at risk for falls r/t (related to) [MEDICAL CONDITION], Shy drager syndrome (neurological disorder affecting the body's involuntary functions), difficulty with functional mobility .hx (history) of falls .9/23/18 - Fall mats to exit side of bed .12/8/18 Staff to position bed . Medical record review of Resident #39's Skilled Daily Nurses Note dated 12/8/18 revealed .RESIDENT ON FLOOR @ (at) SIDE OF BED .BED AGAINST WALL, WAIST HIGH, FALL MAT ROLLED UP @ FOOT OF BED . Medical record review of the facility fall investigation dated 12/10/18 revealed Resident #39 had a fall from the bed on 12/8/18 at 11:30 AM. Further review revealed .Resident states that she was trying to turn in the bed and slid out of bed into the floor . Continued review revealed .Resident was admitted to (named hospital) with [DIAGNOSES REDACTED].staff will adjust bed height to attempt to prevent further falls from bed . Observation of Resident #39 on 1/28/19 at 11:46 AM, in the resident's room, revealed the resident lying on the bed with the electric bed control within reach of the resident. Observation of Resident #39 on 1/29/19 at 1:04 PM, in the resident's room, revealed the resident lying on the bed with the electric bed control by the right side rail within the resident's reach. Interview with Licensed Practical Nurse (LPN) #2 on 1/29/19 at 2:29 PM, on the 400 hallway, confirmed the resident's electric bed control was kept within the resident's reach. Interview with Certified Nursing Assistant (CNA) #3 on 1/29/19 at 2:40 PM, at the 400 hallway nurse's station, revealed the CNA worked on the date of the fall and .I saw her in the floor .the bed was up higher . Continued interview revealed .she (Resident #39) uses the remote (to adjust the bed height) .she still does sometimes but not as frequent .it lays right there beside her usually . During further interview, CNA #3 confirmed the fall mat was not in place at the time of Resident #39's fall on 12/8/18. Interview with the Risk Manager on 1/29/19 at 2:48 PM, in the conference room, confirmed Resident #39's care plan intervention for a fall mat had not been in place at the time of the fall. Further interview confirmed after the resident's fall on 12/8/18 the facility implemented an intervention that the staff were to control the bed positioning and the bed controls should not be kept within reach of the resident. Interview and observation with the Risk Manager on 1/29/19 at 2:58 PM, in the resident's room, confirmed the care plan intervention to keep the electric bed controls out of the resident's reach had not been followed. Telephone interview with Physician #1/Medical Director on 1/30/19 at 2:06 PM revealed it was .his expectation .if the resident had a fall mat care planned to be at the bedside, it would be there at all times .

Based on review of facility policy, medical record review, facility record review and interview, the facility failed to ensure resident wasn't discharged during the appeal process, for an involuntary discharge of 1 resident (#123), of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's, Notice of Involuntary Discharge, revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of a Nurse's Note dated 1/20/18 revealed, .Voices needs without diff (difficulty). Forgetful @ (at) times . independent c (with) transfers and ADLs (activities of daily living). Propels self about facility in w/c (wheel chair). Continent of B&B (bowel and bladder), toilets self. Feeds self .sets up own tray . Review of a Nurse's Note dated 1/21/18 revealed, .Q (every) 15 minute checks/Smoking in bathroom! Continued review revealed the record of the every 15 minute checks began at 7:30 AM on 1/21/18 and continued until 6:15 PM on 1/30/18. Review of the Nurse Practitioner's (NP) #1 Progress Note dated 2/9/18 revealed, .I am seeing pt (patient/Resident #123) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds (medications) will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, confirmed Resident #123 filed an appeal on 1/3/18 related to the Involuntary Discharge notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Resident #123 was discharged on [DATE] to a hotel via the facility's van. Continued interview with the SSD on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM after the resident's discharge and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview with the SSD on 3/7/18 at 10:50 AM, in the Social Services office, confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Continued interview confirmed the medications had not been delivered to the resident. Further interview confirmed the SSD and Licensed Practical Nurse (LPN) #4 had taken some of the prescribed medications that remained at the nursing home to the resident's hotel room on 2/13/18. Continued interview confirmed the resident had been visited at the Long Term Care Facility and assessed by the TennCare Choices (part of the state Medicaid program) Transition Coordinator and a representative from a local group living home. Further interview confirmed the Choices Transition Coordinator had not been informed of the resident's impending discharge on 2/9/18. Interview with the Interim Administrator on 3/19/18 at 3:30 PM, in room [ROOM NUMBER], revealed the Interim Administrator began working at the facility on 1/29/18. Interview continued and in response to why the documented every 15 minute checks on Resident #123 began on 1/21/18, had ended on 1/30/18, the Interim Administrator responded, First I have heard of every 15 minute checks . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .He was discharged because he had continued to violate the smoking policy. I don't know if I would have discharged him but he refused to give me the matches or lighter and he refused to give them to either of us (reference to the SSD) .were not aware of a plan for him to visit (group homes) the following Thursday (2/15/18). Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Interview continued and the Interim Administrator responded to the question of why the Commissioner's Designee was not informed of the impending discharge, I am not required to contact them . Refer to F623, F624

Based on review of facility policy, review of facility records, medical record review and interview, the facility failed to ensure a safe and orderly discharge for 1 resident (#123) of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was admitted following an acute care hospital stay due to a Traumatic Subdural Hemorrhage that required surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating he was assessed as cognitively intact. Review of Resident #123's Admission MDS dated [DATE] revealed, .Problem .does have cognitive deficit . Continued review revealed the Quarterly MDS assessment dated [DATE] revealed a problem, .potential for skin breakdown r/t (related to) cognition and decreased safety awareness. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Medical record review of the facility Attending Physician's History and Physical dated 1/5/18 revealed, .he (Resident #123) has been followed by psych (psychiatric services) and requires [MEDICATION NAME] (antipsychotic medication) to try to prevent mood swings .he continues to smoke. He has been caught smoking in his room twice and he was given a 30 day notice of discharge about 2 weeks ago due to this issue . Review of a Nurse's Note dated 1/20/18 revealed, .Voices needs without diff (difficulty). Forgetful @ (at) times . independent c (with) transfers and ADLs (activities of daily living). Propels self about facility in w/c (wheel chair). Continent of B&B (bowel and bladder), toilets self. Feeds self .sets up own tray . Review of a Nurse's Note dated 1/21/18 revealed, .Q (every) 15 minute checks/Smoking in bathroom! Continued review revealed the record of the every 15 minute checks began at 7:30 AM on 1/21/18 and continued until 6:15 PM on 1/30/18. Medical record review of Resident #123's Physician order [REDACTED]. Review of a Social Progress Note by the Social Services Director (SSD) dated 2/2/18 revealed, This writer contacted (Choices Transition Coordinator-State Medicaid program) for update. He (Transition Coordinator) said he would set up transportation for resident to look at house and meet roommates next week. Medical record review of Nurse Practitioner's (NP) #1 progress note dated 2/9/18 revealed, .I am seeing pt (patient) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Medical record review of the NP orders written 2/9/18, revealed the orders for Resident #123 at discharge included: Diet-NAS (no added salt); Activity as tolerated; Resident to follow up with his primary physician on 2/27/18; Social Service to arrange Home Health services to include skilled nursing, physical and occupational therapy; Discharge meds-see discharge Medication Administration Record; DME (durable medical equipment) O2 concentrator with tubing; O2 at 2Lpm (oxygen at 2 liters per minute) - continuous; Overnight pulse ox test (used to measure oxygen levels in the bloodstream during the hours of sleeping); Review of the medication list prepared for the discharge revealed the following medications checked to be included on the discharge list: multivitamin/mineral tablet 1 daily (vitamin replacement); [MEDICATION NAME] HCL 20 milligrams (mg) 1 tablet every morning (for [MEDICAL CONDITION]); [MEDICATION NAME] 100 mg (vitamin replacement); [MEDICATION NAME] 10 Grams per 15 milliliters (ml) solution 30 ml twice a day (reduces blood ammonia level); [MEDICATION NAME] 500 mg 1 tablet twice a day (for [MEDICAL CONDITION]); [MEDICATION NAME] 5 percent patch apply 1 patch per day (for pain); [MEDICATION NAME] 25 mg 1 tablet twice per day (for lowering blood pressure); [MEDICATION NAME] Extended Release 1200 mg 1 tablet twice per day (for congestion); [MEDICATION NAME] 150 mg tablet 1 tablet twice per day (for reflux disorder); [MEDICATION NAME] inhaler 2 puffs by mouth twice per day; [MEDICATION NAME] 10 mg capsule 1 three times per day (for anxiety disorder); [MEDICATION NAME] 100 mg 1 tablet at bedtime (antipsychotic medication); [MEDICATION NAME] 2.25 inhale contents of one vial by mouth per nebulizer every 4 hours as needed for breathing; [MEDICATION NAME] 2.5-0.5 mg per 3 ml one vial by mouth per nebulizer every 6 hours as needed for wheezing and [MEDICATION NAME] HFA 90 micrograms inhale 1-2 puffs by mouth as needed for wheezing. Review of a document signed by Licensed Practical Nurse (LPN) #4 and Resident #123, dated 2/13/18 at 11:00 AM, revealed the resident acknowledged the receipt of the following medications, at the hotel, from the facility: [MEDICATION NAME] 10 Gm per 15 ml-1 whole bottle, and 1/2 bottle; iprat-albut nebs-1 box (to be used for respiratory treatments with nebulizer); asthmanefrin inhale-1 box (to be used for respiratory treatments with nebulizer); [MEDICATION NAME] 500 mg-27 tablets and [MEDICATION NAME]-12 patches. Interview with NP #1 on 3/7/18 at 9:50 AM, in the conference room, confirmed she wrote the 2/9/18 discharge orders for Resident #123. Continued interview revealed his order for oxygen was PRN (as needed) in the nursing home. Interview continued and revealed the order she wrote on 2/9/18 for an overnight pulse ox test was to evaluate the resident's oxygen levels and see if he would qualify for oxygen. Interview with the Interim Administrator and the SSD on 3/7/18 at 10:50 AM, in the Social Services office, confirmed Resident #123 had filed an appeal on 1/3/18 of the Involuntary Discharge Notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Continued interview with the Interim Administrator and the SSD on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM, after the resident's discharge, .I gave her his hotel room number . Interview continued and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Further interview confirmed on 2/12/18 the SSD became aware the medications had not been delivered to the resident. Continued interview confirmed the SSD and LPN #4 had delivered some of Resident #123's prescribed medications remaining at the Long Term Care facility to the resident at his hotel room on 2/13/18. Interview with the van driver on 3/19/18 at 12:10 PM, in room [ROOM NUMBER], confirmed he transported Resident #123 to the hotel on 2/9/18. Continued interview revealed he transported him .in the 2 o'clock (2:00 PM) hour .helped him put his stuff in the room .he stayed in the his wheelchair the whole time .he (the resident) asked me what was going to happen to him .when I got off work, I took him a (name of fast food) meal .I knew if I had been in that situation I would appreciate it . Interview with LPN #5 on 3/19/18 at 5:50 PM, in room [ROOM NUMBER], revealed, .Me and him (Resident #123) got along quite well .He could do everything for himself .he said often to me that he was forgetful .sometimes he would come to me for his meds (medications) after he had forgotten his meds had been taken . Continued interview revealed LPN #5 answered No to the question of whether Resident #123 could manage his medications on his own. Interview with LPN #6 on 3/19/18 at 6:30 PM, in room [ROOM NUMBER], revealed, .Always complained of not being able to breathe .would forget when he had his inhalers . Continued interview revealed LPN #6 answered No to the question of whether Resident #123 could manage his own medications. Telephone interview with the Ombudsman for the facility, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not made aware Resident #123 was being discharged on [DATE] and stated, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to the nursing home .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them he didn't have his meds on Monday when I was there (at the Long Term Care facility .I was there about 9:00 AM .the sister paid for another night at the hotel . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .not aware of a plan for him to visit (group homes) the following Thursday (2/15/18) .I just started 1/29/18. Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Telephone interview with the Choices Transition Coordinator on 3/20/18 at 1:30 PM revealed the Coordinator learned Monday evening (3/12/18) from an Ombudsman about Resident #123's discharge and stated, I called him Tuesday morning (3/13/18) at the hotel and he (Resident #123) told me, 'in contact with .state legal people' .he told me his last meal was Friday evening .and that he didn't have his meds .he was anxious about what would happen next . Interview with Resident #123's attending physician on 3/20/18 at 5:00 PM, in room [ROOM NUMBER], revealed she was aware of an ongoing plan for (Resident #123) to be discharged to a local area group home in the near future. Continued interview revealed she was not consulted prior to the discharge to the hotel on 2/9/18, but was notified later. Further interview revealed the resident had impulse control problems and failed a gradual dose reduction of [MEDICATION NAME] . Continued interview revealed he needed the psychoactive medications to help him maintain control. (Note: The resident did not have prescribed psychoactive medications of [MEDICATION NAME] at bedtime (from the evening of 2/9/18-2/13/18, [MEDICATION NAME] 3 times a day (from the evening of 2/9/18-2/13/18), or [MEDICATION NAME] each morning (from 2/10/18-2/13/18). Telephone interview with Resident #123 on 3/20/18 at 8:10 PM revealed he had difficulty maintaining focus on the immediate events before and after his discharge on 2/9/18 to the hotel room. At the beginning of the interview, he stated, I have difficulty with days of the week and dates .ever since they put three holes in my head for surgery. Continued interview revealed, They told me get your stuff ready .you will be leaving here .they already had my stuff packed .I thought my meds were packed up .they didn't ask me about a pharmacy, I would have used (name of his previous pharmacy) .at the hotel I went twice to the main office and asked for a phone and didn't get one . Further interview related to food revealed Resident #123 stated he had 1 meal on Friday night and 2 boxes of peanut butter crackers and some candy to eat for the following 3 days. Further interview included a question of whether he went to the breakfast the hotel provided and he responded, .that continental breakfast .stale rolls, I didn't go back . Continued interview revealed, Don't know how the people knew to come and get me (referring to group home personnel). Further interview confirmed he did not have his medications after he was discharged to the hotel and revealed, .my thinking was off. Interview with LPN #4 on 3/21/18 at 8:10 AM, in front of the 200 hall nursing station, confirmed the medications for Resident #123's nebulizer treatments were not provided to him before 2/13/18 when she and the SSD took the medications remaining at the facility to his hotel room, which included 2 medications for respiratory treatments with a nebulizer, an anti-[MEDICAL CONDITION] medication, a medication to lower ammonia level in bloodstream, and [MEDICATION NAME]es for back pain. Interview with LPN #3 on 3/21/18 at 9:45 AM, in room [ROOM NUMBER], revealed, .I guess between 9 and 10 (9:00 AM to 10:00 AM) when (SSD) came to me and asked me to find a PCP and pharmacy for him (Resident #123) .I did try to find a pharmacy that would deliver .Honestly, (SSD) came up with (name of pharmacy) .I went over his meds with him .he came back and asked me to go over his meds with him a second time .he did get forgetful .about whether or not he had taken his meds (medications) and I would jog his memory. Telephone interview by phone with the Advanced Practice Nurse (APN) on 3/21/18 at 11:37 AM revealed the APN stated the psychologist in her practice co-treated Resident #123. Further interview revealed, .he had a negative thought process .impatient .he instigated, argued .I can remember at some points thinking he could be at home and at other times thinking not so much .impulsiveness .didn't think about consequences . Telephone interview with the durable medical equipment (DME) oxygen supplier on 3/21/18 at 11:48 AM revealed, .provided him (Resident #123) with a nebulizer on 2/9/18 .didn't run an O2 sat (saturation) overnight, did not receive an order for [REDACTED]. Telephone interview with the Legal Aid Attorney on 3/21/18 at 5:05 PM, .first actual contact was on 2/12/18 when I heard the voice mail his (Resident #123's) sister had left me on Friday (2/9/18) .she said the facility called her around 4:00 PM after the resident had already been discharged to the hotel .I went to the hotel on Monday morning (2/12/18) and he didn't have a good memory and seemed extremely distressed, especially about what was going to happen to him and about not having his medications . In summary, Resident #123 had an involuntary discharge from the nursing facility, planned and executed on the day of 2/9/18. The attending Physician and Medical Director were not consulted prior to the discharge. The facility paid for 3 nights at the hotel over the weekend (Friday, Saturday, Sunday). By the time the family was notified, Resident #123 had already been discharged to the hotel and plans for more appropriate living arrangements could not be pursued prior to the opening of business on Monday, 2/12/18 . The facility had not ensured the resident received his medications. The facility had not made any arrangements for meals, and did not know if the resident had funds to purchase meals. The facility failed to ensure the resident had a working phone. The facility Interim Administrator and SSD had not contacted anyone in the Choices program who was able to pursue alternative living arrangements. The facility was not aware of the resident not having a working phone and not receiving his medications from the pharmacy until the Ombudsman's visit to the facility on [DATE] at 9:00 AM. The facility had made no plans to check on the resident's wellbeing and did not visited the resident until 2/13/18, when the SSD and LPN #4 delivered some medications to the resident. Refer to F622, F623

Based on review of the facility's profile, facility's policy, review of the Quality Assurance Performance Improvement (QAPI) committee monthly meetings, and interview, the QAPI committee failed to ensure sustained compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities by identifying issues and implementing a corrective action plan with monitors to ensure the adverse event of an Involuntary Discharge Notice, issued 12/21/17, was appropriate and acceptable as a safe discharge. The QAPI committee failed to identify the untoward outcomes and take corrective action related to the unplanned discharge, which took place during the appeals process, and resulted in an unsafe discharge for 1 resident (#123) of 3 residents reviewed for discharge. The failure of the QAPI committee to ensure a safe and orderly discharge resulted in Resident #123's discharge to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of the facility profile revealed the facility had a Federal recertification survey on 12/7/16 and was cited Immediate Jeopardy for the following: 483.10 - Notification of Changes for failure to notify the Physician of the presence of 2 pressure ulcers; 483.12 - Freedom from Abuse, Neglect, and Exploitation for failure to prevent abuse, neglect, report allegations, and complete thorough investigations of allegations. 483.21 - Comprehensive Resident Centered Care Plans for failure to revise the care plan. 483.25 - Quality of Care for failure to provide wound assessment and treatment for [REDACTED]. 483.24 - Quality of Life for failure to provide timely incontinence care. 483.35 - Nursing Services for failure to ensure adequate staffing to provide necessary personal care assistance and incontinence care in a timely manner. 483.70 - Administration, Governing Body, and Medical Director for failure to provide oversight of the facility in a manner to ensure residents attain the highest practicable well-being possible. 483.75 - Quality Assurance and Performance Improvement (QAPI) for failure to ensure the QAPI committee identified issues, implemented corrective action plans when needed, monitored and enforced facility policy. The facility was entered into the Special Focus Facility Program on 3/20/17. Review of the facility's policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Review of the QAPI committee monthly meetings from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the Administrator, the Medical Director, and the Social Services Director were all members of the committee and present at the meetings. Further review revealed the last meeting of the committee submitted for review by the survey team was 12/12/17. Review of the facility's document, Notice of Involuntary Discharge, revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Medical record review of the Attending Physician's History and Physical dated 1/5/18 revealed, .he (Resident #123) has been followed by psych (psychiatric services) and requires [MEDICATION NAME] (antipsychotic medication) to try to prevent mood swings .he continues to smoke. He has been caught smoking in his room twice, and he was given a 30 day notice of discharge about 2 weeks ago due to this issue . Review of a Social Progress Note by the SSD dated 2/2/18 revealed, This writer contacted (Choices Transition Coordinator-State Medicaid program) for update. He (Transition Coordinator) said he would set up transportation for resident to look at house and meet roommates next week. Medical record review of the Nurse Practitioner's (NP) progress note dated 2/9/18 revealed, .I am seeing pt (patient) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Interview with the Interim Administrator and the Social Services Director (SSD) in the Social Services office on 3/7/18 at 10:50 AM, confirmed Resident #123 filed an appeal on 1/3/18 of the Involuntary Discharge Notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he (Resident #23) would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Continued interview on 3/7/18 at 10:50 AM, in the Social Services office revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM, after the resident's discharge, .I gave her his hotel room number . Interview continued and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Further interview confirmed on 2/12/18 the SSD became aware the medications had not been delivered to the resident. Continued interview confirmed the SSD and Licensed Practical Nurse #4 had delivered some of Resident #123's prescribed medications remaining at the Long Term Care facility to the resident at his hotel room on 2/13/18. Telephone interview with the Ombudsman for the facility, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not made aware Resident #123 was being discharged on [DATE] and stated, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to the nursing home .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them he didn't have his meds on Monday when I was there (at the nursing home) .I was there about 9:00 AM .the sister paid for another night at the hotel . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .not aware of a plan for him to visit (group homes) the following Thursday (2/15/18) .I just started 1/29/18. Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Interview with the Medical Director on 3/20/18 at 4:00 PM, in room [ROOM NUMBER], revealed he did not know of the 2/9/18 discharge prior to Resident #123's being discharged to a hotel room, I wasn't called .I knew there was a dust up or whatever because of smoking. Continued interview revealed he did not know until 3/20/18 the resident did not have his meds at discharge, I didn't know he didn't have his meds for those days. Continued interview revealed, I didn't know about Choices planning a transfer. Continued interview revealed the involuntary discharge notice of 12/21/17 had not been addressed by the QAPI committee as an adverse event. The QAPI committee did not convene to identify the cause and take corrective action when the facility failed to ensure a safe and orderly discharge for Resident #123 resulting in Immediate Jeopardy. Refer to F-622 (J), F-623 (J), F-624 (J), F-745 (J), F-835 (J) and F-837 (J).

