Every finding on record at Pinewood Health and Rehabilitation

Based on staff interviews, record reviews, and a review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to protect one of five sampled residents' (R) (R1), right to be free from physical abuse by staff. The deficient practice had the potential to affect resident psychosocial health and safety. Findings include:Review of the facility policy titled, Abuse, Neglect and Exploitation, revised 02/26/2026, documented the definition of abuse as, the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. The policy also included a definition of physical abuse as hitting, slapping, punching, biting and kicking.Review of R1's clinical record revealed he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, dementia, anxiety, major depressive disorder, and adjustment disorder with depressed mood.Review of the 05/28/2026 quarterly Minimum Data Set (MDS) assessment revealed the resident had Brief Interview for Mental Status (BIMS) score of 9, which indicated R1 had moderate cognitive impairment. Section GG revealed R1 and was dependent on staff for Activities of Daily Living (ADL's).Review of the 07/10/2026 Facility Incident Report Form revealed the facility reported staff to resident abuse that occurred on 07/10/2026 at approximately 3:15 PM to the State Survey Agency. The report indicated that the previous Director of Nursing (DON) AA, allegedly struck R1 during perineal care in response to the combative resident. The report indicated that DON AA had been suspended pending investigation and education was started.Review of the 07/17/2026 follow-up summary noted that after the investigation, the facility determined that there was contact made from the employee to the resident. The employee was terminated due to the nature of the isolated event and witness statements. The employee was reported to the licensure board.During an interview with DON BB on 08/10/2026 at 2:20 PM, she stated that DON AA and the Customer Service Concierge took R1 to his room to provide incontinence care. She stated when R1 was transferred to his bed, he swung his arms and tried to spit at staff. As the resident was trying to spit, DON AA stated, If you spit, I'm gonna pop you. The resident then spit and DON AA popped R1 on the mouth. She stated the resident just looked at her then grabbed DON AA's arm. DON BB stated that as DON AA was trying to get her arm loose, she tapped him on the arm. She stated that she heard DON AA tell staff in the hall that she popped the resident on the mouth for spitting. She stated about 15 minutes later that she, the Customer Service Concierge, and Licensed Practical Nurse (LPN) DD went and reported the incident to the Administrator. She stated the police were notified and came to the facility that day.During an interview with the Customer Service Concierge on 08/10/2026 at 2:38 PM, she stated that once they got R1 to his bed, he acted like he was going to spit and DON AA stated, If you spit, I'm gonna pop you on the mouth. The resident then spit and DON AA popped him on the mouth. R1 then grabbed DON AA's arm and then she smacked him on the arm. She stated they went and reported it to the Administrator when they left the room.During an interview with LPN DD on 08/10/2026 at 2:57 PM, she stated that she came in the room later to help with the resident. The resident grabbed DON AA's wrist, and she popped him on his forearm. She stated that DON AA jumped back and said it was reflex. She left the room behind DON AA and heard her tell people in the hall that she popped him in the mouth for spitting. LPN DD stated that she went with Registered Nurse BB, and the Customer Service Concierge and reported to the Administrator. DON AA immediately left the building and never came back to work after that. She stated there was no response from the resident after DON AA hit him and there were no injuries.Review of DON AA's 07/10/2026 written statement provided to the police department indicated that she noticed the resident was going to spit. When he spit, she moved her hand to cover his mouth and he grabbed her wrist. When R1 let go of her wrist the forward motion of her hand continued, and she accidentally hit the resident in the mouth. She assessed R1 and documented it at that point and there were no injuries.Review of the job description for the Director of Nursing that was signed by DON AA on 01/26/2026 revealed Major Duties and Responsibilities included: Ensures delivery of compassionate quality care and nursing supervision as evidenced by adequate staff coverage on the units. Additional tasks included, Treats all residents with dignity and respect. Promotes and protects residents' rights. Protects residents from abuse and cooperates with all investigations.DON AA also signed a form titled, Acknowledgement of Receipt of Training of the Facility's Freedom from Resident Abuse, Neglect and Exploitation Policy and Procedure.