Based on facility policy review, medical record review, review of facility records and interview, the Governing Body failed to ensure the facility followed the discharge policy to develop a safe and orderly discharge for 1 resident (#123) of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Interview with the Interim Administrator and the Social Services Director (SSD) in the Social Services office on 3/7/18 at 10:50 AM, revealed Resident #123 filed an appeal on 1/3/18 for the Involuntary Discharge issued 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM after the resident's discharge and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party. Continued interview revealed the facility paid for 3 nights in a hotel (Friday, Saturday, and Sunday from 2/9/18-2/11/18). Further interview revealed .the hotel provided a phone and complimentary breakfast meal. Continued interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Further interview confirmed the medications had not been delivered to the resident, and the facility did not know this prior to the Ombudsman's visit on 2/12/18. Continued interview revealed the facility had not made a plan to check on the resident's wellbeing. Telephone interview with the Ombudsman for the facility, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not aware Resident #123 was discharged on [DATE] and stated, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to (the facility's proper name) .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them he didn't have his meds . Interview with the Supervisor Administrator on 3/21/18 at 3:00 PM, in room [ROOM NUMBER], revealed the Supervisor Administrator provided oversight of the facility as needed. Continued interview with concurrent review of the organizational chart revealed the Supervisor Administrator reported directly to the President of the Governing Body. Further interview revealed the Supervisor Administrator was not onsite on 2/9/18 and did not have full knowledge of the circumstances of Resident #123's discharge, and stated .I didn't know he didn't have his medications . In summary, Resident #123 had a discharge from the nursing facility planned and executed on the day of 2/9/18. The attending physician and Medical Director were not consulted prior to Resident #123's discharge to a hotel room. The facility paid for 3 nights over the weekend (Friday, Saturday, Sunday). By the time the family was notified, Resident #123 had already been discharged to the hotel and plans for more appropriate living arrangements could not be pursued prior to the opening of business on Monday, 2/12/18 . The facility had not ensured the resident received his medications. The facility had not made any arrangements for meals, and did not know if the resident had funds to purchase meals. The facility failed to ensure the resident had a working phone. The facility Interim Administrator and SSD had not contacted anyone in the Choices program who was able to pursue alternative living arrangements. The facility did not become aware of the resident not having a working phone and not receiving his medications from the pharmacy until the Ombudsman's visit to the facility on [DATE] at 9:00 AM. The facility had made no plans to check on the resident's wellbeing and had not visited the resident until 2/13/18, when the SSD and Licensed Practical Nurse (LPN) #4 delivered some medications to the resident at the hotel. Refer to F-622 (J), F-623 (J), F-624 (J), F-745 (J), F-835 (J) and F-867 (J).

Based on facility policy review, review of facility records, medical record review and interview, the Administrator failed to provide adequate oversight for 1 resident (#123) discharged during an appeal process of an involuntary discharge of 3 residents reviewed for discharge. The Administrator's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of a Nurse's Note dated 1/21/18 revealed, .Q (every) 15 minute checks/Smoking in bathroom! Continued review revealed the record of the every 15 minute checks began at 7:30 AM on 1/21/18 and continued until 6:15 PM on 1/30/18. Review of the Nurse Practitioner's progress note dated 2/9/18 revealed, .I am seeing pt (patient/Resident #123) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds (medications) will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, confirmed Resident #123 filed an appeal on 1/3/18 for the Involuntary Discharge notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM after the resident had been discharged , and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Continued interview confirmed the medications had not been delivered to the resident. Further interview confirmed the SSD and Licensed Practical Nurse (LPN) #4 had taken some of the prescribed medications that remained at the Long Term Care facility to the resident's hotel room on 2/13/18. Further interview confirmed the Choices (part of the state medicaid program) Transition Coordinator had not been contacted on 2/9/18 with information of the resident's impending discharge. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, confirmed the prior Administrator had not provided documentation of notification to the Long Term Care Ombudsman of the Notice of Involuntary Discharge issued to Resident #123 on 12/21/17. Continued interview confirmed the current Interim Administrator and the SSD had not notified the Ombudsman of the Notice of Involuntary Discharge, the pending appeal, or of the resident's discharge on 2/9/18 to a hotel room. Interview with the Interim Administrator on 3/19/18 at 3:30 PM, in room [ROOM NUMBER], revealed she began working at the facility on 1/29/18. Interview continued and in response to why the documented every 15 minute checks on Resident #123 began on 1/21/18, had ended on 1/30/18, she responded, First I have heard of every 15 minute checks . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .He was discharged because he had continued to violate the smoking policy. I don't know if I would have discharged him but he refused to give me the matches or lighter and he refused to give them to either of us (reference to the SSD) .not aware of a plan for him to visit (group homes) the following Thursday (2/15/18). Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Interview continued and the Interim Administrator responded to the question of why the Commissioner's Designee was not informed of the impending discharge, she replied, I am not required to contact them . Refer to F-622 (J), F-623 (J), F-624 (J), F-745 (J), F-837 (J), and F-867 (J).

Based on review of facility policy, medical record review, facility record review, and interview, the facility failed to ensure the Social Services Director fulfilled their duties and responsibilities when a resident was discharged , during the appeal process for an involuntary discharge of 1 resident (#123), of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in the discharge of Resident #123 to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The facility was cited F 745 at a scope and severity of J, which constitutes Substandard Quality of Care (SQC). The findings included: Review of facility policy Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of a Social Progress Note by the SSD dated 12/29/17 revealed, Received phone call from Choices (State Medicaid program) case manager asking why (Resident #123) had been issued 30 day notice. I told her it was rule violation (smoking). She stated she was getting ready to call (Resident #123's) sister .Spoke with her again later and was advised (sister) is going to start hunting place . Review of a Social Progress Note by the SSD dated 2/2/18 revealed, This writer contacted (Choices Transition Coordinator) for update. He said he would set up transportation for resident to look at house and meet roommates next week. Interview with the Interim Administrator and the SSD (Social Services Director) on 3/7/18 at 10:50 AM, in the Social Services office, revealed Resident #123 filed an appeal on 1/3/18 for the Involuntary Discharge issued 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Continued interview revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM of the resident's discharge and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party. Continued interview revealed the facility paid for 3 nights in a hotel (Friday, Saturday, and Sunday from 2/9/18-2/11/18). Further interview revealed .the hotel provided a phone and complimentary breakfast meal. Continued interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Further interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Continued interview confirmed the medications had not been delivered to the resident and the SSD had not known this prior to the Ombudsman's visit on 2/12/18. Further interview confirmed the Choices Transition Coordinator (State Medicaid Care Coordinator) had not been contacted on 2/9/18 with information of the resident's impending discharge. Continued interview revealed the facility had not made a plan to check on the resident's wellbeing and did not visit the resident until 2/13/18, when the SSD and LPN #4 delivered some medications to the resident. Interview with the SSD on 3/19/18 at 3:30 PM, in room [ROOM NUMBER], revealed she had been in her position at the facility for [AGE] years. Continued interview confirmed she had not made contacts with other facilities in an effort to seek placement for Resident #123 after the 30 day notice was issued and revealed, .it was up to Choices . Interview continued and the question of why Choices was not contacted on 2/9/18, was asked and revealed, .something that didn't even come to mind. Refer to F622, F624

Based on facility policy review, medical record review, review of facility records, and interview, the facility failed to notify the Long Term Care Ombudsman of 1 resident (#123) who had an ongoing appeal of a 30 day Involuntary Discharge Notice, of 3 residents reviewed for discharge. The facility's failure to provide advance notice as well as a plan resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of the Nurse Practitioner's (NP #1, employed by the resident's attending physician) progress note dated 2/9/18 revealed, I am seeing pt (patient/Resident #123) today to discharge. Pt was caught again smoking in restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds (medications) will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Medical record review of a NP order dated 2/9/18 revealed .DC (discharge) patient (Resident #123) .today (to hotel) . Interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the social services office, confirmed Resident #123 filed an appeal for the Involuntary Discharge on 1/3/18. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Tennessee Department of Finance and Administration Commissioner's Designee, and the presiding Administrative Law judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the social services office, confirmed a previous Administrator had not provided documentation of notification to the Long Term Care Ombudsman of the Notice of Involuntary Discharge issued to Resident #123 on 12/21/17. Continued interview confirmed the current IA and the SSD had not notified the Ombudsman of the Notice of Involuntary Discharge, the pending appeal, or of the resident's discharge on 2/9/18 to a hotel room. Interview with Resident #123's NP #1 on 3/20/18 at 9:30 AM, in room [ROOM NUMBER], confirmed the NP cared for the resident on behalf of his attending physician. Continued interview revealed, .the physician on call, not sure if it was (name of the resident's attending physician) was called and notified that day . Further interview confirmed the notification was after the resident had been discharged to a hotel. Interview by telephone with the Ombudsman for the East Tennessee Region, District 1, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not aware Resident #123 was discharged on [DATE] and revealed, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to the nursing home .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them (the nursing home) he didn't have his meds when I was there (at the nursing home ) .there about 9:00 AM .the sister paid for another night at the hotel .After I got back (to her office) I called the State Director of the Ombudsman Program . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .He was discharged because he had continued to violate the smoking policy . were not aware of a plan for him to visit (group homes) the following Thursday (2/15/18). Continued interview confirmed the facility's Ombudsman had not been notified prior to the discharge of Resident #123 to a hotel room on 2/9/18. Interview continued and the IA responded to the question of why the Commissioner's Designee was not informed of the impending discharge, I am not required to contact them . Refer to F622, F624

Based on facility policy review, medical record review, review of facility investigations, observation, and interview, the facility failed to be administered in a manner to ensure wound care protocols were available and followed to assess and treat all wounds; to ensure residents with medical devices (immobilizers) did not develop pressure ulcers related to use of the device; to ensure the physician was notified for changes in condition and to obtain treatment orders; to ensure all residents were protected from neglect and abuse and all allegations of neglect and abuse were reported and investigated; to ensure residents were safe from accidents; and to ensure adequate staffing to provide care and services to residents according to their needs and care plans. The facility's failure placed 10 residents (#106, #123, #75, #103, #65, #27, #68, #21, #45, #12, #145) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirement of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Corporate Director of Clinical Services and the Administrator were informed of the Immediate Jeopardy (IJ) in the conference room on 12/7/16 at 9:30 AM. The facility was cited an Immediate Jeopardy at F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-353 (K); F-490 (K); F-493 (K); F-501 (K); and F-520 (K). The facility was cited Substandard Quality of Care (SQC) at F-223 (K), F-224 (J), F-225 (K), F-241 (J), F-309 (J), F-312 (J), and F-314 (J). The IJ was effective on 2/6/16 and is ongoing. The findings included: Interview with the Director of Nursing (DON) on 11/8/16 at 5:05 PM, in her office, confirmed the facility did not have a protocol the nursing staff could refer to for the identification, assessment and treatment of [REDACTED]. Interview with the Nurse Practitioner (NP) on 11/9/16 at 10:25 AM, in the small conference room, revealed she thought standing orders for Decubitus Care stated refer to wound care protocol and were to be followed. She was unaware the facility did not have a wound care protocol to follow. Interview with the Administrator on 11/28/16 at 3:55 PM, in the conference room, confirmed he would expect the facility to follow the procedures outlined in the facility Abuse policy. Interview with the DON on 12/5/16 at 11:40 AM, in the conference room, confirmed the facility had failed to obtain an order for [REDACTED].#106's wound declined between the time it was first identified and the time treatment was initiated. Further interview revealed the DON was unaware of the online protocols for the treatment of [REDACTED]. Interview with the Medical Director on 12/5/16 at 1:55 PM, in his office, confirmed he was unaware the facility did not have protocols in place for wound care. Continued interview confirmed he does not do training or teaching on wound care with the Director of Nursing or the Treatment Nurse. Continued interview confirmed the facility did not have enough staff to care for the residents. Further interview confirmed he has been the Medical Director at this facility for [AGE] years and it had always been an issue. Interview with the Regional Director on Clinical Services on 12/6/16 at 10:00 AM, at the 100-200 hall nurses station, confirmed the facility did have access to wound care protocols and they were located on the company's website portal, available to staff, and could be printed out. Refer to F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-323 (G); F-353 (K); F-493 (K); F-501 (K); and F-520 (K).

Based on review of facility policy, review of facility investigations, medical record review, review of facility staffing, review of personnel files, interview, and observation, the facility failed to prevent mental, physical, and verbal abuse for 9 residents (#75, #103, #65, #106, #27, #68, #47, #66, and #74) of 15 residents reviewed for abuse, of 43 sampled residents. The facility's systematic failure to immediately remove the accused, failure to report allegations to administration, and failure to investigate allegations of abuse, placed residents #75, #103, #65, #106, #27, and #68 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The facility was cited F 223 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy is effective 2/6/16 and is ongoing. The findings included: Review of the facility's policy Abuse, undated, revealed .3 Things to Remember 1. Stop it 2. Get Help 3. Report it .The facility will report and investigate all alleged incidents of resident abuse .Abuse - the willful infliction of injury .intimidation, or punishment with the resulting physical hurt or pain or mental anguish to the resident. Abuse is also the deprivation by an individual, including a caretaker, of goods or services that is necessary to attain or maintain, physical, mental, and psychosocial well being of a resident. This definition presumes that instances of abuse to any resident, even one in coma causes physical harm or pain or mental anguish. Verbal Abuse - Any use of oral .gestured language that will fully include disparaging and derogatory terms to a resident .or within their hearing distance, to describe residents, regardless of a resident's .ability to comprehend or mental and/or physical disability .Mental Abuse - Includes but is not limited to, humiliation, harassment, threats of punishment or deprivation of a resident . Review of a facility investigation dated 2/6/16 at 5:00 AM revealed Resident #75 reported to Registered Nurse (RN) #2 that Certified Nursing Assistant (CNA) #14 had told Resident #75 she was wet and nasty and CNA #14 was going to change her. CNA #14 then grabbed her legs and made her move over. CNA #14 told her .I wouldn't have to do this if your filthy lazy ass would get up and go to the bathroom instead of pissing on yourself . RN #2 stated she heard Resident #75 screaming and crying, and because she had never heard the resident do that before, she immediately went to the resident's room. As RN #2 entered the room, CNA #14 was exiting. RN #2 assessed the resident for injury and administered [MEDICATION NAME] to help settle the resident down. CNA #14 was told not to go back in the resident's room by RN #2, but was allowed to finish his shift unsupervised. Further review of the investigation revealed on 2/8/16 (2 days after the incident), the facility conducted interviews with all the residents that had a BIMS score greater than or equal to 9 (moderately impaired to cognitively intact score). Resident #65 and #103 reported CNA #14 had made inappropriate comments to them on 2/6/16. Review of the investigation revealed the facility substantiated the allegation for verbal abuse and terminated CNA #14. Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #75 had a Brief Interview Mental Status (BIMS) score of 15 out of a possible 15, which indicated she was cognitively intact. Review of the Timecard Report for CNA #14 revealed the CNA clocked out on 2/6/16 at 6:39 AM at the end of his shift. Review of the personnel file revealed CNA #14 was suspended 2/6/16 through 2/10/16, after finishing his shift on 2/6/16, pending investigation of the abuse allegation. Telephone interview with RN #2 on 11/3/16 at 4:45 PM confirmed Resident #75 was so upset RN #2 had to administer [MEDICATION NAME], and did not suspend CNA #14, he was allowed to finish his shift. Telephone interview with CNA #14 on 11/14/16 at 11:45 AM, confirmed he had finished his dry rounds (check to see if incontinent residents need to be cleaned) before he exited the building. Interview with the Director of Nursing (DON) on 11/7/16 at 9:30 AM, in the small conference room, confirmed CNA #14 was terminated on 2/10/16 for verbal abuse. Interview with Resident #75 on 11/19/16 at 12:30 PM, in the resident's room, revealed .I feel like it was abuse because of what he said and because he said no one would believe me (if she reported it to the facility administration or staff) . Review of a facility investigation dated 2/6/16 revealed while the facility was investigating the allegation of abuse for Resident #75 Resident #103 reported to CNA #2 on 2/6/16 she did not want CNA #14 back in her room. Continued review revealed CNA #14 entered the room to provide incontinence care, grabbed the resident by her left arm and pulled her over. The resident told him not to do that because it hurt. CNA#14 told the Resident #103 .could hurt her if he wanted to because it was his job to change her . Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 Day MDS dated [DATE] revealed Resident #103 scored a 15 out of a possible 15 on the BIMS. Interview with the DON on 11/14/16 at 11:35 AM, in her office, confirmed an investigation was not completed for Resident #103 .because she (Resident #103) did not know if what he did was intentional or not . Telephone interview with CNA #14 on 11/14/16 at 11:45 AM confirmed he was allowed to finish his shift on 2/6/16. Telephone interview with RN #2 on 11/3/16 at 4:45 PM confirmed CNA #14, was allowed to finish his shift after Resident #75 alleged abuse. Review of a facility investigation initiated for Resident #75 dated 2/6/16 revealed Resident #65 had reported on 2/7/16 she had told CNA #14 she was soaking wet and requested to be changed. CNA #14 told Resident #65 he was 2 hours behind and he could not get to her and did not return. RN #2 reported the incident to the DON on 2/8/16. On 2/8/16 the DON interviewed Resident #65 and the resident confirmed the allegation of abuse. Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] revealed Resident #65 scored a 14 out of a possible 15 on the BIMS which indicated the resident was cognitively intact. Interview with Resident #65 on 11/9/16 at 11:40 AM, in resident room, revealed .can't remember exactly what (CNA #14) said .didn't have time or something like that .had not changed me all night .it made me feel like I wasn't important . Interview with the Administrator on 11/28/16 at 3:55 PM, in the conference room, revealed .this allegation was not investigated separately because it was a part of . (Resident #75's) .investigation. It was the same perpetrator and he was suspended and then terminated . Continued interview with the Administrator confirmed he would expect the facility to have followed the procedures outlined in the facility Abuse policy. Review of a facility investigation dated 7/8/16 revealed the facility initiated an investigation for 2 allegations of abuse for Resident #106 dated (6/24/16 and 7/1/16). Continued review revealed the first incident on 6/24/16 occurred when CNA #8 allegedly grabbed Resident #106 by the arm to roll her over. The second occurred on 7/1/16 when CNA #8 entered the residents' room and began slinging linens and things around and cursed the resident. Both allegations were witnessed by CNA #16 and reported to Licensed Practical Nurse (LPN) #3 on the date of each occurrence. Further review revealed CNA #8 was employed by the facility through a staffing agency and the facility contacted the agency on 7/8/16 by phone and reported the allegations and requested an interview with CNA #8. The facility again contacted the agency on 7/12/16 with no reported response. Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 Day MDS dated [DATE] revealed Resident #106 had a BIMS score of 3 out of a possible 15 which indicated a severe cognitive impairment. Review of the daily staffing sheets revealed CNA #8 continued working his shift on 6/24/16 and was assigned to Resident #106 on 6/27/16, 7/1/16, 7/2/16, and 7/3/16 during 4 of 7 shifts. Telephone interview with LPN #3 on 11/7/16 at 5:45 PM confirmed she did not report the allegations to Administration and did not recall anyone asking her about either of the allegations. Continued interview revealed .she (CNA #16) came and talked to me and she said something happened .I think something happened a few days before that too .I told him (CNA #8) not to go back in that room .she (Resident #106) had a habit of saying ouch, ouch, when she was moved .so I didn't think anything had happened . Telephone interview with LPN #3 on 11/7/16 at 6:20PM revealed .CNA #16 said she had talked to the DON about the 1st incident so I just thought they knew about it .it was almost time for the Risk Manager (RM) to come to work when she told me so I told her we would talk to her when she came in . Interview with the RM on 11/9/16 at 12:00 PM, in her office, revealed she was notified by CNA #15 on 7/8/16 (13 days after the first allegation) of the allegations of abuse. Interview with LPN #3 on 11/29/16 at 7:00 AM, in the conference room, confirmed she did not send CNA #8 home .placed him on a different hallway . Continued interview revealed she had asked Resident #106 what had happened and the resident said .nothing . Interview with the DON on 11/30/16 at 1:00 PM, in the conference room, revealed .I believe I talked to them, but I don't remember, I think I did and they didn't remember anything . Continued interview revealed no other residents were interviewed to determine if any other residents were harmed. Review of a facility investigation dated 8/12/16 at 1:30 PM Resident #27 reported being threatened by the Business Office Manager (BOM) and requested CNA #7 hide in the bathroom and listen to the conversation during the meeting in her room. As CNA #7 exited the resident's room she saw the BOM and Assistant Business Office Manager (ABOM) coming down the hallway, so she entered the bathroom and closed the door. Continued review revealed the BOM asked the resident to sign a promissory note for $50.00 a month toward her past due balance. The BOM raised her hand during the conversation and told the resident .Do not talk while I am talking . Further review revealed she was to sign the promissory note or she would be out of here . The resident was described as being upset and tearful after the incident. CNA #7 and the ABOM immediately reported the incident to the DON and the Social Services Director (SSD). The DON notified the Administrator by phone of the allegation. The BOM was allowed to finish her shift on 8/12/16 without being interviewed by the DON or SSD regarding the allegation. The BOM was terminated on 8/18/16 for unprofessional conduct. Interview with the ABOM on 11/2/16 at 2:30 PM, in the small conference room, confirmed she had witnessed the incident with the BOM and Resident #27, the BOM raised her hand during the conversation while telling the resident to stop talking and told the resident she was to .sign the promissory note or she would be out of here . Continued interview revealed .I would never talk to someone like that .I felt it was hostile .I think the resident was just trying to plead her case . Telephone interview with CNA #7 on 11/3/16 at 11:15 AM confirmed she overheard the conversation between the BOM and Resident #27. Continued interview revealed .I really don't remember exactly what was said but I know (BOM) sounded aggressive .if she didn't pay (Resident #27) had to leave .the other girl (ABOM) kept trying to get (BOM) out of the room and she finally did .I don't know what would have happened if she didn't . (Resident #27) .was really upset when I came out of the bathroom .told her I was going to go tell someone . CNA #7 immediately reported to the DON. Telephone interview with the BOM on 11/3/16 at 12:10 PM revealed .that was the biggest joke of an investigation .did not ask me for my statement .I did hold up my hand trying to get her to stop talking . Telephone interview with Resident #27 on 11/21/16 at 9:30 AM confirmed she felt threatened by BOM during their conversation on 8/12/16. Continued interview with the resident confirmed no one from the facility followed up with her after the incident to see how she was feeling. Further interview revealed she .was scared of her (BOM) . Interview with the SSD on 11/28/16 at 4:00 PM in the conference room, confirmed Resident #27 had reported to her on 8/15/16 she was scared of the BOM. Continued interview confirmed the SSD had not interviewed any other residents in the facility. Further interview revealed .it would be in the file if I did . Interview with the Administrator on 11/28/16 at 4:00 PM in the conference room, confirmed he wrote the memorandum dated 8/18/16. Review of the memorandum revealed the BOM was separated from employment for .unprofessional conduct stemming from an incident that took place Friday, August 12, 2016. The incident involved a verbal resident altercation in which the resident indicated she felt threatened with having to leave the facility if she did not immediately sign a promissory note to cover an outstanding debt . Review of a facility investigation dated 9/3/16 revealed Resident #27 reported CNA #4 had told the resident she . did not have to get her up that it was a privilege . CNA #4 .grabbed the draw sheet and slung the resident around causing the resident to fall backwards onto the bed. The CNA then grabbed the resident by the arms and manhandled her into the wheelchair . Continued review revealed the Dietary Manager reported to LPN #7 on 9/3/16 the resident was upset and crying and told her LPN #7 and CNA #4 were being hateful and jerking her around. CNA #4 was allowed to finish her shift and continued to provide care for the resident. On 9/4/16 CNA #4 worked on the hall but was told by LPN #7 not to provide care for Resident #27 and was asked to provide a written statement of what had occurred between her and the resident. On 9/6/16 the RM interviewed Resident #27 and reported the incident to the DON and the Administrator. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed Resident #27 had a BIMS score of 15 which indicated the resident was cognitively intact. Telephone interview with Resident #27 on 11/21/16 at 9:35 AM revealed CNA #4 entered room and stated .I don't have to get you up; it's a privilege to get up .she grabbed the draw sheet jerked it and I fell backwards, then grabbed me by my wrists pulled me up, manhandled me and put me in my wheelchair. I got out of the room as fast as I could . Continued interview revealed when the resident returned to the 100-200 hallway .she (CNA #4) said if you want to go back to bed you get down here right now .other people heard it .she slammed the door .she said what was you doing outside talking about me? I told her (name of another resident) heard you (CNA #4) screaming outside of the door .she grabbed me up and put me back in bed .no one else transferred me like that .would use a lift or two people .she (CNA #4) said if I have to file a report I'll take you down with me .don't know what she meant .I kept asking her what was wrong .saw her in the hall on Sunday (9/4/16) .I was scared of her after that .that was abuse .I was a little sore .no one assessed me for bruising or injury .no, the SSD never came and followed up with me .one time she (CNA#4) come to do (supervise) smoke break and I was out there and she (CNA #4) went back in and a guy came out and said she (CNA #4) couldn't smoke us because she was out there, I took it as meaning me .made me feel like I had done something wrong . Review of the staffing sheets for 9/3/16 and 9/4/16 confirmed CNA #4 worked the 100-200 hall way (where the resident was located). Review of the monthly schedule for 9/2016 revealed CNA #4 was scheduled off on 9/5/16 and 9/6/16. CNA #4 was scheduled to work 9/7/16 and 9/8/16. Review of the Individual Timecard for CNA #4 confirmed on 9/3/16 the CNA completed her shift on 9/3/16 and worked a full shift again on 9/4/16. Continued review revealed CNA #4 worked 9/8/16. Review of the personnel file for CNA #4 revealed a 3 day suspension dated 9/7/16 (unsigned by CNA #4 and did not indicate suspension dates). Continued review revealed a written warning on 9/12/16 for inconsiderate treatment of [REDACTED]. Interview with the Certified Dietary Manager (CDM) on 11/28/16 at 11:00 AM, at the 100-200 nurses station confirmed she had reported Resident #27 had stated CNA #4 had been hateful an jerked her around. Continued interview revealed .I took her (Resident #27) back to her room then went and reported to her nurse that she might want to go check on her because she (Resident #27) was upset and crying . Interview with the Administrator on 11/28/16 at 11:30 AM, in the front hallway revealed .both the resident and the CNA stated it happened during transfer .so it came down to being just harsh words .so the CNA received a disciplinary action for unprofessional conduct . Interview with the Director of Nursing on 11/30/16 at 1:00 PM, in the conference room, confirmed the investigation consisted of 4 residents being interviewed by the SSD. Continued interview revealed .upon reviewing we felt it was more unprofessional conduct . Review of a facility investigation dated 8/17/16 the revealed SSD and DON were made aware Resident #68 reported she had her call light on for a while and when no one answered she began yelling. There was no documentation to whom or when the resident reported the incident to and the SSD and DON could not recall. Certified Nursing Assistant (CNA) #15 had entered her room and screamed at Resident #68 .For no reason should you shout .You don't talk to me that way. You can tell everyone here I screamed and no one will tell . CNA #15 was allowed to complete her scheduled shift on 8/16/16 and clocked out at 6:30 AM. Continued review revealed the staffing agency was notified of the investigation and the CNA #15 would not be allowed to return. Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed Resident #68 had a Brief Interview Mental Status score of 14 out of a possible 15 indicating was cognitively intact. Continued review revealed the resident was totally dependent for dressing and bathing, required extensive assistance for transfers, and personal hygiene with 1 person assist. Telephone interview with CNA #15 on 11/23/16 at 9:10 AM revealed she was contacted by the facility by phone on 8/18/16. She spoke with the Administrator and was told of the allegation of abuse. Continued interview revealed the Administrator placed her on speaker phone and asked her a few questions. Further interview revealed she was told by the Administrator he would have to finish the investigation and she could not return to the facility to work. Interview with the Social Services Director on 11/28/16 at 4:00 PM, in the conference, room revealed . there were no investigations initiated and no additional information was available . had taken what (Resident #27, #47, #66, #74, and #75) had stated and summarized it in the written statement . Interview with the DON on 11/30/16 at 2:00 PM, in the conference room confirmed there was no additional documentation for the investigation. Continued interview revealed the facility was unable to determine when they became aware of the allegation of abuse. Review of a facility investigation dated 8/17/16 revealed Resident #47 thought CNA #15 was a smart aleck, pushy, and a know it all. Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed Resident #47 had a BIMS score of 15 out of a possible 15 indicating she was cognitively intact. Continued review revealed the resident was totally dependent for transfers and personal hygiene with the assist of 1 person. Further review revealed the resident was always incontinent of bowel and bladder. Interview with Resident #47 on 11/8/16 at 2:15 PM, in her room, revealed .seems like she was always rushing and I don't like to be rushed . Review of a facility investigation dated 8/17/16 revealed Resident #66 thought CNA #15 was hateful. Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 60 Day MDS dated [DATE] revealed Resident #66 scored a 15 out of 15 on the BIMS indicating she was cognitively intact. Continued review revealed the resident required extensive assist with transfers and was totally dependent for dressing and personal hygiene with the assist of 1 person. Interview with Resident #66 on 12/1/16 at 8:15 AM in her room revealed can't recall the CNA's names, only their faces . Review of a facility investigation dated 8/17/16 revealed Resident #74 thought CNA #15 was a smart aleck, being pushy, and being a know it all. Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the Resident #74 had a BIMS score of 15 out of a possible 15 indicating she was cognitively intact. Interview with the SSD on 11/28/16 at 4:00 PM, in the conference room, revealed there was no additional information available and there were no investigations initiated for residents #47, #66, and #74 allegations regarding CNA #15, who was allowed to fininsh her shift on 8/16/16. Interview with the SSD on 11/1/16 at 1:00 PM, in the small conference room confirmed all staff received education on abuse upon hire, quarterly, and as needed. Interview with the Administrator on 11/28/16 at 4:00 PM in the conference room confirmed he would expect the facility policy to be followed for an allegation of abuse.

Based on facility policy review, medical record review, review of facility investigations, observation, and interview, the Governing Body failed ensure wound care protocols were available and followed to assess and treat all wounds; to ensure residents with medical devices (immobilizers) did not develop pressure ulcers related to use of the device; to ensure the physician was notified for changes in condition and to obtain treatment orders; to ensure facility policy was followed so all residents were protected from neglect and abuse and all allegations of neglect and abuse were reported and investigated; to ensure residents were safe from accidents; and to ensure adequate staffing to provide care and services to residents according to their needs and care plans. The facility's failure placed 10 residents (#106, #123, #75, #103, #65, #27, #68, #21, #45, #12, #145) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirement of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Corporate Director of Clinical Services and the Administrator were informed of the Immediate Jeopardy (IJ) in the conference room on 12/7/16 at 9:30 AM. The facility was cited an Immediate Jeopardy at F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-353 (K); F-490 (K); F-493 (K); F-501 (K); and F-520 (K). The facility was cited Substandard Quality of Care (SQC) at F-223 (K), F-224 (J), F-225 (K), F-241 (J), F-309 (J), F-312 (J), and F-314 (J). The IJ was effective on 2/6/16 and is ongoing. The findings included: Interview with the Director of Nursing (DON) on 11/8/16 at 5:05 PM, in her office, confirmed the facility did not have a protocol the nursing staff could refer to for the identification, assessment and treatment of [REDACTED]. Interview with the Nurse Practitioner on 11/9/16 at 10:25 AM, in the small conference room, revealed she thought standing orders for Decubitus Care stated refer to wound care protocol and were to be followed. She was unaware the facility did not have a wound care protocol to follow. Interview with the Administrator on 11/28/16 at 3:55 PM, in the conference room, confirmed he would expect the facility to follow the procedures outlined in the facility Abuse policy. Interview with the DON on 12/5/16 at 11:40 AM, in the conference room, confirmed the facility had failed to obtain an order for [REDACTED].#106's wound declined between the time it was first identified and the time treatment was initiated. Further interview revealed the DON was unaware of the online protocols for the treatment of [REDACTED]. Interview with the Medical Director on 12/5/16 at 1:55 PM, in his office, confirmed he was unaware the facility did not have protocols in place for wound care. Continued interview confirmed he does not do training or teaching on wound care with the Director of Nursing or the Treatment Nurse. Continued interview confirmed the facility did not have enough staff to care for the residents. Further interview confirmed he has been the Medical Director at this facility for [AGE] years and it had always been an issue. Interview with the Regional Director on Clinical Services on 12/6/16 at 10:00 AM, at the 100-200 hall nurses station, confirmed the facility did have access to wound care protocols and they were located on the company's website portal, available to staff, and could be printed out. Refer to F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-323 (G); F-353 (K); F-490 (K); F-501 (K); and F-520 (K).

Based on review of facility policy, medical record review, review of facility investigations, observation, and interview, and review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, the facility failed to ensure the QAPI committee identified issues and implemented corrective action plans to ensure wound care protocols were available and followed to assess and treat all wounds; to ensure residents with medical devices (immobilizers) did not develop pressure ulcers related to use of the device; to ensure the physician was notified for changes in condition and to obtain treatment orders; to ensure facility policy was followed so all residents were protected from neglect and abuse and all allegations of neglect and abuse were reported and investigated; to ensure residents were safe from accidents; and to ensure adequate staffing to provide care and services to residents according to their needs and care plans. The facility's failure placed 11 residents (#106, #123, #75, #103, #65, #27, #68, #21, #45, #12, #145) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirement of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Corporate Director of Clinical Services and the Administrator were informed of the Immediate Jeopardy (IJ) in the conference room on 12/7/16 at 9:30 AM. The facility was cited an Immediate Jeopardy at F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-353 (K); F-490 (K); F-493 (K); F-501 (K); and F-520 (K). The facility was cited Substandard Quality of Care (SQC) at F-223 (K), F-224 (J), F-225 (K), F-241 (J), F-309 (J), F-312 (J), F-314 (J). The IJ was effective on 2/6/16 and is ongoing. The findings included: Interview with the Director of Nursing (DON) on 11/8/16 at 5:05 PM, in her office, confirmed the facility did not have a protocol the nursing staff could refer to for the identification, assessment and treatment of [REDACTED]. Interview with the Nurse Practitioner on 11/9/16 at 10:25 AM, in the small conference room, revealed she thought standing orders for Decubitus Care stated refer to wound care protocol and were to be followed. She was unaware the facility did not have a wound care protocol to follow. Interview with the Nurse Practitioner revealed .not notified of the shearing .I know they use turning and repositioning for stage I pressure ulcers .should have been treated with something . Interview with the Administrator on 11/28/16 at 3:55 PM, in the conference room, confirmed he would expect the facility to follow the procedures outlined in the facility Abuse policy. Interview with the DON on 12/5/16 at 11:40 AM, in the conference room, confirmed the facility had failed to obtain an order for [REDACTED].#106's wound declined between the time it was first identified and the time treatment was initiated. Further interview revealed the DON was unaware of the online protocols for the treatment of [REDACTED]. Interview with the Medical Director on 12/5/16, in his office, confirmed he was unaware the facility did not have protocols in place for wound care. Continued interview confirmed he does not do training or teaching on wound care with the Director of Nursing or the Treatment Nurse. Continued interview confirmed the facility did not have enough staff to care for the residents. Further interview confirmed he has been the Medical Director at this facility for [AGE] years and it had always been an issue. Review of the Quality Assurance (QA) meeting attendees and interview with the Medical Director on 12/5/16 at 1:55 PM, in his office, confirmed he had not attended a QA meeting in the second quarter of 2016. Continued interview revealed he was not aware the treatment nurse did not have a certification in wound care. Interview with the DON on 12/6/16 at 8:15 AM, in the conference room, confirmed she did not have formal training in wound management. Continued interview confirmed she was not aware Resident #106's pressure ulcer was identified on 11/13/16 instead of 11/15/16. Further interview confirmed no wound treatment was initiated until 11/15/16. The DON was asked about the Nurse Practitioner (NP) and Physician notes on 11/15/16 and 11/17/16 stating eschar (dead tissue) and a 2 cm (centimers)ulceration to the calf. Continued interview confirmed .I don't remember seeing eschar . Further interview confirmed the treatment nurse completed the measurement and treatments .I pop in and do the staging . Interview with the Regional Director on Clinical Services on 12/6/16 at 10:00 AM, at the 100-200 hall nurses station, confirmed the facility did have access to wound care protocols and they were located on the company's website portal, available to staff, and could be printed out. Refer to F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-323 (G); F-353 (K); F-490 (K); F-493 (K); F-501 (K).