Based on observations, staff interviews, and review of the facility policy titled, Infection Prevention and Control Program, the facility failed to maintain the outdoor garbage and refuse area in a sanitary condition. One of two dumpsters was observed with the lid left open, creating the potential to attract and harbor pests and insects. The facility census was 63.Findings include:A review of the facility policy titled, Infection Prevention and Control Program, last revised on 04/09/2026, documented under Waste Management: 21. The facility shall ensure that all dumpster lids and/or covers are kept closed at all times to maintain a safe, sanitary environment and to prevent attraction of pests and the potential spread of infection. Staff are responsible for ensuring lids and covers are securely closed after each use and are to report any damages or missing lids to the appropriate department for immediate repair or replacement.Observations on 05/31/2026 at 11:47 AM, 06/01/2026 at 1:44 PM, and 06/02/2026 at 11:44 AM revealed that one of the two dumpsters had it's lid open.Interview on 06/03/2026 at 11:23 AM with the Certified Dietary Manager (CDM) confirmed that the garbage dumpster lids were open and not closed on 05/31/2026, 06/01/2026, and 06/02/2026. The CDM stated that she had previously instructed dietary staff to ensure that dumpster lids were closed immediately after use. The CDM emphasized that staff were expected to monitor dumpster use and ensure that lids remain closed to maintain proper sanitation standards and prevent potential pest concerns.Interview on 06/03/2026 at 11:25 AM with the Administrator confirmed that the garbage dumpster lid was open and not closed on 05/31/2026, 06/01/2026, and 06/02/2026. The Administrator stated that all staff shared responsibility for ensuring that the dumpster lids remained closed when not in use. The Administrator stated that all staff would be educated regarding the importance of keeping garbage dumpster lids closed when not in use to maintain a safe, sanitary, and pest-free environment.

Based on the record review, staff interviews, and review of the facility's policies titled Abuse, Neglect and Exploitation, and Notification of Changes, and review of procedures titled Foley Irrigation Procedure, the facility failed to ensure two of three Residents (R) (R1 and R2) received the necessary care and services in accordance with physician orders. In addition, the facility also failed to ensure the physician was notified in a timely manner of significant changes in the resident conditions.On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Assistant Direction of Nursing (ADON) were informed of the Immediate Jeopardy (IJ) on [DATE], at 2:23 pm. The noncompliance related to the IJ was identified to have existed on [DATE].An acceptable IJ Removal Plan was received on [DATE]. Based on observation, record reviews, and review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation dated [DATE] under the Policy section revealed, It is the policy of the 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, neglect, exploitation and misappropriation of resident property.Review of the facility's policy titled, Notification of Change dated [DATE] under the Policy section revealed, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.Review of the facility's policy titled, Foley Irrigation Procedure dated [DATE] revealed, contact the physician or nurse practitioner to obtain order for irrigation of Foley catheter.1. Review of the admission Record revealed R1 was admitted to the facility with the following diagnoses that included but were not limited to hypertension, gastroesophageal reflux disease, type 2 diabetes mellitus, orthopedic implant joint prosthesis or bone plate left leg and morbid obesity.Review of the Order Summary Report revealed an order dated [DATE] for Ecotrin (Aspirin) oral tablet delayed release 325 milligrams (mg), give 325 mg by mouth two times a day related to fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis or bone plate left leg. Further review revealed, a phone order dated [DATE] for Foley catheter (18 French 10 milliliters (ml) balloon) care every shift due to wounds.Review of medical records revealed, on [DATE] at end of the day shift (7a-3p), Licensed Practical Nurse (LPN) AA inserted a Foley catheter for Resident (R)1 and after the Foley catheter was inserted, bleeding was noted in the Foley catheter tubing. LPN AA then irrigated the Foley catheter with sterile water without a physician order. The evening shift (3p - 11p) Certified Nursing Assistant (CNA) CC reported to LPN BB that R1 was not having any urine output and had blood in the Foley catheter drainage bag. LPN BB did not communicate to the physician that blood was noted in R1's Foley catheter drainage bag. LPN BB removed the Foley catheter as instructed by the former DON. There was no evidence that the physician gave the order nor was an order obtained to discontinue the Foley catheter. Upon removal of the Foley catheter by LPN BB, R1 started bleeding from his penis and rectum. He began to have altered mental changes and loss of consciousness. Subsequently, R1 was sent to a local hospital.Review of the Emergency Medical Service Report (EMS) dated [DATE] revealed EMS received a call from the facility at 8:26 pm and arrived at the facility at 8:45 pm. A nurse standing by the entrance door giving report to EMS that the resident was bleeding from a Foley catheter removal and was having shortness of breath. It was noted that R1 was conscious and alert on 15 liters per minute (LPM) oxygen via non-rebreather mask and was responsive to EMS. R1 was transferred from his bed to the EMS stretcher. R1 became unresponsive and went into respiratory arrest. EMS personnel called for a fire unit to drive EMS personnel to emergency room (ER) while suctioning R1 mouth due to vomit that had exited from his nose and mouth. R1 was noted to be bleeding profusely from his