Based on review of facility policy, medical record review, interview, review of the facility's investigations and observation, the facility failed to immediately report allegations of abuse and complete thorough investigations for allegations of abuse for 7 residents (#75, #103, #65, #106, #27, #68, and #12) of 15 residents reviewed for abuse. The facility's failure placed residents ((#75, #103, #65, #106, #27, #68, and #12) in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/6/16 and is ongoing. The facility was cited F 225 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The findings included: Review of the facility policy Accidents and Incidents, dated May 2001, revealed .An incident is any occurrence, which is not consistent with the routine operation of the institution or the routine care of a particular patient. It may involve an injury .charge nurse shall: Examine all .victims .Notify the .physician and inform of the accident /incident .Regardless of how minor .it must be reported to the department supervisor, and a report form is to be completed on the shift .must be reported to the Director of Nursing and the Director of Risk Management .All details are to be recorded in the nurses' notes, including disposition and follow up care for a period of 72 hours .The Risk Manager will review .investigation as needed . Review of the facility policy Abuse, undated, revealed .The facility will report and investigate all alleged incidents of resident abuse, mistreatment, neglect .and misappropriation of property. The facility will complete a thorough investigation of an alleged incident by the appropriate staff .Procedures .The charge nurse notifies the shift supervisor of the allegation. The supervisor initiates notification to the Social Services Department (SSD) and begins an investigation immediately .Immediately notify the Director of Nursing (DNS) and the Administrator by phone, if necessary. Investigate the alleged incident during the shift on which the allegation of abuse occurred .Interview the resident or other witnesses. The interview is to be dated, documented and signed by the supervisor. Interview the staff implicated. Have the employee document, in writing if able, their knowledge/version of the incident. Ensure the employee's written narrative is signed and dated. Interview any staff witnesses or other available witnesses. Have the witnesses document their knowledge/version of the incident. If the witnesses are unable to write their knowledge/version, have an administrative staff member write it for them. Ensure the witnesses sign and date their written narrative. Interview all staff on the unit to make sure all the information is gathered promptly. When a staff member is implicated in potential resident abuse situation, the employee is to be removed from all patient care areas and sent home after the narrative is obtained from the employee. The employee is instructed to contact the DNS (Director of Nursing Services) or Administrator the next day .Reporting and Documentation Requirements Facility investigation continues as needed over the next 24-48 hours .Place documentation in the resident's Medical record to reflect any direct observable facts .Social Services should document resident's psychosocial status and assessment of feelings, re: (regarding) safety, any counseling efforts. Documentation should continue over the next few days . Medical record review revealed Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation for Resident #75 revealed on 2/6/16 at approximately 5:00 AM Resident #75 reported to Registered Nurse (RN) #2 Certified Nursing Assistant (CNA) #14 told her she was wet and nasty and he was going to change her, he then grabbed her legs and made her move over. The resident reported the CNA told her I wouldn't have to do this if your filthy lazy ass would get up and go to the bathroom instead of pissing on yourself. The resident began screaming and crying. RN #2 stated she had never heard the resident do that before, she immediately went to the resident's room and as she entered the room CNA #14 was exiting. RN #2 assessed the resident for injury and administered [MEDICATION NAME] to help calm the resident. The CNA was told not to go back in the residents' room and was allowed to finish his shift unsupervised. Further review revealed on 2/8/16 the facility conducted interviews with all the residents that had a BIMS score greater than or equal to 9 (moderately impaired to cognitively intact score 0-15). Resident #65 and #103 reported CNA #14 had made inappropriate comments to them on 2/6/16. The facility substantiated the allegation for verbal abuse and terminated CNA #14. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #75 had a Brief Interview Mental Status (BIMS) score of 15 out of a possible 15 which indicated she was cognitively intact. Review of the Timecard Report for CNA #14 clocked out on 2/6/16 at 6:39 AM. Review of the personnel file revealed CNA #14 was suspended on 2/6/16 through 2/10/16 pending investigation. Investigation substantiates verbal abuse, terminated. Telephone interview with RN #2 on 11/3/16 at 4:45 PM revealed she did not know if CNA #14 had entered Resident #65 and #103's room before or after Resident #75's room. Telephone interview with RN #2 on 11/3/16 at 4:45PM, revealed she did not know if CNA#14 had entered Resident #65 and #103's room before or after Resident #75's room. Telephone interview with CNA #14 on 11/14/16 at 11:45 AM, confirmed he had finished his dry round and wrote a statement before he exited the building. Interview with the Director of Nursing (DON) on 11/7/16 confirmed CNA #14 was terminated for verbal abuse. Continued interview revealed the DON stated .called abuse registry and reported CNA #14 .do not have documentation of report . Interview with Resident #75 on 11/19/16 at 12:30 PM, in the resident's room, revealed .I feel like it was abuse because of what he said and because he said no one would believe me . Review of the facility Reportable Event Form revealed the incident occurred on 2/6/16 at 5:30 AM and was reported to the state agency on 2/10/16 at 6:26 PM (This is 3 days past the deadline of 24 hours). Review a facility investigation dated 2/6/16 revealed Resident #103 had reported to CNA #2 on 2/6/16 she did not want CNA #14 back in her room. The CNA had entered the room to provide incontinence care, grabbed the resident by her left arm and pulled her over. Resident #103 told him not to do that because it hurt. CNA #2 stated . could hurt her if he wanted to because it was his job to change her . Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 Day MDS dated [DATE] revealed Resident #103 scored a 15 out of a possible 15 on the BIMS which indicated she was cognitively intact. Interview with the DON on 11/14/16 at 11:35 AM in her office confirmed an investigation was not completed for Resident # 103 .because she (Resident #103) did not know if what he did was intentional or not . In summary, the facility investigation consisted of interviews with residents that had a BIMS score greater than or equal to 9, statements from CNA #5, RN #2, and Resident #75. The facility failed to: suspend CNA #5 immediately (continued to work at least 1 ½ hours) , interview all staff working during the shift, complete skin assessments for all residents with a BIMS score of less than 9, and failed to investigate Resident's #65 and #103 allegation of abuse. The facility failed to report an allegation of abuse to the state agency. Review of a facility investigation revealed Resident #65 had reported on 2/7/16 she had told CNA #14 she was soaking wet and requested to be changed. CNA #14 told the resident he was 2 hours behind and he could not get to her and did not return. RN #2 reported this to the DON on 2/8/16. The DON interviewed Resident #65 and the resident repeated the same incident. Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] revealed Resident #65 scored a 14 out of a possible 15 on the BIMS which indicated the resident was cognitively intact. Interview with the DON on 11/14/16 at 11:35 AM in her office revealed the allegation of abuse for Resident #65 was .not investigated because the resident did not know if CNA #14 was joking or not . Interview with Resident #65 on 11/9/16 revealed .can't remember exactly what he said .didn't have time or something like that .it made me feel like I wasn't important . Interview with the Administrator on 11/28/16 at 3:55 PM, in the conference room revealed .this allegation was not investigated separately because it was a part of . (Resident #75's) .investigation. It was the same perpetrator and he was suspended and then terminated . Continued interview with the Administrator confirmed he would expect the facility to have followed the procedures outlined in the facility Abuse policy. Review of a facility investigation revealed on 7/8/16 the facility initiated an investigation for 2 reported allegations of abuse for Resident #106. The first occurred on 6/24/16 when Certified Nursing Assistant (CNA) #8 allegedly grabbed Resident #106 by the arm to roll her over. The second occurred on 7/1/16 when CNA #8 entered the residents' room and began slinging linens and things around and cursed the resident. Both allegations were witnessed by CNA #16 and reported to Licensed Practical Nurse (LPN) #3 on the date of the occurrence. Further review revealed CNA #8 was employed by the facility through a staffing agency and the facility contacted the agency on 7/8/16 by phone and reported the allegations and requested an interview with CNA #8. The facility again contacted the agency on 7/12/16 with no reported response. Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 Day Minimum (MDS) data set [DATE] revealed Resident #106 had a Brief Interview Mental Status score of 3 out of a possible 15 which indicated a severe cognitive impairment. Review of the daily staffing sheets revealed CNA #8 continued working his shift on 6/24/16 and was assigned to Resident #106 on 6/27, 7/1, 7/2, and 7/3 during 4 of 7 shifts. Telephone interview with LPN #3 on 11/7/16 at 5:45 PM confirmed she did not report the allegations to Administration and did not recall anyone asking her about either of the allegations. Continued interview revealed .she (CNA #16) came and talked to me and she said something happened .I think something happened a few days before that too . I told him not to go back in that room .she (Resident #106) had a habit of saying ouch, ouch, when she was moved .so I didn't think anything had happened . Telephone interview with LPN # 3 on 11/7/16 at 6:20PM revealed .CNA #16 said she had talked to the DON about the 1st incident so I just thought they knew about it .it was almost time for the Risk Manager (RM) to come to work when she told me so I told her we would talk to her when she came in . Interview with the RM on 11/9/16 at 12:00 PM in her office revealed she was notified by CNA #15 on 7/8/16 of the allegations of abuse and reported to Administration immediately. Interview with the DON on 11/9/16 at 12:30 PM, in her office, .chose who (residents) to interview because of the physical layout of the facility . Interview with LPN #3 on 11/29/16 at 7:00 AM in the conference room confirmed she did not send CNA #8 home .placed him on a different hallway . Continued interview revealed she had asked Resident #106 what had happened and the resident said nothing . Interview with the Social Services Director on 11/29/16 at 4:00 PM, in the conference room, confirmed she felt it was a complete investigation. Interview with the DON on 11/30/16 at 1:00 PM, in the conference room, revealed .I believe I talked to them, but I don't remember, I think I did and they didn't remember anything . Continued interview revealed no other residents were interviewed to determine if any other residents were harmed. In summary, the facility investigation for Resident #106 consisted of 2 statements that were written by CNA #16, notification of the residents' family and the staffing agency, 2 resident interviews, and the resident was assessed by the physician. The facility failed to: suspend the CNA #8 immediately, notify the Administrator or DON timely (13 days after the 1st allegation), interview all residents with a BIMS score of 9 or greater, conduct skin assessments for those residents with a BIMS score less than 9. Review of a facility investigation dated 8/12/16 at approximately 1:30 PM Resident #27 reported to Certified Nursing Assistant (CNA) #7 she was being threatened by the Business Office Manager (BOM). The BOM asked the resident to sign a promissory note for $50.00 a month toward her past due balance. The BOM raised her hand during the conversation and told the resident .Do not talk while I am talking . The BOM was quoted as having said to the resident she was to sign the promissory note or she would be out of here. CNA #7 and the ABOM immediately reported the incident to the Director of Nursing (DON) and the Social Services Director (SSD). The DON then notified the Administrator by phone and made him aware of the allegation. The BOM was notified by the Administrator per a phone call on evening of 8/12/16 (Friday). The BOM was terminated on 8/18/16 (Thursday) for unprofessional conduct. Interview with the ABOM on 11/2/16 at 2:30PM in the small conference room confirmed she had witnessed the incident with the BOM and Resident #27, the BOM had raised her hand during the conversation while telling the resident to stop talking and had told the resident she was to sign the promissory note or she would be out of here. Continued interview revealed .I would never talk to someone like that .I felt it was hostile .I think the resident was just trying to plead her case . Telephone interview with CNA # 7 on 11/3/16 at 11:15 AM confirmed she had overheard the conversation between the BOM and Resident #27. Continued interview revealed .I really don't remember exactly what was said but I know (BOM name) sounded aggressive .if she didn't pay she had to leave .the other girl (ABOM) kept trying to get (BOM name) out of the room and she finally did .I don't know what would have happened if she didn't . Resident #27 .was really upset when I came out of the bathroom .told her I was going to go tell someone . CNA #7 immediately reported to the DON. Telephone interview with the BOM on 11/3/16 at 12:10 PM revealed .that was the biggest joke of an investigation .did not ask me for my statement .I did hold up my hand trying to get her to stop talking . Telephone interview with Resident #27 on 11/21/16 at 9:30 AM confirmed she had felt threatened by BOM during their conversation on 8/12/16. Continued interview with the resident confirmed no one from the facility had followed up with her after the incident to see how she was feeling. Further interview revealed she was scared of her (BOM) . Interview with the Administrator on 11/28/16 at 4:00 PM, in the conference room confirmed he had written the memorandum dated 8/18/16. Continued interview and review of the memorandum revealed the BOM was separated from employment for .unprofessional conduct stemming from an incident that took place Friday, August 12, 2016. The incident involved a verbal resident altercation in which the resident indicated she felt threatened with having to leave the facility if she did not immediately sign a promissory note to cover an outstanding debt . Interview with the SSD on 11/28/16 at 4:00 PM, in the conference room, confirmed Resident #27 had reported to her on 8/15/16 she was scared of the BOM. Continued interview confirmed the SSD had not interviewed any other residents in the facility. Further interview revealed .it would be in the file if I did . Review of the State Reportable Incident form revealed date of occurrence as 8/12/16 at 3:00 PM with a report date of 8/18/16 (5 days past the required 24 hours). Interview with the Administrator on 11/28/16 at 4:00 PM, in the conference room, confirmed he wrote the memorandum dated 8/18/16. Review of the memorandum revealed the BOM was separated from employment for .unprofessional conduct stemming from an incident that took place Friday, August 12, 2016. The incident involved a verbal resident altercation in which the resident indicated she felt threatened with having to leave the facility if she did not immediately sign a promissory note to cover an outstanding debt . In summary, the facility investigation consisted of interview and statements from the BOM, ABOM, CNA #7, and Resident #27. The facility failed to: immediately interview and remove the BOM, interview other residents and family members the BOM may have spoken with, and assess, document and provide psychosocial support for Resident #27 following the incident. Review of a facility investigation revealed dated 9/3/16 Resident #27 reported Certified Nursing Assistant (CNA) #4 told Resident #27 she .did not have to get her up that was a privilege . CNA #4 grabbed the draw sheet and slung the resident around causing the resident to fall backwards onto the bed. The CNA then grabbed the resident by the arms and manhandled her into the wheelchair. The Dietary Manager reported to Licensed Practical Nurse (LPN) #7 on 9/3/16 the resident was upset and crying and had told her the nurse and CNA were being hateful and jerking her around. CNA #4 was allowed to finish her shift and continued to provide care for the resident. Continued review revealed on 9/6/16 the Risk Manager (RM) interviewed Resident #27 and reported the incident to the Director of Nursing (DON) and the Administrator. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #27 had a BIMS score of 15. Interview with Social Services Director (SSD) on 11/7/16 at 9:30 AM, in the small conference room, confirmed she interviewed those residents with a BIMS score of 9 or greater (indication of moderate impairment to cognitively intact). Continued interview confirmed .they all voiced CNA#4 was a good CNA and has never talked harsh or handled them roughly . Interview with the DON on 11/7/16 at 9:30 AM, in the small conference room, revealed .that was the only hall she was working at that time .didn't have a reason to do skin assessments on residents since the residents that were interviewed were saying positive things about her . Telephone interview with Resident #27 on 11/21/16 at 9:35 AM revealed CNA #4 entered room and stated .I don't have to get you up; it's a privilege to get up .she grabbed the draw sheet jerked it and I fell backwards, then grabbed me by my wrists pulled me up, manhandled me and put me in my wheelchair. I got out of the room as fast as I could . When the resident returned to the hallway .she (CNA) said if want to go back to bed you get down here right now .other people heard it .she slammed the door .she said what was you doing outside talking about me? I told her (name of another resident) heard you (CNA) screaming outside of the door .she grabbed me up and put me back in bed .no one else transferred me like that .would use a lift or two people . Interview with the Certified Dietary Manager (CDM) on 11/28/16 at 11:00 AM, at the 100-200 nurses station confirmed she had reported Resident #27 had stated CNA #4 and the nurse had been hateful an jerked her around. Continued interview revealed .I took her (Resident #27) back to her room then went and reported to her nurse that she might want to go check on her because she (resident) was upset and crying . This allegation was not reported to the state agency and was not reported to Administration until 2 days after the incident. Review of the facility investigation revealed on 10/17/16 the SSD and DON were made aware Resident #68 reported she had her call light on for a while and when no one answered she began yelling. Certified Nursing Assistant (CNA) #15 had entered her room and screamed at her saying .For no reason should you shout .You don't talk to me that way. You can tell everyone here I screamed and no one will tell . There was no documentation to whom or when the resident reported the incident to and the SSD and DON could not recall. CNA #15 was allowed to complete her scheduled shift on 10/16/16. Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed Resident #68 had a Brief Interview Mental Status score of 14 out of a possible 15 indicating she was cognitively intact. Interview with the Social Services Director on 11/28/16 at 4:00 PM in the conference room revealed . there were no investigations initiated and no additional information was available . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating the resident had severe cognitive impairment. Continued review revealed the resident was totally dependent for bed mobility and transfers with 2 or more person physical assist. Review of a Physician's Progress Note dated 7/13/16, authored by Nurse Practitioner (NP) #2, revealed .nursing report pt (patient) w/ (with) LLE (left lower extremity) bruising, [MEDICAL CONDITION] .LLE w/ large bruised/reddened area, warm to touch .painful (grimacing w/palp (palpation)) . Continued review revealed assessment/plan .venous Doppler R/O (rule out) blood clot . Review of Nurse's Notes revealed no documentation of the bruising by the nurses on 7/13/16. Review of a Physician's Progress Note dated 7/19/16, authored by the Physician, revealed .new bruising and swelling of the left leg .no injuries that have been reported by staff .xray to rule out underlying fracture .Ultrasound negative for [MEDICAL CONDITION] ([MEDICAL CONDITION] . Review of an imaging report dated 7/19/16 revealed .proximal (nearer to center) tibial and fibular (bones of lower leg) mildly displaced fractures . Review of a Resident Incident Report dated 7/20/16 revealed .Resident C/O (complained of) pain when turned, order received for xray .Green bruising noted to shin and calf area . Continued review revealed 4 witness statements by staff stated they had no knowledge of the cause of the fractured leg. Further review of a typed summary of the investigation, unsigned, revealed .noted protrusion in wall and bruise consistent with rolling toward wall and coming in contact with the protrusion .resident unable to recall direct force incident .According to research a side ways bend at ankle or knee could have caused practure (fracture) . Review of the Physician's Progress Note dated 7/20/16 revealed .Tib/fib (tibia/fibula bones of lower leg) fx (fracture) . Interview with the Director of Nursing (DON) on12/1/16 at 8:51 AM, in the conference room, confirmed bruises were to be documented by the assigned nurse upon discovery. Further interview confirmed no investigation had been started until the fracture was discovered on 7/20/16. Interview with the DON on12/2/16 at 9:57AM, in the resident's room, confirmed the resident's left leg was probably bent when the resident was turned on her left side. The resident's left leg probably went between the bed and the mattress and hit the protrusion on the wall. Interview and observation with the Maintenance Director on 12/1/16 at 4:10 PM, in resident's room, confirmed there was a buffer (wood panel to prevent bed from scraping wall) on the bed side of the wall 18 from the floor, below the top of the mattress, and extended the entire length of the left wall. Continued observation and interview revealed the protrusion had a curved, smooth surface on the top edge and protruded outward 9/16 of an inch from wall. Interview with Licensed Practical Nurse (LPN) #12 on 12/2/16 at 12:45 PM, at the 300/400 nurses station, confirmed a CNA (couldn't remember which one) reported bruising and swelling to Resident #12's leg on 7/13/16. Continued interview revealed LPN #12 notified the NP on the same day (7/13/16), but did not document in the nurse's notes or fill out an incident report. Further interview confirmed LPN #12 should have documented the bruising and swelling and initiated an incident report. Continued interview confirmed Resident #12 was unable to roll over in the bed independently. Interview with the resident's Physician on 12/2/16 at 3:55 PM, in the conference room, confirmed Resident #12 was seen by Nurse Practitioner (NP) #2 on 7/13/16 for [MEDICAL CONDITION] and discoloration of the left lower leg. Continued interview revealed the Physician was .surprised when the xray report revealed a fracture because the resident was so cooperative with care . Further interview with the Physician revealed the fracture most likely occurred around 7/13/16 (when the bruising and [MEDICAL CONDITION] was first noticed). In summary, review of the facility investigative documentation for Resident #12 revealed the facility did not initiate an investigation into the injury of unknown origin on the date the injury was discovered, 7/13/16. Further review of the facility's investigative documentation revealed the facility failed to obtain interviews from staff who had worked prior to and on 7/13/16. Further review revealed no skin assessments were completed for resident's unable to be interviewed to identify additional potential injuries.

Based on medical record review, review of daily staffing assignments, review of staffing schedules, and interview, the facility failed to ensure adequate staffing to provide necessary personal care assistance and incontinence care in a timely manner for 11 residents (#106, #123, #75, #103, #65, #27, #68, #21, #45, #12, #145) of 43 residents reviewed. The facility's failure placed Residents #106, #123, #75, #103, #65, #27, #68, #21, #45, #12, #145 in Immediate Jeopardy (a situation which the provider's non compliance has caused, or is likely to cause, serious harm, injury, impairment of death). The Immediated Jeopardy was effective 2/6/16 and is ongoing. The findings included: Medical record review of the Treatment Administration Record (TAR) for Resident #54 dated 7/2016 revealed pressure ulcer treatment to the right buttocks was not completed on 9 out of 24 days. Review of the Daily Staffing Sheet revealed no treatment nurse scheduled for 7/9/16, 7/10/16, 7/16/16, 7/17/16, 7/22/16, 7/23/16, 7/24/16, 7/27/16, and 7/28/16. Medical record review of the TAR for Resident #54 dated 8/16 revealed pressure ulcer treatment to the right buttocks was not completed on 3 out of 19 days. Review of the Daily Staffing Sheet revealed no treatment nurse scheduled for 8/7/16, 8/13/16, and 8/14/16. Interview with the Director of Nursing (DON) on 12/6/16 at 8:34 AM, in the conference room, confirmed no pressure ulcer treatments to the right buttocks were documented on 9 occasions in July 2016 and 3 occasions in August 2016. Interview with the Treatment Nurse on 12/7/16 at 3:22 PM, in the conference room, confirmed .They pull me off the cart (treatment cart) somedays at 3PM (and assigned patient care) .I also work the cart (medication cart) if don't have a scheduled nurse working to cover shift . Continued interview confirmed the nurse failed to provide pressure ulcer treatment to Resident #54's pressure ulcers. Medical record review of the Interdisciplinary Progress Notes dated 12/12/15 for Resident #21 revealed .Resident is paraplegic and requires total care for ADL's (activities of daily living) .Incont (incontinent) of B&B (bowel and bladder) c (with) peri care q2 (every 2 hours) + (and) PRN (as needed) . Interview with Certified Nursing Assistant (CNA) #19 on 11/30/16 at 8:04 PM, in the 400 hall, revealed .I have done my first dry rounds (6:00PM rounds) .Starting 8's (8:00 PM rounds) now .Last rounds at 4 (4:00 PM) before I got here . Observation on 11/30/16 at 8:08 PM, on the 400 hall, revealed Resident #21 had a strong urine odor. Continued observation revealed a wet stain to the resident's pants from the groin, inner thigh, down to the knee. Interview with Resident #21 on 11/30/16 at 8:08 PM, on the 400 hall, confirmed .They haven't changed or clean me yet .not since last state person (state surveyor) was here . Interview with CNA #19 on 11/30/16 at 8:09 PM, on the 400 hall, confirmed .I haven't changed her (Resident #21) yet tonight . Observation and Interview with Licensed Practical Nurse(LPN) #13 on 11/30/16 at 8:12 PM, on the 400 hallway, revealed Resident #21 sitting in a wheelchair with wet saturation pants from the groin, to inner thigh, down to the knees. Interview with LPN #13 confirmed .She (Resident #21) is soiled .She is a lift transfer .I expect her to be changed every 2 hours . Medical record review of Resident #45's Care Plan dated 3/25/16 and updated 9/15/16 revealed .Self Care Deficit .Assist with ADL's as needed .Has incontinence bowel & bladder .Incontinence to be provided by staff as needed . Medical record review of Resident #45's Nursing Weekly Summary dated 11/19/16 revealed .ass (assist) x (times) 2 c ADL's + t/f's (transfers) .Incont of B+B (bowel and bladder) peri care PRN (as needed) + q2 (every 2 hours) .non amb (ambulatory) is in the bed most of the time . Interview with Resident #45 on 11/30/16 at 8:18 PM, in the resident's room, confirmed .I haven't been changed since before supper before 5 (PM) . Continued interview revealed the resident was aware she was soiled and needed to be changed. Interview with RN #2 on 11/30/16 at 8:25 PM, on the 300 hall, confirmed the CNAs were to check and change the residents every 2 hours. Continued interview confirmed the CNAs started their rounds at 6:00 PM. Further interview confirmed CNA's were not to change residents during meals times. Telephone interview with CNA #18 on 12/1/16 at 8:38 PM, confirmed she was assigned to Resident #45 on the night of 11/30/16. Continued interview confirmed she finished her first dry rounds after 10:00 PM. Further interview confirmed the CNA's were instructed in training not to change residents while passing trays or when trays are on the halls. Interview with the DON on 12/5/16 at 2:17 PM, in the conference room, confirmed she expected the residents to be checked and changed every 2 hours and as needed. Interview with Resident #45 on 12/7/16 at 9:39 AM, in the resident's room, confirmed .It is what it is. What can you do about it . Medical record review of a TAR for Resident #123 dated 10/2016 revealed .Twice Daily [MEDICATION NAME] dressing until seen by (Orthopedic Doctor) 11/3/16 . Further review revealed treatment was not documented as completed on 10/29/16. Continued medical record review of a TAR dated 11/2016 revealed a dressing order dated 10/21/16 .Clean Surgical Incision To RT (right) Knee with [MEDICATION NAME], Apply (named dressing) & (and) Wrap with (named gauze), Change BID (twice a day) . Continued review revealed treatments were not documented as completed on 11/8/16,11/11/16, 11/12/16 and 11/14/16. Review of the monthly staff schedules, revealed no treatment nurse on the schedule for 10/29/16, 11/8/16, 11/11/16,11/12/16, and 11/14/16. Interview with the Treatment Nurse on 11/29/16 at 2:37 PM, at the 100 nursing station, confirmed Resident #123 had a pressure area on the posterior right leg. Further interview confirmed the pressure ulcer was not measured on 11/28/16 because the Treatment Nurse was working on the medication cart. Interview with the Treatment Nurse on 12/5/16 at 9:15 AM, in the conference room, confirmed it was difficult to complete all wound treatments when she was pulled to the medication cart. Further interview confirmed wound treatments not completed by the treatment nurse are not always completed by the other nurses. Interview with Registerd Nurse (RN) #1 on 12/6/16 at 9:50 AM, in the 100 hall, confirmed there were times she was unable to complete treatments and dressing changes as ordered by the physician. Review of a facility investigation dated 2/7/16 revealed Resident #65 reported on 2/7/16 she told CNA #14 she was soaking wet and requested to be changed. CNA #14 told the resident he was 2 hours behind and he could not get to her and did not return. RN #2 reported the incident to the DON on 2/8/16. The DON interviewed Resident #65 and the resident repeated the same incident. Interview with Resident #65 on 11/9/16, in the resident's room, revealed .can't remember exactly what he said .didn't have time or something like that .it made me feel like I wasn't important . Medical record review of the Admission Resident Data Set for Resident #106 dated 7/25/16 revealed the resident had a sacral area circled on the body diagram with .shearing . written out beside of the area. There were no measurements or description of the wound and no treatment was initiated. Medical record review of the care plan dated 7/25/16 revealed .treatments as ordered .Measure wound at least weekly .Record . Medical record review of the Nursing Weekly Summary dated 7/29/16 revealed .open area in coccyx area. Bilateral buttocks reddened irritated, blood noted in brief from irritated areas on buttocks . Continued review revealed there were no measurements of the wound. Review of the Daily Staffing Sheets for 7/22-7/31/16 revealed there was no Treatment Nurse scheduled. Medical record review of the wound assessment report dated 8/12/16 revealed no measurements for the right buttock wound. Medical record review of the TAR dated 8/2016 revealed no treatment of [REDACTED]. Review of the Daily Staffing Sheets revealed there was no Treatment Nurse scheduled on 8/7/16, 8/13/16, and 8/14/16. Interview with the Treatment Nurse on 11/8/16 at 4:45PM, in the small conference room, confirmed there were no weekly wound assessments completed on 8/12/16 for the right buttock. Interview with the Treatment Nurse on 12/5/16 at 9:15 AM, in the conference room, confirmed it was difficult to complete all wound treatments when she was pulled to the medication cart. Further interview confirmed wound treatments not completed by the treatment nurse are not always completed by the other nurses. Interview with Registerd Nurse (RN) #1 on 12/6/16 at 9:50 AM, in the 100 hall, confirmed there were times she was unable to complete treatments and dressing changes as ordered by the physician. Medical record review revealed Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the wound assessment reports for the R BKA and the L BKA revealed 15 out of 30 assessments for 8/25/16 through 12/1/16 were not completed. Review of the daily staffing revealed no Treatment Nurse was scheduled for 11 days out of 30 days. Medical record review of the TAR dated 11/2016 revealed the treatments to the left lower extremity stump and the right hip wound had not been initialed as complete for 5 out of 30 days (11/12/16, 11/13/16, 11/19/16, 11/26/16, and 11/27/16). Interview with the Treatment Nurse on 12/7/16 at 3:20 PM, in the conference room, confirmed she did not have any additional measurements for the wounds for Resident #145. Continued interview revealed .if I work a cart (medication cart) I do the treatments on that hall only .the other nurses are supposed to do their treatments . Interview with Resident #145 on 12/6/16, in the 200 hall way, revealed .yes, they change it pretty much every day especially if the treatment nurse is here, but if she's not it's usually every other day . Medical record review of Resident #145's September 2016 TAR revealed no documentation the treatment had been completed on 9/29/16 and 9/30/16. Review of the Monthly Schedule, Daily Staffing Sheets, and Payroll Reports for September 2016, revealed no Treatment Nurse was working at the facility on 9/29/16 and 9/30/16. Interview with the DON on 12/5/16 at 11:15 AM, in the conference room, revealed .knew there were holes in the MARS/TARS so we can't prove they were done . Interview with CNA #7 on 11/19/16 at 10:20 AM, on the 100 hallway, revealed . it's hard to cover both hallways with 2 people .can't hear alarms down the other hall especially if you are in a room or giving a shower . Interview with Resident #46 at 10:45 AM, in her room, revealed .we have not got enough help .just once in a while someone will come in here .takes a half a day or longer sometimes to answer call light . Interview with CNA #21 on 11/19/16 at 11:00 AM, on the 400 hallway, revealed .no I haven't gotten to everyone yet .no haven't told my nurse . Interview with CNA #20 on 11/19/16 at 11:20 AM, on the 300 hallway, revealed .still have 3 or 4 residents to get to .came in at 6:00 AM .typical day .it takes time .the nurses know . Interview with LPN #15 on 11/19/16 at 12:15 PM, in the 300-400 nurses station, revealed she was unaware the CNA's were behind on their rounds. Continued interview revealed .think staffing could be better .If we have call ins we really don't have a lot of prn help . Interview with LPN #1 on 11/19/16 at 12:35 PM, in the 300 hallway, revealed .not aware the CNA's were behind .just happens sometimes . Interview with Resident #93 on 11/30/16 at 10:07 AM, in the resident's room, revealed she requires a walker and assistance of staff to ambulate to the bathroom. Further interview confirmed she is incontinent at times because it takes up to 30 minutes for staff to come to her room. Interview with Resident #47 on 12/1/16 at 7:40 AM, in resident's room, revealed .we don't have enough help cause sometimes don't have enough people to get me up cause it takes 2 people . Telephone interview with LPN #10 on 12/3/16 at 2:05 PM revealed .I had someone fall .I can't get the treatments done .the DON is here and I ask for help and she told me not to get so worked up over this. I could do it and if I couldn't I just needed to write a statement and clock out and go home. I had to work over 21 ½ hours last weekend because someone called in last Saturday and we have had another call in today .I can't do it again .It's not safe to work here. We can't get everything done .These people are not being taken care of like they should be. On 11/13 into 11/14/16 when I was working there were several dressings that had not been changed since 11/8/16. I called the DON and told her about it and she told me to just write a statement of who the residents were. So I did and (LPN #13) signed it too .everybody has been mad since then .(RN #1) told me I lied and I told her if they were done then why did the dressing say 11/8/16 .the Treatment Administration Records were not signed but they probably are now .if I don't get to them I don't initial that I did them. I'm sure sometimes others initial when they didn't change the dressing . Interview with the DON on 12/5/16 at 11:15 AM, in the conference room, revealed she was aware treatments were not being completed as ordered. Interview with the Medical Director on 12/5/16 at 1:55 PM, in his office, confirmed he was aware of the staffing issues at the facility. Continued interview revealed .I have been the Medical Director for [AGE] years and it's always been an issue here . Interview with the Treatment Nurse on 12/6/16 at 3:40 PM, on the 100 hall, confirmed sometimes she has come back to work after being off and discovered wound treatment had not been done while she was off. Telephone interview with LPN #13 on 12/6/15 at 4:30 PM revealed .we found multiple, multiple, multiple dressings that had been signed as done but the dressings were dated 11/8/16. I cannot remember everybody .(LPN #10) and I wrote a statement out of how many dressings were dated 11/8, 11/9, and 11/10 (2016) had been initialed as having been changed but were not .I have to stay over every day .I do my med pass and treatments and have to stay over to do documentation and charting .things like that .it's too much to get done in one shift . Interview with the Treatment Nurse on 12/7/16 at 3:20 PM, in the conference room, revealed .If I work a cart (medication cart) I work a cart and then do treatments on that hall. Sometimes I get to work on treatments ½ day .I'm not going to lie .it's been hell around .I actually do 3 peoples jobs. I am the treatment nurse, a cart nurse, and I do the scheduling too. If there is no one to schedule to work the shift I have to work the cart .we don't have any open positions right now . Refer to F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-241 (J); F-280 (J); F-309 (J); F-312 (J); and F-314 (J).

Based on review of the Medical Director Services Agreement, facility policy review, medical record review, review of facility investigations, observation, and interview, the facility failed to ensure the Medical Director participated in the implementation of resident care policies and in attendance of Quality Assurance (QA) meetings to ensure wound care protocols were available and followed to assess and treat all wounds; to ensure residents with medical devices (immobilizers) did not develop pressure ulcers related to use of the device; to ensure the physician was notified for changes in condition and to obtain treatment orders; to ensure facility policy was followed so all residents were protected from neglect and abuse and all allegations of neglect and abuse were reported and investigated; to ensure residents were safe from accidents; and to ensure adequate staffing to provide care and services to residents according to their needs and care plans. The facility's failure placed 11 residents (#106, #123, #75, #103, #65, #27, #68, #21, #45, #12, #145) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirement of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Corporate Director of Clinical Services and the Administrator were informed of the Immediate Jeopardy (IJ) in the conference room on 12/7/16 at 9:30 AM. The facility was cited an Immediate Jeopardy at F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-353 (K); F-490 (K); F-493 (K); F-501 (K); and F-520 (K). The facility was cited Substandard Quality of Care (SQC) at F-223 (K), F-224 (J), F-225 (K), F-241 (J), F-309 (J), F-312 (J), F-314 (J). The IJ was effective on 2/6/16 and is ongoing. The findings included: Review of the facility Medical Director Services Agreement dated 3/11/13 revealed .Doctor agrees to perform the following duties under this Agreement .Assist in developing and implementing resident care policies, procedures and guidelines regarding admissions, transfers, discharges, infection control, safety .pressure sore reduction, physician privileges and practices, responsibilities of non-physician health care workers and other aspects of residents care to ensure adequate and comprehensive services. Participate in establishing policies related to accidents and incidents .overall quality of care .Review all new policies and procedures .Review all incident and accident reports from the Facility to identify clinical risks and safety hazards .Direct coordinate the medical care in Facility and ensure the Facility is providing appropriate care as required .Participate in Facility's resident care management system, which will include attendance and active participation in the Facility's monthly Quality Assurance Committee and Patient Care Policy Committee meetings .Participate in the development of the Comprehensive Care plan for resident for whom Medical Director serves as attending Physician .Advise Facility Administrator about the adequacy and appropriateness of the Facility's .professional and support staff .Consult with Facility Administrator regarding (i) staffing .Conduct in-service education for Facility personnel as may be requires .Doctor will continually work to improve the quality of medical care . Interview with the Medical Director on 12/5/16, at 1:55 PM, in his office, confirmed he was unaware the facility did not have protocols in place for wound care. Continued interview confirmed he does not do training or teaching on wound care with the Director of Nursing or the Treatment Nurse. Further interview confirmed he was unaware the wound care nurse did not have formal training in the treatment of [REDACTED]. Further interview confirmed he had been the Medical Director at the facility for [AGE] years and staffing had always been an issue. Continued interview confirmed there were times he was unable to attend the QA meetings and he gets filled in later. Further interview confirmed the facility has discussed concerns of abuse with the Medical Director. Refer to F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-323 (G); F-353 (K); F-490 (K); F-493 (K); and F-520 (K).

Based on medical record review, review of facility investigation, interview, and observation, the facility failed to provide timely incontinence care to maintain dignity for 3 dependent residents (#65, #21, and #45) of 43 residents reviewed. The facility's failure placed residents #65, #21, and #45 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death) and was likely to place any resident requiring assistance with incontinence care in Immediate Jeopardy. The facility was cited F-241 at a scope and severity of J which constitues Substandard Quality of Care. The Immediate Jeopardy was effective 2/7/16 and is ongoing. The findings included: Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #65 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Continued review revealed the resident required extensive assist with transfers and dressing, total assist for hygiene and bathing, and was always incontinent of bowel and bladder. Review of a facility investigation revealed Resident #65 reported on 2/7/16 she told Certified Nursing Aide (CNA) #14 she was soaking wet and requested to be changed. Continued review revealed CNA #14 told the resident he was 2 hours behind, and he could not get to her, and the CNA did not return. Registered Nurse (RN) #2 reported the incident to the Director of Nursing (DON) on 2/8/16. The DON interviewed Resident #65 and the resident confirmed the incident. Interview with Resident #65 on 11/9/16 at 11:40 AM, in the resident's room, revealed .can't remember exactly what he (CNA #14) said .didn't have time or something like that .it made me feel like I wasn't important . Interview with the DON on 12/5/16 at 2:17 PM, in the conference room, confirmed care was not provided to maintain the resident's dignity. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #21 had a BIMS Score of 15, indicating the resident was cognitively intact. Continued review revealed Resident #21 was total dependence of one person for mobility, transferring and toileting, and the resident was always incontinent. Medical record review of the Resident's Care Plan dated 10/18/16 revealed .Self Care Deficit r/t (related to) [MEDICAL CONDITION] .Provide Peri care with each incontinent episode .Assist with ADLs (activities of daily living) as needed . Medical record review of the Interdisplinary Progress Notes dated 12/12/15 revealed .Resident is paraplegic and requires total care for ADL's .Incont (incontinent) of B&B (bowel and bladder) c (with) peri care q2 (every 2 hours) + (and) PRN (as needed) . Observation on 11/30/16 at 8:08 PM, on the 400 hall, revealed Resident #21 had a strong urine odor. Continued observation revealed the resident's pants had a wet stain from her groin to the knee. Observation with Licensed Practical Nurse (LPN) #14 on 11/30/16 at 8:12 PM, in the 400 hallway, revealed Resident #21 was in a wheelchair, with a wet saturation on the resident's pants, from the groin to, down the inner thigh, to her knees. Interview with Resident #21 on 11/30/16 at 8:08 PM, on the 400 hall, confirmed .They haven't changed or clean me yet . Interview with CNA #19 on 11/30/16 at 8:09 PM, on the 400 hall, revealed .I haven't changed her yet tonight (shift began at 6:00 PM) . Continued interview confirmed the resident had to wait 3 hours to be provided incontinence care. Interview with LPN #14 on 11/30/16 at 8:12 PM, on the 400 hall, confirmed .She is soiled . Further interview confirmed the resident's dignity was not maintained. Medical record review revealed Resident #45 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 3/25/16 and updated 9/15/16 revealed .Self Care Deficit .Assist with ADL's as needed .Has incontinence bowel & (and) bladder .Incontinence (care) to be provided by staff as needed . Medical record review of the Quarterly MDS dated [DATE] revealed Resident #45 had a BIMS Score of 15, indicating the resident was cognitively intact. Continued review of the MDS revealed the resident was total dependence with toileting. Further review revealed the resident was always incontinent. Medical record review of the Nursing Weekly Summary dated 11/19/16 revealed .ass (assist) x (times) 2 c (with) ADL's + t/f's (transfers) .Incont of B+B peri care PRN + q2 (every 2) .non amb (ambulatory) is in the bed most of the time . Medical record review of a Nurse Aide's Information Sheet undated, revealed .Incontinent .Total care .Geri chair .Lift to chair .(mechanical lift) . Interview with Resident #45 on 11/30/16 at 8:18 PM, in the resident's room, confirmed . I haven't been changed since before supper before 5 (5:00 PM) . Telephone interview with CNA #18 on 12/1/16 at 8:38 PM, confirmed she was assigned to Resident #45 on the night of 11/30/16. Continued interview confirmed she finished her first dry rounds (checking for bowel and urinary incontience needs) after 10:00 PM. Further interview confirmed the resident had to wait more than 3 hours to be changed. Continued interview confirmed Resident #45's dignity was not maintained. Interview with the Director of Nursing on 12/5/16 at 2:17 PM, in the conference room, confirmed she expected the residents to be checked and changed at least every 2 hours. Interview with Resident #45 on 12/7/16 at 9:39 AM in the resident's room, revealed .It is what it is. What can you do about it .

Based on review of facility policy, medical record review, and interview, the facility failed to promptly notify the Physician of the presence of a pressure ulcer for 2 residents (#106 and #123) of 8 residents reviewed for pressure ulcers, of 43 residents sampled. The facility's failure placed residents #106 and #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The Immediate Jeopardy was effective 7/25/16 and is ongoing. The findings included: Review of the facility policy, Pressure Ulcer Prevention of, dated 2006 revealed .Notification of the physician is required when a new pressure ulcer is identified as well as when treatment is not effective . Medical record review revealed Resident #106 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Re-Admission Resident (MDS) data set [DATE] revealed Resident #106 had the sacral area circled on the body diagram with .shearing (skin injury caused by opposite but parallel sliding motion) . written out beside of the area. There were no measurements or description of the wound, and no treatment was initiated. Medical record review of the Nursing Weekly Summary dated 7/29/16 revealed .open area in coccyx area. Bilateral buttocks reddened irritated, blood noted in brief from irritated areas on buttocks . Medical record review of the physician's telephone orders dated 7/30/16 revealed .clean coccyx (with) ns (normal saline), skin prep apply [MEDICATION NAME] to coccyx Q (every) three days and prn (as needed) till resolved . Medical record review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #106 had one Stage 1 (defined by the MDS as intact skin with non-blanchable redness of a localized area usually over a bony prominence) and one Stage 2 pressure ulcer (defined by MDS as partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed without slough. May also present as an intact or open/ruptured serum filled blister) identified upon admission. Medical record review of the wound assessment report dated 8/5/2016 revealed .wound type pressure ulcer .location sacrum .present upon admission yes .stage 2 .measurements length - 0.7 cm (centimeters) width - 0.4 cm wound type pressure ulcer .wound location right buttock .present upon admission .yes .stage 1 .measurements length - 0.7 cm width - 0.50 cm (centimeter) . Interview with the treatment nurse on 11/8/16 at 4:45PM, in the small conference room, confirmed the physician was not notified of the stage 1 or stage 2 pressure ulcers on admission and there were no orders obtained for wound care. Interview with the Director of Nursing (DON) on 11/8/16 at 5:05 PM, in her office, revealed .with stage 1 pressure ulcers we basically reposition and then notify the Doctor or Nurse Practitioner (NP) when they visit to do their assessment .if more than a stage one (stage 2 or above) they (nurses) would call the doctor for an order . Interview with the Nurse Practitioner on 11/9/16 at 10:25 AM, in the small conference, room confirmed .not notified of the shearing .I know they use turning and repositioning for stage 1 pressure ulcers .should have been treated with something . Interview with the DON on 12/5/16 at 11:40 AM, in the conference room, confirmed the facility had failed to notify the resident's physician to obtain an order for [REDACTED].#106's wound declined after it had been identified and a treatment was not implemented. Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Daily Skilled Nurses Note dated 11/13/16 at 12:00 AM, revealed .brace on R (right) leg, Brace is off due to rubbing quarter size area (open) to calf (lower leg) area, to have tx (treatment) nurse address . There was no documentation the physician was notified on 11/13/16. Medical record review of a Wound and Skin Status Report, completed by the Treatment Nurse, revealed the wound was documented as identified on 11/15/16 (the same wound identified in the nurses note dated 11/13/16). Continued review revealed the right calf wound was a Stage 1 (defined by the MDS as intact skin with nob-blanchable redness of a localized area usually over a bony prominence). Medical record review of a Nurse Practitioner's note dated 11/15/16, revealed .Pt (patient) has eschar (dry patches of dead tissue) on posterior RLE (right lower extremity) that was caused by brace . Medical record review of a Physician's Note dated 11/17/16 revealed .There is a 2 cm ulceration on the posterior right calf . Interview with the DON on 12/6/16 at 8:15 AM, in the conference room, confirmed the facility was not aware the pressure ulcer had been identified on 11/13/16 instead of 11/15/16. Further interview confirmed the new pressure ulcer had not been reported to the Nurse Practitioner until 11/15/16. Refer to F-314