penis with dark red blood and clots noted on the towels that was placed on his pelvic region. R1 was suctioned multiple times and bagged (use of bag-valve-mask) enroute to the emergency room with no improvement.Review of the first (named) hospital Emergency Documentation dated [DATE] revealed, R1 with a history of paraplegia presents to ER with concerns of respiratory distress. Associated with history is the fact that a Foley catheter was placed this morning, there was a large amount of blood that was expressed, and a decision was made this evening (by the nursing facility) to remove his Foley catheter. The onset of symptoms of shortness of breath was occurring approximately at the same time that this Foley procedure was taken place. The only other concern that was present is the fact the patient had a headache all day.Further review of hospital records revealed that R1 was transferred to a second hospital on [DATE] in critical condition and was admitted to intensive care unit (ICU). R1 was intubated and ventilated with multiple vasoactive drips administered. A urologist was consulted and a Foley catheter was placed at bedside in the unit with cystoscopy. Bleeding continued from numerous sites including his penis. R1 had received multiple blood components that included 11 packed red blood cells, four units of cryoprecipitate, three units of platelets and eight units of fresh frozen plasma. He sustained eight cardia arrests through the evening and early morning with failure to achieve return of spontaneous circulation and on the final instance, he was pronounced decease at 2:39 am on [DATE].Review of the Death Certificate dated [DATE] revealed the immediate cause of death was acute cardiac and respiratory failure, disseminated intravascular coagulation (DIC) and urethral injury. During an interview on [DATE] at 11:07 am, LPN AA revealed that at the end of her shift (day 7a-3p), she received the foley catheter order obtained by the former DON. When she inserted the foley catheter, she got urine and a small trace of blood. The Foley catheter went in with ease and R1 did not complain of any pain. R1 panicked when he saw blood in the Foley catheter tubing, LPN AA stated that she had reassured him and went and got some sterile water to irrigate the Foley catheter. LPN AA stated that she did not have an order to irrigate the catheter because Foley catheter irrigation was basic nursing. During an interview on [DATE] at 4:04 pm, CNA CC revealed on [DATE] she came in the facility, she saw that the R1 had a Foley catheter with no urine in the drainage bag and blood was coming out of his penis. She then left the resident's room and went to look for his nurse (LPN BB) to let her know about the blood. At 7:30 pm, CNA CC stated that she went into R1 room who was lying on his back and when she turned him over, she saw blood coming out of his penis and rectum. CNA CC stated that she reported to LPN BB that R1 was bleeding bad from his penis and rectum, and that he needed to go to the hospital. LPN BB came back and said she was given orders to take the catheter out. CNA CC went to LPN HH and asked her to call the former DON and let her know that the resident looked like he was going into shock. CNA CC stated she was upset because she felt LPN BB was not doing enough for R1 however, she later sent the resident out to the hospital.During an interview on [DATE] at 10:00 am, LPN BB revealed that she got report earlier that day that R1 had a Foley catheter and that LPN AA had gotten back some blood return and left the Foley catheter in place. Between 7:30 pm and 8:30 pm, she observed 100 ml of blood in R1's Foley catheter bag. The former DON who was on the phone with LPN HH overheard the conversation and told LPN HH to tell her to pull the Foley catheter out and give the resident water to see if he could pee on his own. She stated that she pulled out the Foley catheter and that the [NAME] (located at the tip of the catheter) had 10 ml of water in it. Resident oxygen(O2) level began to drop during this time and EMS was called who arrived around 8:15 pm. LPN BB confirmed she did not have a physician order to remove the Foley catheter and that she was following the former DON instructions. She revealed she had called the physician but he didn't answer so she sent the physician a phone text that she was sending R1 to the hospital. At 8:28 pm the physician responded back, ok to her text. During an interview on [DATE] at 1:49 pm, LPN HH revealed that LPN BB was the assigned nurse for R1. LPN BB came to the nursing desk to ask her do she think she needs to call the doctor or send him out. LPN HH stated that she was on the phone with the former DON at the time. The former DON heard LPN BB and told her to flush the Foley catheter. LPN BB stated that she did not know how to flush the Foley catheter. The former DON then said, just take the Foley catheter out and we can have the physician to write a discontinuation order for the Foley catheter. 2. Review of medical records revealed, R2 was admitted to the facility on [DATE] with diagnoses that included but not limited to Human Immunodeficiency Virus (HIV), morbid obesity obstructive and reflux uropathy, anemia, chronic pain, hypertensive heart disease, cerebral Infarction affecting the left dominant side, uropathy, and an indwelling foley catheter.Review of R2's physician order dated [DATE] revealed, an order to obtain a urine sample for urinalysis and urine culture and to remove the Foley catheter.Record review of R2's medical records revealed that the Foley catheter was discontinued after admission; however, the resident was noted with some retention concerns and the foley was reinserted and an order for a urinalysis (UA)/ culture and sensitivity (C&S) in addition to a consult with a Urologist ordered due to urine being cloudy with a foul odor noted.Review of the Order Summary Report revealed R2 had an order dated [DATE] for a routine catheter change once a month