Based on facility policy, medical record review, observation and interview the facility failed to provide services to prevent neglect for 3 residents (#65, #21 and #45) of 43 residents reviewed. The facility's failure to provide services to prevent neglect is likely to place all residents requiring assistance with incontinence care in Immediate Jeopardy (a situation which the provider's noncompliance has caused,or is likely to cause, serious harm, impairment or death). The facility was cited F224 at a scope and severity of J which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy is effective 2/7/16 and is ongoing. The findings included: Review of facility policy Abuse undated revealed Abuse .deprivation by an individual .of goods or services that is necessary to attain or maintain, physical, mental and psychosocial well being of a resident .Residents most at risk: of neglect .residents who are bedfast and totally dependent on care . Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] revealed Resident #65 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Continued review revealed the resident required extensive assist with transfers and dressing and total assist for person hygiene and bathing with 1-2 person assist and was always incontinent of bowel and bladder. Review of a facility investigation dated 2/7/16 revealed Resident #65 reported to RN #2 she told CNA #14 she was soaking wet and requested incontinence care. Continued review revealed CNA #14 told the resident he was . 2 hours behind and he could not get to her . Further review revealed RN #2 reported the incident to the DON on 2/8/16. Continued review revealed the DON interviewed Resident #65 and the resident reported the same incident. Interview with Resident #65 on 11/9/16 revealed .can't remember exactly what he said .didn't have time or something like that .it made me feel like I wasn't important . Interview with Resident #65 on 11/19/16 at 11:25 AM confirmed CNA #14 did not return to the resident's room to provide incontinence care. Interview with the DON on 12/5/16 at 2:17 PM, in the conference room, confirmed she expected residents to be checked and changed every 2 hours and as needed. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Interdisciplinary Progress Notes dated 12/12/15 revealed .Resident is paraplegic and requires total care for ADL's .Incont (incontinent) of B&B (bowel and bladder) c (with) peri care q2 (every 2 hours) + (and) PRN (as needed) . Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Continued review revealed Resident #21 was totally dependent on staff with assistance of one person for with mobility, transferring and toileting. Further review of the MDS revealed the resident was always incontinent. Medical record review of the Care Plan dated 10/18/16 revealed .Self Care Deficit r/t (related) [MEDICAL CONDITION] .Potential for skin breakdown d/t (due to) decrease mobility .Provide Peri care with each incontinent episode .Potential for urinary tract infection r/t incontinence of B&B (bowel and bladder) .Self Care Deficit r/t [MEDICAL CONDITION] .Assist with ADLs as needed . Medical record review of the Nurse Aide's Information Sheet undated, revealed Resident #21 was incontinent and required total care assistance. Continued review revealed the resident required a mechanical lift for transfers. Interview with Certified Nursing Assistant (CNA) #19 on 11/30/16 at 8:04 PM, in the 400 hall, revealed .I have done my first dry rounds .Starting 8's (8:00 PM rounds) now .Last rounds at 4 (4:00 PM) before I got here . Observation on 11/30/16 at 8:08 PM, on the 400 hall, revealed Resident #21 had a strong urine odor. Continued observation revealed the resident had a wet stain from the groin to her knee. Interview with Resident #21 on 11/30/16 at 8:08 PM, on the 400 hall, confirmed .They haven't changed or clean me yet .not since last state person (state surveyor) was here . Interview with CNA #19 on 11/30/16 at 8:09 PM, on the 400 hall, revealed .I haven't changed her yet tonight (shift begin at 6:00 PM) . Further interview confirmed CNA #19 failed to provide services for incontinence care for Resident #21. Continued interview confirmed the resident had to wait 3 hours to be provided incontinence care. Observation with Licensed Practical Nurse (LPN) #13 on 11/30/16 at 8:12 PM, in the 400 hallway, revealed Resident #21 was in the wheelchair with a wet saturation on the resident's pants from the groin, to inner thigh, to knee. Interview with LPN #14 on 11/30/16 at 8:12 PM, on the 400 hall, confirmed .She is soiled .She is a lift transfer .I expect her to be changed every 2 hours . In Summary Resident #21 had a BIMS of 15. Observation and interview on 11/30/16 confirmed the resident was visibly soiled with urine in the wheelchair while in the 400 hallway. Interview with LPNs and CNAs confirmed the resident was incontinent and required incontinence care. Resident #21 had to wait 3 hours to be cleaned and changed. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 3/25/16 and updated 9/15/16 revealed .Self Care Deficit .Assist with ADL's as needed .Has incontinence bowel & bladder .Incontinence to be provided by staff as needed . Medical record review of the Quarterly MDS dated [DATE] revealed Resident #45 had a Brief Interview for Mental Status Score of 15, indicating the resident was cognitively intact. Continued review of the MDS revealed the resident was total dependence with toileting. Further review of the MDS revealed the resident was always incontinent. Medical record review of the Nurses Note dated 11/6/16 revealed .we do not want any skin breakdown or skin issues that can arise d/t (due to) poor hygiene . Medical record review of the Nursing Weekly Summary dated 11/19/16 revealed .ass (assist) x (times) 2 c (with) ADL's + (and) t/f's (transfers) .Incont of B+B (bowel and bladder) peri care PRN + q2 (every 2 hours) .non amb (ambulatory) is in the bed most of the time . Medical record review of the Bladder Evaluation dated 11/26/15 revealed .Functional Status/Assist .Total dependence .multiple daily episodes (incontinence) . Medical record review of Nurse Aide's Information Sheet (Kardex), undated, revealed .Incontinent .Total care .Geri chair .Lift to chair .(mechanical lift) . Interview with Resident #45 on 11/30/16 at 8:18 PM, in the resident's room, confirmed .I haven't been changed since before supper before 5 (5:00 PM) . Interview with Registered Nurse #2 on 11/30/16 at 8:25 PM, on the 300 hall, confirmed the CNAs were to check and change the residents every 2 hours. Continued interview confirmed the CNAs started their rounds at 6:00 PM. Telephone interview with CNA #18 on 12/1/16 at 8:38 PM, confirmed she was assigned to Resident #45 on the night of 11/30/16. Continued interview confirmed she finished her first dry rounds (rounds to check residents for incontinence and hygiene needs) after 10:00 PM (took 4 hours to complete 6:00 PM dry rounds). Further interview confirmed CNA #18 failed to provide services for incontinence care for Resident #45. Interview with RN #5 on 12/2/16 at 2:37 PM, in the conference room, confirmed Resident #45 was incontinent and required a mechanical lift for mobility. Interview with the Director of Nursing on 12/5/16 at 2:17 PM, in the conference room, confirmed she expected the residents to be checked and changed every 2 hours and as needed. Interview with CNA #13 on 12/7/16 at 8:01 AM, on the 300 hall, confirmed she was assigned to Resident #45 on the dayshift on 11/30/16 and finished her dry rounds at 5:00 PM. Interview with Resident #45 on 12/7/16 at 9:39 AM in the resident's room, confirmed .It is what it is. What can you do about it . In Summary Resident #45 had a BIMS of 15. During the interview on 11/30/16 the resident stated she had not been changed since before dinner time at 5:00 PM. Interview with CNA assigned to resident on the night shift on 11/30/16 confirmed she had not finished her first set of dry rounds till 10:00 PM and had not cleaned and changed Resident #45 till 8:30 PM. Resident #45 had to wait 3 hours to be provided incontinent care.

Based on medical record review and interview, the facility failed to revise the care plan to include interventions for an immobilizer for 2 residents (#12 and #123) and failed to revise the care plan for pressure ulcers for 3 residents (#12, #123, and #54) of 43 residents reviewed. The facility's failure placed residents #12 and #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The Immediate Jeopardy was effective [DATE] and is ongoing. The findings included: Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating the resident had a severe cognitive impairment. Continued review revealed the resident was totally dependent for bed mobility and personal hygiene with one person physical assist. Further review revealed Resident #12 was totally dependent for transfers and bathing with 2+ person physical assist. Review of a Physician's Progress Note dated [DATE] revealed .Tib/fib (tibia/fibula bones of lower leg) fx (fracture) .Brace noted to LLE (left lower extremity) . Review of a Physician's Telephone Orders dated [DATE] at 11:30 AM revealed .knee immobilizer to LLE q (every) shift . Review of the care plan implemented [DATE] revealed a care plan revision dated [DATE], .Knee immobilizer to LLE (left lower extremity) as ordered. Check as ordered . Continued review revealed no other documentation for specific interventions, goals, and outcomes that were time sensitive, including what was to be checked and how often. Review of the LAB (Laboratory) Record (record utilized by the facility to document immobilizer assessments) dated [DATE], revealed .Leg imobilizer (immobilizer) to LLE check q shift . Further review revealed no documentation the immobilizer had been checked until [DATE] on the 6A-6P shift. Review of the Nursing Supplemental Record dated [DATE] revealed .Knee immobilizer to LLE, check skin integrity q shift .Order date [DATE] . Continued review revealed, XXX[DATE] May continue to wear brace with activity and transfers but can remove @ (at) rest . Further review revealed no documentation skin integrity was checked on the [DATE] 6P-6A shift. Review of the resident's care plan revealed no revision to the care plan the leg brace was to be removed at rest. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 3 of possible 15, indicating the resident had severe cognitive impairment. Continued review revealed the resident was totally dependent for bed mobility, bathing, and personal hygiene with one person assistance. Further review revealed Resident #12 was totally dependent for transfers with 2 plus persons physical assistance and was at risk for developing pressure ulcers. Review of the Nursing Supplemental Record dated [DATE] revealed .Knee immobilizer to LLE with activity & (and) transfers but can remove @ rest; check skin integrity q shift Order Date: [DATE] . Continued review revealed no documentation the skin integrity had been checked on any days in September except the [DATE] 6A-6P shift. Review of the resident's care plan revealed the care plan was not revised to indicate the immobilizer could be removed at rest or to check the skin integrity every shift. Review of a Progress Note, authored by Nurse Practitioner (NP) #1 and dated [DATE], revealed .pt (patient) with 2 open areas on LLE. Ankle measures 3 x 3 L (left) lateral leg area measures 1 (centimeter) x 4.8 (centimeters) . Review of the [DATE] Treatment Administration Record revealed XXX[DATE] Clean area on (L) ankle with NS (normal saline), pat dry apply .(treatment for [REDACTED].(change) QD (every day) . Continued review revealed no documentation treatments had been done on [DATE], [DATE], and [DATE]. Medical record review of the [DATE] Treatment Administration Record revealed XXX[DATE] Clean area on (L) lower leg with NS pat dry apply .cover with ABD pad et wrap . Continued review revealed no documentation the treatment had been completed on [DATE], [DATE] and [DATE]. Review of the resident's care plan revealed a handwritten revision to the care plan, with no date, .Staged area to LLE . Further review of the care plan revealed no specific interventions or treatments for the staged area, and no time-sensitive goals. Further review revealed no documentation of the stage, character, or size of the staged area. Medical record review of the Nursing Supplemental Record dated [DATE] revealed .Remove LLE knee immobilizer brace while in bed, but place it with transfers, check skin integrity Q shift .Order Date: [DATE] . Medical record review of the resident's care plan revealed the care plan was not revised to indicate the need to remove the LLE immobilizer while the resident was in bed or to check the skin integrity every shift. Review of a Nurse's Note dated [DATE] at 5:00 PM, revealed .leg and ankle small amount of drainage and blood noted . Further review revealed a note on [DATE] at 8:00 AM, .leg and ankle small amount of drainage and blood noted. Foul odor .NP made aware and N.O. (New Order) [MEDICATION NAME] (antibiotic) .for wound infection . Review of the Physician's Progress Note dated [DATE] revealed .out of immobilizer which was causing wounds. Interview with Resident #12's Physician on [DATE] at 3:55 PM, in the conference room, confirmed the pressure ulcers should have been discovered at a Stage 1 and Stage 3 pressure ulcers would take ,[DATE] days to develop. Further interview confirmed the pressure ulcers could have been avoided if the skin had been checked every shift. Interview with the Treatment Nurse on [DATE] at 9:15 AM, at the ,[DATE] nurses station, confirmed on [DATE] a CNA discovered 2 pressure ulcers to Resident #12's left shin and ankle during a shower and reported those to the treatment nurse. Continued interview revealed it was the nurses responsibility to check the skin when check skin integrity was ordered. Telephone interview with Licensed Practical Nurse (LPN) #15 on [DATE] at 8:38 PM, confirmed she did not remove the brace every shift and look at the skin. Telephone interview with LPN #11 on [DATE] at 8:52 PM, confirmed the LPN did not check the skin integrity every shift. Interview with RN #5 on [DATE] at 12:53 PM in the conference room confirmed the MDS nurses were responsible for the updates on the care plan. Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #123's Care Plan dated [DATE] revealed .Potential for skin breakdown .Weekly skin assessment .Treatments as ordered .Rt (right) knee immobilizer as ordered . Medical record review of a Daily Skilled Nurses Note dated [DATE] at 12:00 AM, revealed .brace on R (right) leg, Brace is off due to rubbing quarter size area (open) to (lower) calf area, to have tx (treatment) nurse address . Medical record review of a Wound and Skin Status Report revealed the wound was documented as identified on [DATE], and was the same wound identified in the nurses notes dated [DATE]. Continued review revealed the right calf wound was a Stage 1 (defined by the MDS as intact skin with non-blanchable redness of a localized area usually over a bony prominence) and measured 1.5 x 2.3 x 0.0 (unit of measurement not identified, but usually in centimeters (cm)) on [DATE]. Medical record review of a Wound Assessment Report dated [DATE], revealed the wound type was a pressure ulcer; the location of the wound was the right calf; it was Stage 1 with measurements of 1.50 cm length x 2.30 cm width; and there was no description of the wound. Medical record review of an Interdisciplinary Progress Noted dated [DATE], revealed .res (resident) with area to back of R calf 1.5 cm x 2.3 cm Stage 2 (defined by the MDS as partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.) Resident with new brace . Medical record review of an Interdisciplinary Disciplinary Team (IDT) progress note dated [DATE], revealed .area to the back of R calf noted to be scabbed, daily application of [MEDICATION NAME], et (and) wrap with kerlix (gauze dressing wrap) . Medical record review of a Physicians Order dated [DATE], revealed Clean area on back of R lower extremity with NS (normal saline) pat dry. Apply polymem (medicated dressing treatment) et cover with dry dsg (dressing) et wrap with kerlix change Tues, Friday. Interview with the DON on [DATE] at 8:30 AM, in the resident's room, confirmed the pressure ulcer was now unstageable due to the slough in the wound bed. Interview with the Treatment Nurse on [DATE] at 9:15 AM, in the conference room, confirmed the care plan for Resident #123 was not revised to include a pressure ulcer, treatments or interventions, or time-sensitive goals. Medical record review revealed Resident #54 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Continued medical record review revealed the resident was on hospice and expired on [DATE]. Medical record review of a Nurse's Note dated [DATE] revealed .Scratch to R hip 2.5 x 0.3 cm and 0.9 x 0.4 cm . Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 2, indicating the resident was severely cognitively impaired. Continued review revealed the resident was totally dependent for bed mobility, transfers, personal hygiene, and required 1 person assist with bathing, and extensive assist with eating. Further review revealed Resident #54 had a Stage 1 or higher pressure ulcer identified upon admission to the facility. Medical record review of the Care Plan dated [DATE] revealed .potential for increase in further skin breakdown .was admitted with staged area to Rt (right) buttocks .Weekly skin assessment .Treatment as ordered . Medical record review of the Nursing Weekly Summary dated [DATE] revealed .Ongoing tx (treatment) Rt hip . Medical record review of the Wound Healing Progress Report revealed .Measurement of Wound Identified .blister Right Hip .0.6 (centimeters) x 3.60 . [DATE] (date the measurement was obtained) . Medical record review of the Wound Assessment Report dated [DATE] revealed .blister .Right hip .Cause Unknown . Medical record review of the Wound Healing Progress Report revealed the blister on the right hip was documented as 2.8 x 3.30 on [DATE] (increase in size from [DATE]). Medical record review of a Physician Telephone Order dated [DATE] revealed .Clean area on R hip with NS (normal saline) pat dry .Apply [MEDICATION NAME] (wound care dressing with honey) and cover with dry drsing (dressing) M/W/F (Monday, Wednesday and Friday) and prn . Medical record review of the Nurses Note dated [DATE] revealed .R hip area noted to have slough (a mass of dead tissue separating from an ulcer) . Medical record review of the Resident #54's care plan revealed the care plan did not include the identification of the right hip blister or interventions to treat and prevent a decline in the wound. Interview with the Director of Nursing (DON) on [DATE] at 8:34 AM, in the conference room, confirmed .A blister is a stage 2 . (pressure ulcer). Interview with the Treatment Nurse on [DATE] at 12:55 PM, in the conference room, confirmed a Stage 2 pressure ulcer would require interventions. Interview with RN #5 on [DATE] at 12:53 PM, in the conference room, confirmed the facility failed to revise Resident #54's care plan to include the right hip blister (a Stage 2 pressure ulcer). Refer to F-314