with an indwelling catheter size 18 French (Fr) 10 cc balloon and to change leg securing devices with routine catheter change monthly and as needed. Further review revealed, an order dated [DATE] to irrigate catheter with 60 cc (cubic centimeter) normal saline or 60 cc sterile water as needed for leakage/blockage every eight hours as needed for urinary retention.Review of a laboratory requisition dated [DATE] for urinalysis with microscopic sample revealed no evidence that the urine sample was collected. On the handwritten laboratory requisition form dated [DATE] it was noted R2 was discharged to the hospital on [DATE] however there was no documentation to reflect that the resident was sent to the hospital and the census did not reflect a leave of absence. Further review of R2's medical records revealed, there was no indication that the urine specimen was obtained as ordered by the physician however, a Urology appointment was scheduled for [DATE] and was rescheduled for [DATE] at 2:00 pm.Review of (Named) hospital records History and Physical dated [DATE] revealed R2 admitted from nursing home with altered mental status and a concern for sepsis. It was noted that R2 had a chronic indwelling Foley catheter with a history of complicated urinary tract infections (UTI). The UA was positive for extremely turbid urine with 500 leukocyte esterase, 491 WBCs (white blood count). R2 was discharge back to the nursing home with a Foley catheter changed in the emergency department with no antibiotics indicated upon discharge on [DATE].Review of progress notes dated [DATE] revealed, R2 was observed with altered mental status and was transferred to the hospital via EMS to the ER.Review of (Named) hospital records History and Physical dated [DATE] revealed that R2 was hypotensive and met the criteria for septic shock with a likely source of a urinary tract infection or infected decubitus ulcer/osteomyelitis. It was also noted that R2's Foley catheter was changed out. Reportedly, the Foley catheter had been in there for more than a month. The Consultation Notes (Urology) dated [DATE] revealed R2 was last seen by the Urologist for a leaking Foley catheter.Review of the Death Certificate dated [DATE] revealed the immediate cause of death was urosepsis and pneumonia. During an interview on [DATE] at 3:32 pm Registered Nurse (RN) GG revealed that she had not changed the R2's Foley catheter on [DATE] and sent her to the hospital. She stated that she had checked on the resident and the resident had a low pulse oxygenation. She stated that she reported it to the charge nurse and called the physician who gave orders to send R2 to the ER.During an interview on [DATE] at 1:37 pm, the current Administrator revealed that the expectation was that all residents receive excellent care from staff.The former Administrator and former DON were unavailable for interviews.

Based on record review, staff interviews and review of the facility's policy titled Comprehensive Care Plan, the facility failed to implement care plan interventions for two of three Residents (R ) (R1 and R2). Specifically, R1 was prescribed antiplatelet medication and had care plan interventions that included monitoring and documenting adverse outcome. In addition, R2 had a care plan for obstructive uropathy and an indwelling Foley catheter with care plan interventions to provide catheter care.On March 3, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Assistant Direction of Nursing (ADON) were informed of the Immediate Jeopardy (IJ) on March 3, 2026, at 2:23 pm. The noncompliance related to the IJ was identified to have existed on November 22, 2025.An acceptable IJ Removal Plan was received on March 5, 2026. Based on observation, record reviews, and review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on March 4, 2026.Finding include:Review of the facility's policy titled Comprehensive Care Plan, dated 10/1/2024 under the section titled Policy revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing and mental ans psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Under the section titled Policy Explanations and Compliance Guidelines revealed, 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being.1. Review of the admission Record revealed R1 was admitted to the facility with the following diagnoses that included but were not limited to hypertension, gastroesophageal reflux disease, type 2 diabetes mellitus, orthopedic implant , joint prosthesis or bone plate left leg and morbid obesity. Review of the undated care plan revealed that R1 is receiving antiplatelet medication therapy. The Interventions/Tasks included but not limited to, administer antiplatelet medication therapy as ordered; monitor skin for bruising, notify physician of new areas of bruising/discoloration; and monitor/document PRN adverse reactions of antiplatelet medication therapy (blood tinged or blood in urine, black, tarry stools, sudden severe headaches, nausea, vomiting, lethargy, sudden change in mental status. Review of the Order Summary Report revealed an order dated 9/7/2023 for Ecotrin (Aspirin) oral tablet delayed release 325 milligrams (mg), give 325 mg by mouth two times a day related to fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis or bone plate left leg.Review of R1 medical records revealed there was no evidence of a daily monitoring tool in place for the adverse risk for the antiplatelet medication.2. Review of the admission Record revealed R2 was admitted with the following diagnoses that include but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, morbid obesity, obstructive and reflux uropathy, and hypertension. Review of the undated care plan revealed, R2 has a foley catheter related to obstructive uropathy. Resident also has wounds to buttocks. The Interventions/Tasks included but not limited to, change foley catheter as ordered and as needed (PRN); provided foley catheter care per facility protocol, clean every shift and prn; and observe for signs/symptoms of infection (i.e. elevated temperature, cloudy urine in tubing, foul smelling urine, complaints of lower abdominal pain, change in cognition) and to report abnormal findings to the physician.Review of the Treatment Administration Record (TAR) dated 10/1/2025 through 10/31/2025 revealed no evidence of daily catheter care for day shift (7a - 3p) on 10/2/2025 10/3/2025 10/4/2025, 10/5/2025, 10/6/2026, 10/7/2025, 10/9/2025, 10/19/2025, 10/22/2025, 10/23/2025, 10/27/2025 and 10/30/2025; The evening shift (3p-11p) on 10/1/2025, 10/2/2025, 10/3/2025, 10/4/2025, 10/5/2025, 10/6/2025, 10/7/2025, 10/8/2025, 10/9/2025, 10/10/2025, 10/12/2025, 10/13/2025, 10/20/2025, 10/22/2025, and 10/23/2025; and the night shift (11p -7a) on 10/1/2025, 10/3/2025, 10/4/2025, 10/5/2025, 10/9/2025, 10/10/2025, 10/11/2025, 10/12/2025, 10/132025, 10/14/2025, 10/19/2025, 10/21/2025, 10/24/2025, 10/26/2025, 10/28/2025, and 10/31/2025 as indicated by blank boxesThe Documentation Survey Report v2 Nov-25 revealed that there was no evidence for day, evening and night shift of catheter care for day shift (7a-3p) on 11/1/2025, 11/2/2025, 11/3/2025, 11/4/2025, 11/5/2025, 11/6/2026, 11/7/2025, 11/10/2025, 11/12/2025, 11/13/2025, 11/15/2025, 11/16/2025, 11/17/2025, 11/19/2025 and 11/21/2025; The evening shift (3p-11p) on 11/1/2025, 11/2/2025, 11/3/2025, 11/6 /2025, 11/7/2025, 11/9/2025, 11/10/2025, 11/13/2025, 11/15/2025, 11/16/2025, 11/172025, and 11/21/2025; and the night shift (11p-7a) on 11/3/2025, 11/10/2025, 11/11/2025, 11/13/2025, 11/15/2025, 11/16/2025 and 11/21/2025 as indicated by blank boxes. During an interview on 2/16/2026 at 10:04 am, RN MDS Coordinator revealed that she was unsure why staff were not following the care plan.The former DON was unavailable for interview.Cross reference to F600

Based on record review, staff interviews, and review of the facility's policy titled Incidents and Accidents, the facility failed to ensure one of one Hoyer lifts to transfer 13 residents was functional and free of defective parts. Specifically, the facility failed to remove a malfunctioned Hoyer lift and to ensure that it was properly repaired prior to the residents' use and the purchase of a new Hoyer lift. On March 3, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Assistant Direction of Nursing (ADON) were informed of the Immediate Jeopardy (IJ) on March 3, 2026, at 2:23 pm. The noncompliance related to the IJ was identified to have existed on October 4, 2025.An acceptable IJ Removal Plan was received on March 5, 2026. Based on observation, record reviews, and review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on March 4, 2026. Finding include:Review of the facility's policy titled Incidents and Accidents, dated 4/1/2025 under the section titled Policy, revealed, It is the policy of this facility for staff to utilize the Risk Management portal to report, investigate, and review any accidents or incidents that occur or allegedly occur, on a facility proper and may involve or allegedly involve a resident. Under the section titled, Compliance Guidelines: revealed, 5. The following incidents/accidents required an incident report but are not limited to: equipment malfunction.Review of the undated Hoyer lift facility report revealed that 13 residents were transferred by a mechanical lift.A review of R1's progress notes revealed that on 10/4/2025, R1 was being transferred with a defective Hoyer lift. It was noted that two Certified Nursing Assistants (CNA) were transferring R1 from his wheelchair to his bed when the mechanical lift tilted over causing R1 to fall to the floor. R1 did not sustain any injuries but the next day had complaints of pain. Review of R1's x-ray report dated 10/5/2025 revealed no fracture, dislocation or bony destructive lesions noted. Review of the Task Type and Task Description form dated January 2025 through December 2025 revealed on 10/4/2025 that the maintenance director had assessed the defective and malfunctioning Hoyer lift on 11/8/2025 and 12/29/2025. However, the facility continued to use the defective Hoyer lift until parts ordered from an online vendor were available for the necessary repairs. The parts ordered included a motor, the arm lift and wheels.Review of a ticket order dated 8/3/2025 through 2/3/2026 revealed that a Lift 600 pounds capacity was ordered on 12/1/2025.During an interview on 2/16/2026 at 10:04 am, Registered Nurse (RN) Minimum Data Set (MDS) revealed that she knew R1 fell from the Hoyer lift. She revealed, after the fall the maintenance director assessed the Hoyer lift and refurbished it and to her knowledge the Hoyer lift was still in use until parts came in. During an interview on 2/16/2026 at 11:45 am, CNA II revealed that the facility had only one Hoyer lift in the building available for them.During an interview on 2/16/2026 at 2:45 pm, CNA RRR revealed they (CNAs) had to stand on the leg of the Hoyer lift to keep it from tilting over. She revealed she told the former Director of Nursing (DON).During an interview on 2/17/2026 at 10:14 am, the Maintenance Director revealed on the day R1 fell from the Hoyer lift, he assessed the lifts the same day and determined that the Hoyer lift needed parts. The Maintenance Director revealed the facility had an old Hoyer lift that was used for parts but did not have the parts needed to repair the current Hoyer lift. Therefore, he ordered the parts from an online vendor. He confirmed that the Hoyer lift continued to be used. He revealed that when the parts arrived, he refurbished the Hoyer lift. The parts that he had ordered from the online vendor were the motor, wheels and an arm lift. The Maintenance Director revealed that the new Hoyer lift was received in January 2026.During an interview on 2/24/2026 at 1:37 pm, the current Administrator revealed he was recently hired and was not aware of the malfunctioning Hoyer lift.The former Administrator was unavailable for an interview.