Based on facility policy review, review of facility standing orders, medical record review, observation, and interview, the facility failed to provide the necessary care to prevent avoidable pressure sores from developing or worsening for 3 residents (#12, #123, #106) of 8 residents reviewed for pressure sores. The facility's failure placed the residents #12, #123, #106 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death. The facility was cited F314 at a scope and severity of J which constitutes Substandard Quality of Care. The Immediate Jeopardy is effective 7/20/16 and is ongoing. The findings included: Review of facility policy Pressure Ulcer Prevention, dated 2006, revealed .If a pressure ulcer is present, the licensed nurse is responsible to record condition of the skin, including stage, size, site, depth, color, drainage and odor as well as the treatment provided . Review of the facility Standing Orders, dated 6/7/16 revealed .Decubitus Care: Follow skin integrity and wound care protocol . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Treatment Administration Record dated July 2016 revealed, .Weekly Skin Assessment .Order Date 6/15/12 .See Wkly (weekly) Nrsg (nursing) Note . Review of a Physician's Progress Note dated 7/20/16 revealed .Tib/fib (tibia/fibula bones of lower leg) fx (fracture) .Brace noted to LLE (left lower extremity) . Review of a Physician's Telephone Orders dated 7/21/16 at 11:30 AM revealed .knee immobilizer to LLE q (every) shift . Review of the LAB (Laboratory) Record (record used by the facility for documenting some assessments) dated July 2016 revealed .Leg imobilizer (immobilizer) to LLE check q shift . Further review revealed no documentation the immobilizer had been checked until 7/26/16 on the 6A-6P shift. Review of the Nursing Supplemental Record dated August 2016 revealed .Knee immobilizer to LLE, check skin integrity q shift .Order date 7/21/16 .8/1/16 May continue to wear brace with activity and transfers but can remove @ (at) rest . Further review revealed no documentation skin integrity was checked on the 8/11/16 6P-6A shift. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 3 of possible 15, indicating the resident had severe cognitive impairment. Continued review revealed the resident was totally dependent for bed mobility, bathing, and personal hygiene with one person assistance. Further review revealed Resident #12 was totally dependent for transfers with 2 plus persons physical assistance and was at risk for developing pressure ulcers. Review of the LAB Record for September 2016 revealed, .9/22/16 remove brace while in bed, but place it for transfers . Review of the Nursing Supplemental Record dated September 2016 revealed .Knee immobilizer to LLE with activity & (and) transfers but can remove @ rest; check skin integrity q shift Order Date: 8/01/16 . Continued review revealed no documentation the skin integrity had been checked on any days in September except the 9/1/16 6A-6P shift. Review of a Progress Note, authored by Nurse Practitioner (NP) #1 dated 9/23/16 revealed .pt (patient) with 2 open areas on LLE. Ankle measures 3 x (by) 3 L (left) lateral leg area measures 1 (centimeter) x 4.8 (centimeters) .No infection or purulent drainage noted .Wound care nurse treating . Review of the September 2016 Treatment Administration Record revealed .9-23-16 Clean area on (L) ankle with NS (normal saline), pat dry apply .(treatment for [REDACTED].(change) QD (every day) . Continued review revealed no documentation treatments had been done on 9/25/16, 9/29/16, and 9/30/16. Medical record review of the September 2016 Treatment Administration Record revealed .9-23-16 Clean area on (L) lower leg with NS pat dry apply .cover with ABD pad et wrap . Continued review revealed no documentation the treatment had been completed on 9/24/16, 9/29/16 and 9/30/16. Medical record review of the Nursing Supplemental Record dated October 2016 revealed .Remove LLE knee immobilizer brace while in bed, but place it with transfers, check skin integrity Q shift .Order Date: 9/22/16 . Review of a Nurse's Note dated 10/1/16 at 5:00 PM revealed .leg and ankle small amount of drainage and blood noted . Further review revealed a note on 10/2/16 at 8:00 AM .leg and ankle small amount of drainage and blood noted. Foul odor .NP made aware and N.O. (Nursing Order) [MEDICATION NAME] (antibiotic) .for wound infection. Culture to wound .Culture obtained . Review of the Physician's Progress Note dated 10/6/16, authored by NP #1, revealed .DC (discontinue) [MEDICATION NAME] (antibiotic) .[MEDICATION NAME] (antibiotic) IM (intramuscular injection) . Review of the October 2016 weekly Wound Assessment Reports revealed no documentation of wound measurements on 10/7/16 for the left shin or the left ankle. Review of the Treatment Administration Record dated October 2016 revealed Clean areas on Lt outer ankle with ABD pad and secure with tape, change Q day .Order Date: 9/23/16 . Further review revealed no documentation of the treatment being completed on 10/10/16, 10/16/16, 10/18/16, and 10/30/16. Continued review revealed Clean area on Lt lower leg with NS, pat dry .change q day .Order Date: 9/23/16 . Further review revealed no documentation of the treatments being completed on 10/10/16, 10/16/16, 10/18/16, and 10/30/16. Review of the November 2016 weekly Wound Assessment Reports revealed no documentation of wound measurements for the weekly assessments of 11/4/16, 11/11/16, or 11/18/16 for the left ankle, and 11/25/16 for the left ankle and shin. Review of the Nursing Supplemental Record dated November 2016 revealed, .check skin integrity Q shift . Further review revealed documentation skin integrity was not checked on 11/14/16 6A-6 P shift. Review of the Physician's Progress Note dated 11/22/16, authored by the physician, revealed .out of immobilizer which was causing wounds. Interview with Resident #12's Physician on 12/2/16 at 3:55 PM, in the conference room, confirmed the pressure ulcers should have been discovered at a Stage 1 and the Stage 3 pressure ulcers would take 2-5 days to develop. Further interview confirmed the pressure ulcers could have been avoided if the skin had been checked every shift. Interview with the Treatment Nurse on 12/5/16 at 9:15 AM, at the 100/200 nurses station, confirmed on 9/23/16 a CNA discovered 2 pressure ulcers to Resident #12's left shin and ankle during a shower and reported those to the treatment nurse. Continued interview revealed it was the nurses responsibility to check the skin when check skin integrity was ordered. Continued interview confirmed there were no wound assessments done for a total of 7 weekly assessments (2 assessments for the shin and 5 assessments for the ankle) while the pressure ulcers were present. Telephone interview with Licensed Practical Nurse (LPN) #15 on 12/5/16 at 8:38 PM, confirmed she did not remove the brace every shift and look at the skin, she just made sure the resident could wiggle her toes, made sure the brace was not too tight, and ensured the circulation was good. Telephone interview with LPN #11 on 12/5/16 at 8:52 PM, confirmed the LPN did not check the skin integrity every shift, she only made sure the brace was off. Interview with the Director of Nursing (DON) on 12/6/16 at 8:45 AM, in the conference room, confirmed when a nurse initials that skin integrity was checked every shift, the nurse would be expected to look under the brace for any open areas or skin issues. Further interview confirmed the pressure ulcer should have been discovered prior to becoming a Stage 3 pressure ulcer. Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #123's Care Plan dated 10/18/16 revealed .Potential for skin breakdown .Weekly skin assessment .Treatments as ordered .Rt (right) knee immobilizer as ordered . Medical record review of a Daily Skilled Nurses Note dated 11/13/16 at 12:00 AM, revealed .brace on R (right) leg, Brace is off due to rubbing quarter size area (open) to (lower) calf area, to have tx (treatment) nurse address . Continued review revealed there was no documentation of a wound assessment, no physician orders, and no treatment completed on 11/13/16. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #123 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15, indicating the resident was cognitively intact. Further review revealed the resident required limited assistance of 1 staff for bed mobility, personal hygiene, bathing, and eating. Medical record review of a Wound and Skin Status Report revealed the wound was identified on 11/15/16 (the same wound identified in the nurses note dated 11/13/16). Continued review revealed the right calf wound was a Stage 1 (defined by the MDS as intact skin with non-blanchable redness of a localized area usually over a bony prominence). Medical record review of a Nurse Practitioner's note dated 11/15/16, revealed .Pt (patient) has eschar (dead tissue) on posterior RLE (right lower extremity) that was caused by brace . Medical record review of a Physician's Note dated 11/17/16 revealed .Patient notes that he has some discomfort on the back of his right leg where the brace rubbed an area on it .There is a 2 cm ulceration on the posterior right calf . Medical record review of a Wound Assessment Report dated 11/17/16, revealed the wound type was a pressure ulcer; the location of the wound was the right calf; it was Stage 1 with measurements of 1.50 cm length x 2.30 cm width; and there was no description of the wound appearance. Medical record review of daily skilled nursing notes dated 11/15/16 through 11/18/16, 11/22/16, 11/26/16, 11/28/16, 11/30/16, and 12/5/16, revealed no documentation of skin assessments or the status of the pressure ulcer. Medical record review of a Treatment Administration Record (TAR) for November 2016 revealed the weekly skin assessments for 11/8/16, 11/15/16, 11/22/16, and 11/29/16 had not been signed as completed. Medical record review of an Interdisciplinary Disciplinary Team (IDT) progress note dated 11/23/16, revealed .area to the back of R calf noted to be scabbed, daily application of [MEDICATION NAME], et (and) wrap with kerlix (gauze dressing wrap) . Medical record review of a Physicians Order dated 11/30/16, revealed Clean area on back of R lower extremity with NS (normal saline) pat dry. Apply polymem (medicated dressing treatment) et cover with dry dsg (dressing) et wrap with kerlix change Tues, Friday. Medical record review of a Wound Assessment Report dated 12/2/16 revealed .Stage Unstageable due to slough (mass of dead tissue separating from living tissue)/eschar (dead tissue) .measurements Length - 1.60 cm (centimeters) Width - 2.50 cm .Wound Bed Granulation Tissue - 90.00 %, Slough - 10.00 % . Observation of a dressing change to the right calf of Resident #123 on 12/1/16 at 8:15 AM, with the Treatment Nurse in the resident's room, revealed a wound to the right calf with visible slough noted in the wound bed. Continued observation revealed the treatment nurse measured the pressure ulcer at 1.7 cm x 2.1 cm. Further observation revealed the treatment nurse requested the Director of Nursing (DON) to observe the wound. Interview with the DON on 12/1/16 at 8:30 AM, in the resident's room, confirmed the pressure ulcer was now unstageable due to the slough in the wound bed. Interview with the Physician on 12/2/16 at 4:00 PM, in the conference room, confirmed if skin checks had been completed every shift, the pressure ulcer could have been prevented. Continued interview confirmed she expected the nurse supervisors to be trained in wound staging and wound management. Interview with the Treatment Nurse on 12/5/16 at 9:15 AM, in the conference room, confirmed it was the responsibility of the nurses to check skin integrity on Resident #123 every shift. Further interview confirmed she had not received wound education beyond the Licensed Practical Nursing (LPN) program. The treatment nurse stated it was difficult to complete all wound treatments when she was reassigned to other duties, which included assignment to the medication cart to administer medications. Further interview confirmed wound treatments not completed by the Treatment Nurse were not always completed by the nurses on the oncoming shift . During an interview with LPN #5 on 12/6/16 at 8:00 AM, in the 200 hallway, the LPN described her method for checking skin integrity was to check the skin on the back of the resident's hand by pinching the resident's skin. Interview with the DON on 12/6/16 at 8:15 AM, in the conference room, confirmed she did not have formal training in wound management. Continued interview confirmed she was not aware the pressure ulcer was identified on 11/13/16 instead of 11/15/16. Further interview confirmed no wound treatment was initiated until 11/15/16. The DON was asked about the Nurse Practitioner (NP) and Physician notes on 11/15/16 and 11/17/16 stating eschar and a 2 cm ulceration to the calf. The DON stated, .I don't remember seeing eschar . Further interview confirmed the treatment nurse completed the measurement and treatments .I pop in and do the staging . Interview with the Treatment Nurse on 12/7/16 at 3:30 PM, in the conference room, confirmed wound assessments with measurements were to be completed weekly by the treatment nurse. Further interview confirmed the wound assessment and measurements for the week of 11/24/16 had not been completed. Continued interview confirmed the DON was responsible for the staging of pressure ulcers. Further interview confirmed the treatment nurse had staged wounds without the DON present, even though it was the DON's responsibility and the treatment nurse had not received formal training in staging wounds. Continued interview revealed several months ago the treatment nurse requested education on wound management from the DON and the Administrator, but there had been no response to the request. Medical record review revealed Resident #106 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Re-Admission Resident (MDS) data set [DATE] revealed Resident #106 had the sacral area circled on the body diagram with .shearing (skin injury caused by opposite but parallel sliding motion) . written out beside of the area. There were no measurements or description of the wound, and no treatment was initiated. Continued review of the risk for pressure ulcers assessment revealed the resident scored a 13 out of a possible 23 which indicated the resident was high risk for the development of pressure ulcers. Medical record review of the care plan dated 7/25/16 revealed .Stage 1 to sacrum. Stage I to R (right) buttock .Treatments as ordered .Measure wound at least weekly. Record . Medical record review of the Nursing Weekly Summary dated 7/29/16 revealed .open area in coccyx area. Bilateral buttocks reddened irritated, blood noted in brief from irritated areas on buttocks . There were no measurements or description of the wound. Medical record review of the Physician's Telephone Order dated 7/30/16 revealed .clean coccyx (with) ns (normal saline), skin prep apply [MEDICATION NAME] to coccyx Q (every) three days and prn (as needed) till resolved . Medical record review of the Treatment Administration Record (TAR) revealed the treatment was initiated on 7/30/16. Medical record review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #106 had a Brief Interview for Mental Status (BIMS) score of 5 indicating the resident had a severe cognitive impairment. Continued review revealed the resident was totally dependent for bed mobility, transfers, personal hygiene, bathing with 1-2 person assistance and required limited assistance for eating with 1 person assistance. Further review revealed the resident had a Stage 1 (intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes) and a Stage 2 (partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) pressure ulcers identified upon admission. Medical record review of the Daily Skilled Nurses Note dated 8/1/16 revealed .Res (resident) has 2 areas, 1 on sacrum that measures 0.7 (cm) X (by) 0.4 (cm) .1 on R (right) buttock that measures 0.7 (cm) X (by) 0.5 (cm) . Medical record review of the Physician's Telephone Order dated 8/1/16 revealed .d/c (discontinue) [MEDICATION NAME] .Greer's Goo to buttocks and sacrum QD (every day) . Medical record review of the Wound Assessment Report dated 8/5/16 revealed .wound type pressure ulcer .location sacrum .present upon admission yes .stage 2 .measurements length - 0.7 cm width - 0.4 cm wound type pressure ulcer .wound location right buttock .present upon admission .yes .stage 1 .measurements length - 0.7 cm width - 0.50 cm . Medical record review of the Wound Assessment Report, dated 8/12/16 revealed .location sacrum .measurements length - 0.8 cm width - 0.4 cm length . There were no measurements for the wound to the right buttock. Interview with the Treatment Nurse on 11/8/16 at 4:45PM, in the small conference room, confirmed no orders were obtained for wound care upon until 7/30/16 (5 days after the resident was admitted ). Continued interview confirmed the sacral wound had increased in size from 8/5/16 to 8/12/16. Further interview confirmed there were no weekly wound assessments completed on 8/12/16 for the right buttock and 9/8/16 for the sacrum. Interview with the Director of Nursing on 11/8/16 at 5:05 PM, in her office revealed the DON stated the facility does not have a protocol for the treatment of [REDACTED].with stage 1 pressure ulcers we basically reposition and then notify the Doctor or Nurse Practitioner when they visit to do their assessment .if more than a stage one they (nurses) would call the doctor for an order . Interview with the Nurse Practitioner on 11/9/16 at 10:25 AM, in the small conference room revealed .not notified of the shearing .I know they use turning and repositioning for stage I pressure ulcers .should have been treated with something . Continued interview confirmed standing orders for Decubitus Care were to follow wound care protocol and was she was unaware the facility did not have a wound care protocol. Interview with the DON on 12/5/16 at 11:40 AM in the conference room confirmed the facility had failed to obtain an order for [REDACTED].#106's wound continued to decline after it had been identified and treatment was not implemented.

Based on medical record review, observation, interview, and facility policy review, the facility failed to provide wound assessment and treatment for 3 (#123, #145, and #170) residents of 3 residents reviewed for non-pressure wounds; failed to obtain weights as ordered for one resident with [MEDICAL CONDITION] (#55); and failed to follow facility policy for taking pre-and post (before and after) vitals signs and monitoring of a [MEDICAL TREATMENT] catheter for 1 (#20) of 1 resident reviewed for [MEDICAL TREATMENT], out of 43 residents reviewed. The facility's failure to provide assessment and treatment placed Residents #123 and #145 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The facility was cited F-309 at a scope and severity of J which constitutes Substandard Quality of Care. The Immediate Jeopardy is effective 10/27/16 and is ongoing The findings included: Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's care plan dated 10/18/16, revealed .Potential for skin breakdown .Surgical incision .Weekly skin assessment .Treatments as ordered .Assist resident with repositioning as need for comfort and pressure relief .Rt (right) knee immobilizer as ordered . Medical record review of a Physician's Order dated 10/21/16, revealed .Please arrange appt (appointment) with (orthopedic doctor) ASAP (as soon as possible) .Clean surgical incision to R (right) knee with [MEDICATION NAME], apply ABD (large wound dressing) wrap with .(named guaze) change QD (every day) . Medical record review of a Wound Assessment Report dated 10/21/16 revealed .Wound Type .Surgical Incision .Measurements Length 10.0 cm (centimeters) Width 0.00 Depth 0.00 .Wound Bed [MEDICATION NAME] Tissue 100% .Incision Detail closed, healing. Staples present and intact . Medical record review of an Orthopedic doctor's note dated 10/27/16, revealed .His incision does have some eschar at the midportion .He will need to start twice daily [MEDICATION NAME] dressing changes . Medical record review of a Physician's Order dated 10/27/16, revealed Twice daily [MEDICATION NAME] dressings until seen back by (Orthopedic doctor). Medical Record review of a Treatment Administration Record dated October 2016 revealed a dressing order dated 10/27/16 Twice Daily [MEDICATION NAME] dressing until seen by (Orthopedic Doctor) 11/3/16 . with 7 of 10 treatments not documented as completed between 10/27/16 through 10/31/16. Medical record review of a Wound Assessment Report dated 10/28/16, revealed .Wound Type .Surgical Incision .Measurements Length 10.0 cm (centimeters) Width 0.00 Depth 0.00 .Wound Bed [MEDICATION NAME] Tissue 100% .Incision Detail closed, healing. Staples present and intact . Medical record review of an Orthopedic Doctor progress note dated 11/3/16, revealed .He does have some [DIAGNOSES REDACTED] around eschar site at the middle third of his incision .Continue with twice daily [MEDICATION NAME] dressing changes until that followup appointment . Medical record review of a Wound Assessment Report dated 11/4/16, revealed .WoundType .Surgical incision .Measurements Length 10.0 cm (centimeters) Width 0.00 Depth 0.00 .Wound Bed [MEDICATION NAME] Tissue 100% .Incision Detail closed, healing. Staples present and intact . Medical record review of a Physician's Order dated 11/8/16 revealed .[MEDICATION NAME] (antibiotic) 1 gm (gram) IV (intravenous) daily x 7 days-Wound infection . Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #123 had a BIMS score of 15 out of a possible score of 15, indicating the resident was cognitively intact. Further review revealed the resident required limited assistance of 1 staff for bed mobility, personal hygiene, bathing and eating. Further review revealed the resident had a surgical incision. Medical record review of a Treatment Administration Record dated November 2016 revealed a dressing order dated 10/21/16 .Clean Surgical Incision To RT Knee with [MEDICATION NAME], Apply ABD Pad & (and) Wrap with Kerlix, Change BID . Further review revealed 27 of 60 treatments were not documented as completed 11/7/16 through 11/30/16. Medical record review of an Orthopedic Nurse Practitioner (NP) progress note dated 11/14/16 revealed .He has a little eschar in the center .okay for us to remove the staples at this point .and apply Steri-Strips . Medical record review of a Wound Assessment Report dated 11/17/16 revealed .Wound Location Right Knee .Measurements Length- 3.90 cm .Width- 0.00 cm Depth 0.00 cm .Wound Bed Granulation Tissue 75% Eschar 25% .Incision Detail Wound dehiscence (wound rupture along surgical line) noted-minor .Notes Staples removed from knee at Ortho appointment, steri strips intact, wound dehisced in mid incision line, scant amount of drainage noted . Medical record review of an Interdisciplinary Progress Note dated 11/23/16 revealed .reviewed current surgical incision, area noted to improve dehised (dehiscence) area noted to be scabbed, steri strips in place . Medical record review of a Wound assessment dated [DATE], revealed .Wound location Right Knee .Measurements Length 2.80 cm Width 0.00 cm Depth 0.00 cm .Wound Bed Granulation Tissue- 100.00 % .Incision Detail Closed, healing. Steri-strips present and intact . Medical record review of a Wound Assessment Report dated 12/2/16 revealed .Wound Location Right Knee .Measurements Length- 2.5 cm Width- 0.4 cm Depth 0.00 cm .Wound bed Granulation Tissue- 75.00 % Eschar- 25.00 % .Incision Detail Open/healing by secondary intension . Observation of the Treatment Nurse changing the resident's right knee dressing on 12/6/16 at 5:00 PM, in the resident's room, revealed the old right knee dressing that was removed by the treatment nurse was dated 12/6/16. Continued observation revealed the right knee had black tissue (eschar) and the surrounding skin was slightly reddened. During the wound treatment the Treatment Nurse mesured the wound and stated that the wound mesured 2.1 cm x 5.3 cm. Medical record review of a Wound Assessment Report dated 12/7/16 revealed .Wound Location Right Knee .Measurements Length-5.30 cm Width- 3.00 cm .Wound bed Eschar-100.00% .Length of wound separation 5 .Notes Steri strips in place, resident had shower, steri strips came off, wound dehisced noted, surrounding skin red . Interview with the Director of Nursing (DON) on 12/6/16 at 8:13 AM, in the conference room, confirmed a wound assessment was not completed for the week of 11/11/16. Further interview confirmed the wound assessments were to be completed weekly. Interview with Registered Nurse (RN) #1 on 12/6/16 at 9:50 AM, in the 100 hall, confirmed there were times she was unable to complete treatments and dressing changes as ordered by the physician. Further interview confirmed she reported treatments not done to the next shift. Interview with the Treatment Nurse on 12/6/16 at 5:10 PM, in the 200 hallway, confirmed the wound assessment and measurements were not completed for the week of 11/11/16. Further interview confirmed the meaurements of the right wound performed on 12/2/16 were 2.5 cm x 0.4 cm. Continued interview confirmed the measurements during observation of the dressing change on 12/6/16 were 2.1 cm x 5.6 cm. Further interview confirmed the resident had a shower last night and went to an orthopedic appointment yesterday (12/5/16). Continued interview confirmed the wound had steri strips covering most of the wound and the Treatment Nurse was measuring the areas of the wound she could visualize only. Continued interview confirmed the wound measurements were inaccurate. Further interview confirmed the steri strips were now off so the current measurement was 2.1 cm x 5.6 cm. Interview with the Physician on 12/6/16 at 5:20 PM, at the 100/200 nurses station, confirmed Resident #123's knee incision had eschar. Continued interview confirmed if dressing changes and treatments to the wound were not completed as ordered, it could delay healing of the wound. In summary the facility failed to provide care and services for Resident #123's wound as evidenced by a missing wound assessment for the week of 11/11/16 and discrepencies of wound measurements and wound descriptions by the Treatment nurse on 10/28/16 and 11/4/16, with no documentation of eschar. The Resident's Orthopedic Surgeon and Nurse Practitioner's notes on 10/27/16 and 11/3/16 showed documentation of eschar to the wound. During observation of the resident's wound on 12/6/16 with the Treatment Nurse, she stated the wound measurements were 2.1 cm x 5.3 cm. Review of the Wound assessment dated the following day, 12/7/16 revealed documentation of wound mesurements of 3.0 cm x 5.3 cm. Review of the Treatment Administration Record revealed 34 of 70 missed treatments from 10/27/16-11/30/16, and the resident's wound had a decline. Medical record review revealed Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 9/2/16 revealed .admitted with .recent surgical incisions with recent Rt. (right) amputation with .weekly skin assessment, treatments as ordered . Medical record review of the 60 Day MDS dated [DATE] revealed Resident #145 had a BIMS score of 15 out of a possible 15 which indicated he was cognitively intact. Continued review revealed the resident was totally dependent for transfers with 1 person assist and required extensive assist for personal hygiene and bathing with 1 person assist. Further review revealed identification of the surgical wounds. Medical record review of the wound assessment reports for the R BKA and the L BKA revealed 15 out of 30 assessments for 8/25/16 through 12/7/16 were not completed. Medical record review of the physician's orders dated 10/12/16 revealed .Clean LLE (left lower extremity) stump with NS (normal) saline .apply . (wound dressing) .change Q (every) day . Medical record review of the Treatment Administration Record dated 11/2016 revealed the treatments to the left lower extremity stump and the right hip (R BKA) wound had not been initialed as having been completed for 5 out of 30 days (11/12/16, 11/13/16, 11/19/16, 11/26/16, and 11/27/16). Medical Record review of the telephone order dated 11/15/16 revealed .culture wound of (L) (left) stump .[MEDICATION NAME] (antibiotic) 100mg PO (by mouth) BID (twice daily) X (times) 10 days.[MEDICATION NAME] Q Day X 14 days . Medical record review of the wound culture dated 11/18/16 revealed .Source, Wound Stump Left .Critical result called to .MRSA ([MEDICAL CONDITION]) . Medical record review of the telephone order dated 11/18/16 revealed .D/C (discontinue) [MEDICATION NAME]. [MEDICATION NAME] IM (intramuscular) X 7 days [MEDICAL CONDITION] wound infection . Medical record review of the wound assessment report for the L BKA revealed on 8/26/16 the wound measured length (L) 2.5 cm (centimeters) by (X) width (W) 2.2 cm X depth (D) 0.8 cm. Medical record review of the wound assessment report for the L BKA revealed on 11/4/16 the wound measured L 0.9 cm X W 1.00 cm X D 0.0 cm. Medical record review of the wound assessment report for the L BKA revealed on 11/18/16 the wound measured L 1.2 cm X W 1.2 cm X D 0.0, an increase in size from 11/4/16. Medical record review of the wound assessment report for the L BKA revealed on 12/6/16 the wound measured L 1.8 cm X W 2.3 cm X D 0.7 cm, an increase in size from 11/18/16. Medical record review revealed there were no wound assessment measurements completed between 11/4/16 and 11/18/16. The wound had increased in size and had developed an infection. Telephone interview with Licensed Practical Nurse (LPN) #10 on 12/3/16 at 2:05 PM revealed on 11/14/16 she had changed Resident #145's 2 dressings. Continued interview revealed the dressings were dated 11/10/16 and 11/11/16 and were ordered to be changed daily. Further interview revealed she had provided a written statement to the Director of Nursing (DON) and was also signed by LPN #13 as a witness to the dates on the dressings. Telephone interview with LPN #13 on 12/6/16 at 4:30 PM, confirmed she had witnessed Resident #145's dressings on 11/14/16 were dated 11/10/16 and 11/11/16 and were ordered to be changed daily. Interview with the Treatment Nurse on 12/7/16 at 3:20 PM in the conference room, confirmed she did not have any measurements for the wounds for Resident #145 between 11/4/16 and 11/18/16. Continued interview revealed .if I work a cart (medication cart) I do the treatments on that hall only .the other nurses are supposed to do their treatments . Further interview confirmed the treatment nurse was assigned to provide nursing care to residents when a staff nurse was not available to provide services. Interview with Resident # 145 on 12/6/16, in the 200 hall way revealed if the treatment nurse was not working, Resident #145's dressing did not always get changed every day as ordered. Interview with the DON on 12/5/16 at 11:15 AM, in the conference room when asked if she was aware of treatments were not being completed as ordered she stated .knew there were holes in the MARS/TARS (medication administration records/treatment administration records) . Interview with the Physician on 12/7/16 at 2:15 PM, in front of the building confirmed the dressing not being changed to the L BKA for 2 days would contribute to the wound becoming infected. Medical record review revealed Resident #170 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician order sheet dated 11/4/16 revealed orders for .weekly skin assessment .bilateral nephrostomy tube site care q (every) shift & PRN (as needed) . Medical record review of an acute care facility History and Physical (H&P) dated 11/23/16 revealed .recent bilateral ureteric stents placement and bilateral nephrostomy tube placement done by [MEDICATION NAME] Radiology on 10/25/16 . Medical record review of a Treatment Administration Record (TAR) for November 2016 and December 2016 revealed bilateral nephrostomy tube site care was to be provided every shift 11/4/16 through 12/5/16, for an opportunity of 65 treatments. Continued review revealed the treatments were not documented as completed for 30 of those opportunities on the following dates: Day shift on 11/11/16, 11/13/16, 11/14/16, 11/19/16, 11/20/16, 11/22/16, 11/26/16, 11/27/16, and 12/2/16; Night shift on 11/7/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/12/16, 11/14/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/21/16, 11/22/16, 11/26/16, 11/27/16, 11/30/16, 12/1/16, 12/2/16, 12/4/16, and 12/5/16. Medical record review of a Nurse Practitioner (NP) Progress Note dated 11/8/16 revealed .F/U (follow up) on report of R) (right) nephrostomy tube site red and painful . Medical record review of a care plan dated 11/10/16 revealed .Resident desires to be free from s/sx (signs and symptoms) of infection through next review .Monitor skin for reddened or excoriated areas .Potential for increase in skin breakdown .weekly skin assessment .treatments as ordered .bilateral nephrostomy tube site care as ordered . Medical record review of a NP progress noted dated 11/15/16 revealed R) nephrostomy tube purulent drainage. F/U on report of pt having green purulent drainage from R) nephrostomy tube site. Moderate amt (amount) noted . Medical record review of the Interdisciplinary Progress Notes dated 11/23/16 revealed .nephrostomy care to bil (bilateral) nephrostomy sites . Medical record review of a NP progress noted dated 11/29/16 revealed .Nephrostomy site redness. Pt (patient) /c (with) yeast around R) nephrostomy site . Telephone interview with Licensed Practical Nurse (LPN) #10 on 12/3/16 at 2:05 PM confirmed she changed the dressing on 11/13/16 for the bilateral nephrostomy tubes and the date on the dressing she removed was 11/8/16. Further interview confirmed she informed the Director of Nursing (DON) regarding this finding of the dressing not being changed for 5 days, on the morning of 11/13/16, before she left her shift, and was instructed by the DON to .write a statement and leave in her office . Revie of a hand written signed statement by LPN #10 revealed .bilateral nephrostomy tubes /c dressings to be changed due to drainage, which was heavily saturated /c odor, dated 11/8/16 .all were dated 11/8/16 . LPN #10 changed the dressing on 11/13/16. Interview with LPN #13 by telephone on 12/6/16 at 4:30 PM confirmed she did the treatments as ordered but .have to stay over every day to get done . Interview with Registered Nurse (RN) #1 on 12/6/16 at 5:19 PM at the 100/200 nursing station confirmed if she .did not sign on any of those days . she didn't do the treatment by .passed it off to the night shift for them to do . Review of a facility weight policy, undated, revealed .all new admissions are weighed weekly x (times) 4 weeks .If there is a 5 pound discrepancy then the resident must be re-weighted on the next business day with a licensed nurse verifying that weight . Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE], 9/3/16, 9/25/16, and 10/29/16, with [DIAGNOSES REDACTED]. Medical record review of a care plan dated 6/10/16 and revised 10/29/16 revealed .potential for significant weight change & (and) dehydration d/t (due to) resident morbidly obese .weigh resident, record results and report any significant changes to physician and dietician .9/4/16 daily weight as ordered . Medical record review of a nursing note dated 9/2/16 at 8:00 AM revealed .restorative nursing informed this nurse that resident has went from 360 lbs on August 3rd to 435 lbs today . Medical record review of a nursing note dated 9/3/16, untimed, revealed .readmitting .426.8 lbs . Medical record review of a nursing note dated 9/4/16, untimed, revealed .resident's weight was 419 lbs this am . Medical record review of the Physician's orders revealed an order dated 9/4/16 for Resident #55 to be weighed daily due to fluctuating weights and a [DIAGNOSES REDACTED]. Medical record review of the weight sheet from 6/3/16 through 12/1/16 revealed between 9/4/16 and 10/14/16, (41 days), the resident was in an acute care facility 4 days of the daily weights (leaving 37 days) and 8 days during the weekly weights. Medical record review of the daily weights revealed the weights were obtained 18 days and a total of 19 daily weights were not documented. Review of the weight sheet revealed no weights documented on the following days and the amount of weight change were as follows: missed weights on 9/5/16, 9/6/16, 9/7/16, 9/8/16 with a 12.5 lbs (pounds) weight loss in 5 days; on 9/14/16 and 9/15/16 with a 3.2 lbs weight gain in 3 days; and on 9/17/16, 9/18/16, 9/19/16 with a 17.6 lbs weight gain in 4 days. Medical record review of a nursing note dated 9/20/16 at 11:30 AM revealed .wt (weight) gain noted . Medical record review revealed the resident was in an acute care facility from 9/22/16 through 9/25/16. Medical record review of a Physician's order dated 9/25/16 revealed .daily weight d/t [MEDICAL CONDITION] & fluctuating weights . Medical record review of the weight sheet revealed no weights documented on the following days and the amount of weight change were as follows: 9/26/16, 9/27/16, and 9/28/16 with an 18.4 lbs weight loss in 8 days; on 10/1/16 with a 14.6 lbs weight gain in 1 day; on 10/3/16 and 10/4/16 with a 3.6 lbs weight gain in 3 days; on 10/9/16 with a 10.2 lbs weight loss in 2 days; on 10/11/16 with a 4.4 lbs weight loss in 2 days; and on 10/13/16 and 10/14/16. The last daily weight was documented on 10/12/16 at 409 lbs. Medial record review of a nursing note dated 10/2/16 at 11:30 AM revealed .resident noted to have a weight gain of 15.4 lbs. resident was weighted 9/30/16 and was 409 lbs. Resident weighted 10/2/16 and is 424.4 lbs . Medical record review of a Physician's order dated 10/14/16 revealed .(symbol for change) to weekly (weights) . Medical record review of the weight sheet revealed the next weight was documented on 10/18/16, 6 days after the last weight, with a weight of 394.4 lbs, a 14.6 lbs weight loss. Medical record review revealed the resident was hospitalized [DATE] through 10/29/16, and returned to the facility on [DATE]. Medical record review of a weight sheet revealed the first recorded weight after returning from the acute care facility was on 11/6/16 and was 385.8 lbs., an 8.6 lbs weight loss since the previous weight on 10/18/16. Continued weekly weights were recorded on 11/12/16 (6 days) at 366 lbs, a 19.8 lbs weight loss and on 11/17/16 (5 days) with a 2.2 lbs weight gain Medical record review of a Physician's order dated 11/18/16 revealed .wkly (weekly) weights . Medical record review of a weight sheet revealed a weight on 11/24/16 with a 1.2 lbs weight gain. Telephone interview with Registered Dietitian on 12/2/16 at 3:15 PM confirmed there were days the resident wasn't weighed as ordered. Interview with Medical Doctor (MD) #1 on 12/2/16 at 3:45 PM in the conference room confirmed the resident .weights were not completed daily. Doesn't surprise me .usually write orders like that just for more data points because they don't always get done as ordered . Medical record review revealed Resident #20 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the facility policy [MEDICAL TREATMENT] Residents, undated, revealed .Take blood pressure and pulse before going out to [MEDICAL TREATMENT] .take blood pressure and pulse upon return from [MEDICAL TREATMENT] .Document resident's condition and interventions . Medical record review of the Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9 indicating Resident #20 had moderate cognitive impairment. Medical record review of the vital signs and weight record revealed the last vital signs documented were on 11/2/16. Interview with Resident #20 on 12/1/16 at 10:15 AM, in the resident's room, confirmed the resident went to [MEDICAL TREATMENT] Monday, Wednesday and Friday, before 11:30 AM. Continued interview confirmed he had a temporary catheter in his right neck and he had an appointment to have another access placement. Interview with Licensed Practical Nurse (LPN) #2 on 12/1/16 at 10:30 AM, at the 300 nurse's station, confirmed there was not a policy on the care of a [MEDICAL TREATMENT] patient. Continued interview confirmed there iwas no communication documents sent to the [MEDICAL TREATMENT] clinic from the facility. Interview with LPN #12 on 12/1/16 at 4:20 PM, at the 300 nurse's station, confirmed no vital signs were documented on the resident since 11/2/16. Further interview confirmed vital signs were to be taken pre-[MEDICAL TREATMENT], and upon return from [MEDICAL TREATMENT], and documented on a nurses note or flow sheet. Continued interview revealed no communication documents were sent with the resident to [MEDICAL TREATMENT]. Telephone interview with the RN at the [MEDICAL TREATMENT] clinic on 12/2/16 at 8:45 AM, confirmed .I have worked here for [AGE] years and (the Nursing home) has never sent a [MEDICAL TREATMENT] communication sheet to the [MEDICAL TREATMENT] clinic. Continued interview confirmed the resident .had a lot of fluid on and we got it off over time . Further interview confirmed the resident did have bleeding from the [MEDICAL TREATMENT] access at the facility and was sent to the emergency room . Continued interview revealed the access was infected and was removed, and a catheter was inserted. Telephone interview with the Clinical Manager of the [MEDICAL TREATMENT] clinic on 12/2/16 at 8:50 AM, confirmed the facility did not send a [MEDICAL TREATMENT] communication document with vital signs and a weight with the resident. If there were concerns with the resident, the clinic would notify the facility by phone. Interview with the Director of Nursing (DON) on 12/5/16 at 2:47 PM, in the conference room, confirmed there was no documentation the resident's [MEDICAL TREATMENT] catheter site was being assessed, or documentation vital signs pre and post [MEDICAL TREATMENT] were completed.