Based on record review, staff interview, and the facility job description for the former Administrator and Director of Nursing, the facility failed to provide administrative oversight to ensure physician orders were obtained and implemented as written and failed to ensure adequate supervision of the quality of care was provided for two of three Residents (R) R1 and R2.On March 3, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Assistant Direction of Nursing (ADON) were informed of the Immediate Jeopardy (IJ) on March 3, 2026, at 2:23 pm. The noncompliance related to the IJ was identified to have existed on October 4, 2025.An acceptable IJ Removal Plan was received on March 5, 2026. Based on observation, record reviews, and review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on March 4, 2026. Findings include:Review of the Administrator job description under the section titled Position Purpose, revealed, Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents.Review of the Director of Nursing job description under the section titled Position Purpose, revealed, planning, organizing, developing and directing the overall operations of the Nursing Services Department in accordance with local, state and federal standards and regulations established facility policies and procedures and as may be directed by the Administrator and the Medical Director to provide appropriate care and services to the residents.1. Review of the admission Record revealed R1 was admitted to the facility with the following diagnoses that included but were not limited to hypertension, gastroesophageal reflux disease, type 2 diabetes mellitus, orthopedic implant joint prosthesis or bone plate left leg and morbid obesity.Review of R1's medical records revealed, on 11/20/2025 at end of the day shift (7a-3p), Licensed Practical Nurse (LPN) AA inserted a Foley catheter for Resident (R)1 and after the Foley catheter was inserted, bleeding was noted in the Foley catheter tubing. LPN AA then irrigated the Foley catheter with sterile water without a physician order. The evening shift (3p - 11p) Certified Nursing Assistant (CNA) CC reported to LPN BB that R1 was not having any urine output and had blood in the Foley catheter drainage bag. LPN BB did not communicate to the physician that blood was noted in R1's Foley catheter drainage bag. LPN BB removed the Foley catheter as instructed by the former DON. There was no evidence that the physician gave the order nor was an order obtained to discontinue the Foley catheter. Upon removal of the Foley catheter by LPN BB, R1 started bleeding from his penis and rectum. He began to have altered mental changes and loss of consciousness. Subsequently, R1 was sent to a local hospital.2. Review of medical records revealed on 9/19/2025, R2 was admitted to the facility on [DATE] with diagnoses that included but not limited to Human Immunodeficiency Virus (HIV), morbid obesity obstructive and reflux uropathy, anemia, chronic pain, hypertensive heart disease, cerebral Infarction affecting the left dominant side, uropathy, and an indwelling foley catheter.Review of R2's physician order dated 9/19/2025 revealed, an order to obtain a urine sample for urinalysis and urine culture and to remove the Foley catheter. Further review of medical records for R2 revealed that the Foley catheter was removed; however, the urine sample was not collected.Review of an order dated 9/22/2025 revealed, an order for a Foley catheter 18 French 10 milliliters (ml) bulb to be re-inserted due to retention concerns and an order for a urinalysis (UA)/ culture and sensitivity (C&S) in addition to a consult with a Urologist ordered due to urine being cloudy with a foul odor noted. Review of a laboratory requisition dated 9/22/2025 for urinalysis with microscopic sample revealed no evidence that the urine sample was collected. On the handwritten laboratory requisition form dated 9/22/2025 it was noted R2 was discharged to the hospital on 9/25/2025 however there was no documentation to reflect that the resident was sent to the hospital and the census did not reflect a leave of absence. Further review of R2's medical records revealed, there was no indication that the urine specimen was obtained as ordered by the physician however, a Urology appointment was scheduled for 9/25/2025 and was rescheduled for 10/2/2025 at 2:00 pm.Review of (Named) hospital records History and Physical dated 10/15/2025 revealed, R2 was observed with altered mental status and was transferred to the hospital via emergency medical service (EMS) to the ER and admitted with altered mental status and a concern for sepsis. R2's Foley catheter was replaced in the ER on [DATE] and report was given to the nursing home regarding the Foley change.Review of R2's medical records revealed, R2 was sent back to the hospital for labored breathing via EMS services on 11/22/2025. R2 admitting diagnosis was septic shock and complicated urinary tract infection (UTI). 3. Review of medical records revealed that the facility had a malfunctioned Hoyer lift that was not removed from staff use. Subsequently, on 10/4/2025, R1 was being transfer with the Hoyer lift by two CNAs from his wheelchair to bed. In the process R1 had a fall due to the Hoyer lift tilting over during the transfer. The following day on 10/5/2025, R1 complained of pain and x-rays were obtained which were negative.Review of the facility Quality Assessment and Assurance process dated 12/23/2025 revealed current month (December) had nine falls and the previous month (November) had 15 falls. There was no evidence to support any other resident fell from the malfunction of the Hoyer lift.During an interview on 2/24/2026 at 1:47 pm, the current Administrator revealed that the expectation was that all residents receive excellent care from staff. He further revealed, he was recently hired in January 2026 and was unaware of these incidents.The former Administrator and former Director of Nursing were unavailable for interviews.

Based on records review, staff interviews, and the facility policy titled Fall Prevention Policy, the facility failed to ensure that one Resident (R1) with a history of multiple falls and receiving Plavix daily had accurate and complete neurological checks for a head injury on [DATE] and a second fall on [DATE] resulting in an acute bilateral tentorial subdural hemorrhage to the left side of the head with a right-to-left midline shift. The resident expired on [DATE] with an immediate cause of death determined to be a subdural hematoma. The facility census was 60. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Interim Director of Nursing, Director of Nursing, MDS (Minimum Data Set) Coordinator, and Registered Nurse Wound Care were informed of the Immediate Jeopardy on [DATE], at 4:07 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance while the facility continues to develop and implement a Plan of Correction (POC). This oversight process includes analyzing the facility's staff's conformance with the facility's policies and procedures related to ensuring resident safety, including staff education, care plan review and interventions, fall risk assessments, resident neurological checks, and quality assurance. Findings include:Review of the policy Fall Prevention Policy dated [DATE]. Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Policy Explanation and Compliance Guidelines: 9. When any resident experiences a fall, the facility will a. Assess the resident. b. Complete a post-fall assessment. f. Document all assessments and actions. h. Initiate neurological checks (if unwitnessed or witnessed and the resident hit their head).Review of the Electronic Medical Record (EMR) for R1 revealed the following diagnoses that included but were not limited to traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, type 2 diabetes mellitus, and hypertension.Review NBC (nonspecific tool by name)-Fall Risk Assessment dated [DATE] revealed a score of 16, indicating high risk.Review of progress notes dated [DATE] to [DATE] revealed a history of multiple falls. An entry dated [DATE] at 1:47 pm revealed R1 was found lying on the floor on his back with his walker rollator next to him. R1 sustained a hematoma to the top of his head. It was noted that the physician was notified of the fall, and neurological checks were started per fall protocol.Review of the Neurological Assessment Flowsheet dated [DATE] revealed the flowsheet was to be completed for each fall with a head injury or any unwitnessed fall. The parameters listed on the flowsheet are to Complete Every 15 minutes x 2 hours, Every 30 minutes x 2 hours. And the instructions: Document the date and time of each assessment, proceed as follows. Level of Consciousness, Pupil Response, Motor Functions - Hand grasp, extremities. Pain Response, Vitals and Observation.There was a discrepancy in time intervals between the last 15 minutes and the beginning of the 30-minute neurological checks for R1. There was no evidence that the neurological check assessments were completed for the [DATE] night shift (11:00 pm to 6:00 am), [DATE] for each of the three shifts, and [DATE] day shift (7:00 am to 3:00 pm).The progress note (nursing) dated [DATE] revealed R1 was noted to be on the floor in his room. R1 had discoloration from a previous fall ([DATE]). The nurse noted she attempted to notify the physician and the emergency contact. She returned to R1's room to do neurological checks, and R1 was not responding to commands. The resident was in a state of sleep, and she was unable to get the resident to respond. R1 was sent out via Emergency Medical Services (EMS) for an evaluation. The nurse noted that she had received a call from the hospital that his diagnosis was a brain bleed with a midline shift. On [DATE], R1 returned from the hospital on hospice care.Review of the Medication Administration Record (MAR) for R1, dated [DATE] through [DATE], revealed an order for clopidogrel bisulfate [generic Plavix (a medication used to prevent blood clotting)] oral tablet 75 milligrams (mg) by mouth one time a day related to essential primary hypertension. Further review revealed the medication was documented as administered daily as ordered. Review of the Medication Administration Record (MAR) dated [DATE] through [DATE] revealed R1 received clopidogrel bisulfate (Plavix) oral tablet 75 mg by mouth one time a day. He was administered Plavix on [DATE] through [DATE] as indicated by initials on the MAR.Review of the hospital emergency room (ER) documentation dated [DATE] revealed that R1 was sent to the closest hospital. The resident was noted to have an unwitnessed fall and was on Plavix. EMS stated the hematoma was on the back of the head. R1 received a Computed Tomography (CT) scan, which revealed a right-sided subdural and epidural bleed. R1 emergency contact reversed the DNR (Do Not Resuscitate) and requested that any intervention be done to the patient. R1 had a blunt fall epidural hemorrhage. R1 was unconscious. The CT dated [DATE] revealed there are acute bilateral tentorial subdural hemorrhages (a type of brain bleed located beneath the dura mater and adjacent to the tentorium cerebelli, a [NAME] fold in the brain) present, left greater than right, measuring up to 6 