Based on medical record review, observation, and interview, the facility failed to provide incontinence care for 3 residents(#65, #21, and #45)of 5 residents reviewed for activities of daily living. The facility's failure to provide incontinence care placed residents #65, #21, and #45 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death)and is likely to put all residents requiring incontinence care in Immediate Jeopardy. The facility was cited F312 at a scope and severity of J which constitutes substandard Quality of Care (SQC). The Immediate Jeopardy is effective 2/7/16 and is ongoing. The findings included: Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] revealed Resident #65 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Continued review revealed the resident required extensive assist with transfers and dressing and total assist for person hygiene and bathing with 1-2 person assist and was always incontinent of bowel and bladder. Review of a facility investigation dated 2/7/16 revealed Resident #65 reported to RN# 2 she told CNA #14 she was soaking wet and requested incontinence care. Continued review revealed CNA #14 told the resident he was . 2 hours behind and he could not get to her . Further review revealed RN #2 reported the incident to the DON on 2/8/16. Continued review revealed the DON interviewed Resident #65 and the resident reported the same incident. Interview with Resident #65 on 11/9/16 revealed .can't remember exactly what he said .didn't have time or something like that .it made me feel like I wasn't important . Interview with Resident #65 on 11/19/16 at 11:25 AM confirmed CNA #14 did not return to the resident's room to provide incontinence care. Interview with the DON on 12/5/16 at 2:17 PM, in the conference room, confirmed she expected residents to be checked and changed every 2 hours and as needed. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Interdisciplinary Progress Notes dated 12/12/15 revealed .Resident is paraplegic and requires total care for ADL's (activities of daily living) .Incont (incontinent) of B&B (bowel and bladder) c (with) peri care q2 (every 2 hours) + (and) PRN (as needed) . Medical record review of the Interdisciplinary Progress Notes dated 8/2/16 revealed .Total care c ADL's .Incontinent bowel and bladder . Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Continued review revealed Resident #21 was totally dependent on staff with assistance of one person for mobility, transferring and toileting. Further review of the MDS revealed the resident was always incontinent. Medical record review of the Care Plan dated 10/18/16 revealed .Self Care Deficit r/t (related to) [MEDICAL CONDITION] .Potential for skin breakdown d/t (due to) decrease mobility .Provide Peri care with each incontinent episode .Potential for urinary tract infection r/t incontinence of B&B .Self Care Deficit r/t [MEDICAL CONDITION] .Assist with ADLs as needed . Medical record review of the Nurse Aide's Information Sheet (Kardex), undated, revealed Resident #21 was incontinent and required total care assistance. Continued review revealed the resident required a mechanical lift for transfers. Interview with Certified Nursing Assistant (CNA) #19 on 11/30/16 at 8:04 PM, in the 400 hall, revealed .I have done my first dry rounds .Starting 8's (8:00 PM rounds) now .Last rounds were at 4 (4:00 PM) before I got here . Observation on 11/30/16 at 8:08 PM, on the 400 hall, revealed Resident #21 had a strong urine odor. Continued observation revealed a wet stain to the resident's pants from the groin, inner thigh, and down to the knee. Interview with Resident #21 on 11/30/16 at 8:08 PM, on the 400 hall, confirmed .They haven't changed or clean me yet .not since last state person (state surveyor) was here . Interview with CNA #19 on 11/30/16 at 8:09 PM, on the 400 hall, confirmed .I haven't changed her yet tonight . Continue interview confirmed the resident had not been cleaned and changed since the rounds done between 4:00 PM and 5:00 PM. Observation with Licensed Practical Nurse (LPN) #13 on 11/30/16 at 8:12 PM, in the 400 hallway, revealed Resident #21 was in the wheelchair with a wet saturation on the resident's pants from the groin, to inner thigh, to knee. Interview with LPN #14 on 11/30/16 at 8:12 PM, on the 400 hall, confirmed .She is soiled .She is a lift transfer .I expect her to be changed every 2 hours . Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 3/25/16 and updated 9/15/16 revealed .Self Care Deficit .Assist with ADL's as needed .Has incontinence bowel & bladder .Incontinence to be provided by staff as needed . Medical record review of the Quarterly MDS dated [DATE] revealed Resident #45 had a Brief Interview for Mental Status Score of 15, indicating the resident was cognitively intact. Continued review of the MDS revealed the resident was total dependence with toileting. Further review of the MDS revealed the resident was always incontinent. Medical record review of the Nurses Note dated 11/6/16 revealed .we do not want any skin breakdown or skin issues that can arise d/t (due to) poor hygiene . Medical record review of the Nursing Weekly Summary dated 11/19/16 revealed .ass (assist) x (times) 2 c (with) ADL's + (and) t/f's (transfers) .Incont of B+B (bowel and bladder) peri care PRN + q2 (every 2 hours) .non amb (ambulatory) is in the bed most of the time . Medical record review of the Bladder Evaluation dated 11/26/15 revealed .Functional Status/Assist .Total dependence .multiple daily episodes (incontinence) . Medical record review of Nurse Aide's Information Sheet (Kardex), undated, revealed .Incontinent .Total care .Geri chair .Lift to chair .(mechanical lift) . Interview with Resident #45 on 11/30/16 at 8:18 PM, in the resident's room, confirmed .I haven't been changed since before supper before 5 (5:00 PM) . Interview with Registered Nurse (RN) #2 on 11/30/16 at 8:25 PM, on the 300 hall, confirmed the CNAs were to check and change the residents every 2 hours. Continued interview confirmed the CNAs started their rounds at 6:00 PM. Telephone interview with CNA #18 on 12/1/16 at 8:38 PM, confirmed she was assigned to Resident #45 on the night of 11/30/16. Continued interview confirmed she finished her first dry rounds (rounds to check residents for incontinence and hygiene needs) after 10:00 PM (took 4 hours to complete 6:00 PM dry rounds). Interview with RN #5 on 12/2/16 at 2:37 PM, in the conference room, confirmed Resident #45 was incontinent and required a mechanical lift for mobility. Interview with the Director of Nursing on 12/5/16 at 2:17 PM, in the conference room, confirmed she expected the residents to be checked and changed every 2 hours and as needed. Interview with CNA #13 on 12/7/16 at 8:01 AM, on the 300 hall, confirmed she was assigned to Resident #45 on the dayshift on 11/30/16 and finished her dry rounds at 5 PM. Interview with Resident #45 on 12/7/16 at 9:39 AM in the resident's room, confirmed .It is what it is. What can you do about it .

Based on facility policy review, medical record review, review of a facility investigation, observation, and interview, the facility failed to identify an accident hazard and implement interventions to reduce the risk of injury for 1 resident (#12) of 7 residents reviewed for accidents, of 43 sampled residents. This failure resulted in Harm (a fractured tibia/fibula) to Resident #12. The findings included: Review of the facility policy Accidents and Incidents, dated May 2001, revealed .An incident is any occurrence, which is not consistent with the routine operation of the institution or the routine care of a particular patient. It may involve an injury .charge nurse shall: Examine all .victims .Notify the .physician and inform of the accident /incident .Regardless of how minor .it must be reported to the department supervisor, and a report form is to be completed on the shift .must be reported to the Director of Nursing and the Director of Risk Management .All details are to be recorded in the nurses' notes, including disposition and follow up care for a period of 72 hours .The Risk Manager will review .investigation as needed . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating the resident had severe cognitive impairment. Continued review revealed the resident was totally dependent for bed mobility and personal hygiene with one person physical assist and was totally dependent for transfers and bathing with 2+ person physical assist. Continued review revealed the resident was always incontinent of bladder and bowel. Review of a Physician's Progress Note dated 7/13/16, authored by Nurse Practitioner (NP) #2, revealed .nursing report pt (patient) w/ (with) LLE (left lower extremity) bruising, edema .LLE w/ large bruised/reddened area, warm to touch .painful (grimacing w/palp (palpate) .assessment/plan .venous Doppler R/O (rule out) blood clot . Review of Nurse's Notes revealed no documentation of the problem identified by the NP and no documentation of nursing assessments or interventions. Review of a Physician's Progress Note dated 7/19/16 authored by Physician #1 revealed .new bruising and swelling of the left leg .no injuries that have been reported by staff .xray to rule out underlying fracture .Ultrasound negative for DVT (deep vein thrombosis) . Review of the facility's investigation revealed a Resident Incident Report dated 7/19/16 .Resident C/O (complained of) pain when turned order received for xray .Green bruising noted to shin and calf area . Continued review revealed 4 witness statements authored by staff with no knowledge of the cause of the fractured leg. Further review revealed an unsigned typed summary of the investigation, .noted protrusion in wall and bruise consistent with rolling toward wall and coming in contact with the protrusion .resident unable to recall direct force incident .According to research a side ways bend at ankle or knee could have caused practure (fracture) . Review of the Physician's Progress Note dated 7/20/16 revealed .Tib/fib (tibia/fibula bones of lower leg) fx (fracture) . Observation and interview with Resident #12 on 11/29/16 at 3:30 PM, in the resident's room, revealed the resident lying in bed on her back with no response to questions from this surveyor. Continued observation revealed the resident replied to staff members with yes or no to questions. Interview with the Director of Nursing (DON) on12/1/16 at 8:51 AM, in the conference room, confirmed bruises should be documented by the assigned nurse upon discovery. Continued interview with the DON confirmed .this was not an injury of unknown origin (bruise) .the bruise was consistent with a protrusion on the wall . Further interview confirmed no investigation had been started until the fracture was discovered on 7/20/16. Interview and observation with the Maintenance Director on 12/1/16 at 4:10 PM, in resident's room, confirmed there was a buffer on the bed side of the wall 18 inches from the floor, below the top of the mattress, and extended the entire length of the left wall. Continued observation and interview revealed the protrusion had a curved, smooth surface on the top edge which protruded outward 9/16 of an inch from wall. Observation and interview with the DON on 2/2/16 at 9:57AM, in Resident #12's room, confirmed the resident's left leg was .probably bent when the resident was turned on her left side. The resident's left leg probably went between the wall and the mattress and hit the protrusion on the wall . Observation revealed the DON was referring to the buffer on the bed side of the wall, below the top of the mattress, and extending the entire length of the left wall, as the protrusion. Interview with Licensed Practical Nurse (LPN) #12 on 12/2/16 at 12:45 PM, at the 300/400 nurses station, confirmed a Certified Nurses Aide (CNA) (couldn't remember which one) reported bruising and swelling to Resident #12's leg. Continued interview revealed LPN #12 notified the NP on the same day (7/13/16) but did not document in the nurse's notes or fill out an incident report. Further interview confirmed LPN #12 should have documented the bruising and swelling and initiated an incident report. Continued interview confirmed Resident #12 was unable to roll over in the bed independently. Interview with Physician #1 on 12/2/16 at 3:55 PM, in the conference room, confirmed Resident #12 was seen by NP #2 on 7/13/16 for edema and discoloration of the left lower leg. Continued interview revealed the Physician was surprised when the xray report revealed a fracture because the resident was so cooperative with care. Further interview with the Physician revealed the fracture most likely occurred around 7/13/16. Continued interview with Physician #1 on 12/2/16 in the resident's room confirmed it was possible the fracture had resulted if the resident's foot fell between the bed and the wall and staff repositioned her during that time.

Based on observation, interview, and record review, the facility failed to be administered in a manner to maintain the safety of residents by failure to ensure the fire sprinkler system was in reliable operating condition. The facility's failure placed all 161 residents in the facility in Immediate Jeopardy from the likelihood of burns, smoke inhalation, and death should an undetected fire occur. The Administrator was informed of the Immediate Jeopardy on November 7, 2011, at 4:02 p.m. Refer to Life Safety Code K-62, related to failing to maintain the fire sprinkler system in reliable operation. Refer to Life Safety Code K-154, related to evacuating the building or providing an approved fire watch if the fire sprinkler system is out of service. A fire watch was implemented immediately on the evening of November 7, 2011, removing the immediacy of the jeopardy. An Allegation of Compliance was accepted November 8, 2011, lowering the scope and severity of the deficient practice to an F level.