centimeters (cm). There is a 14 millimeter (mm) right-to-left midline shift. A chronic left subdural hematoma is present, measuring up to 1 cm in thickness. Right subdural hematoma, measuring up to 2.1 cm, with mass effect upon the right cerebral. The Emergency Department (ED) deposition dated [DATE] revealed that R1's trauma required a higher level of care. Resident 1 was transported via ALS (Advance Life Support) ambulance to another hospital in a different county. On [DATE], R1 returned to the facility in a state of unconsciousness and with hospice care. He remained in a state of unconsciousness until he expired on [DATE],Review of the Georgia Death Certificate revealed Immediate Cause of death was a Subdural Hematoma with a week's onset. date of death [DATE].An interview on [DATE] at 2:14 pm, Certified Nurse Aide (CNA) CC revealed that the day before R1 fell the first time ([DATE]), R1 was using his walker (rollator). On [DATE] at 10:22 am, CNA CC revealed resident could do for himself. He used his walker to walk. He was going to the dining room and participating in activities. He was not the type to lie in bed. He always came out of his room. When he returned from the hospital on [DATE], he was totally dependent and unresponsive.An interview on [DATE] at 9:52 am with CNA DD revealed that R1 was able to go to the shower, dress, feed himself, and ambulate before his fall with a walker on wheels (rollator). CNA DD stated that R1 would participate in activities and is not the type of person to be in bed. He would always come to the dining room before meals were served. She stated that R1 changed after the fall before he had the last fall. He started urinating on himself. He had to be encouraged to come to the dining room, start taking off his clothes, and would sleep a lot, which was not his usual routine. CNA DD revealed his normal routine was to move around following the CNAs. CNA DD stated that after the first fall ([DATE]), he had to be bathed. She stated that after the last fall on [DATE], when he came back from the hospital, he was not talking, could not open his eyes, and was not eating. An interview on [DATE] at 2:02 pm with Registered Nurse (RN) BB revealed that R1 fell on [DATE]. She stated that the resident stood and tumbled while going into his room and fell backward. RN BB stated that he hit his head on the door as he was falling. She talked to him to make sure his mental status was normal and revealed his mental status, face, and pupils were normal, but he did complain of pain. On [DATE] at 9:27 am, RN BB stated that R1 was assisted by CNA VV after the fall on [DATE]. She stated that CNA VV was in the hallway close to the resident's room. RN BB stated that she called the physician about the fall and told him R1 seemed fine and didn't have any changes. She continued to state that she initiated the neuro checks. RN BB confirmed that she did not inform the physician of R1's daily Plavix.An interview on [DATE] at 1:24 pm with LPN II revealed that after the fall on [DATE], R1 started needing some assistance with dressing, but was still walking using his walker (rollator). LPN II stated that R1 had some confusion, and she was going to get a urine sample because R1 had a history of urinary tract infection. She revealed that RN BB told her that she had done neurological checks and that R1 was fine. LPN II further revealed that when she saw the hematoma, it was like a goose egg but was the size of a pecan when she noticed the knot the first time. LPN II could not recall if she did the neurological checks if her initials were not on the form, and that LPN SS may have documented her neuro checks for the [DATE] day shift. An interview on [DATE] at 9:07 am with CNA VV revealed that she recalled that after the fall on [DATE], R1 was spending more time in bed. He would get up to go to his bathroom and get back in bed or sit in his chair.An interview on [DATE] at 1:14 pm with LPN AA revealed that she came to work and received a shift report stating that R1 had a previous fall on [DATE]. LPN AA stated that she noticed R1 had a knot on his head, which was getting larger, and his head looked warped. She revealed that the former Director of Nursing (DON) was aware of the knot. She stated that R1 was walking down the hall naked; he was somewhat disoriented. LPN AA further revealed that R1 had a fall ([DATE]) in his room and was placed in bed. He was unresponsive, and she called the physician, but did not wait for a return call to send R1 to the hospital. She called the hospital for an update and was told the resident had a brain bleed with a midline shift. An interview on [DATE] at 4:43 pm with LPN HH revealed R1 on [DATE] was coming down the hall naked from the waist down. Staff walked R1 to his room and put some pants on him. LPN HH stated that there was some confusion going on with him, and he has good and bad days. LPN HH further revealed that after the first fall ([DATE]), R1 started wanting to be in bed more, and his hematoma was the size of a lemon plus or minus on the left side near the front of the head. After the resident last fall, she went back and read the previous fall ([DATE]) note and felt that the resident should have been sent out and felt that the nurse who was assigned did not give the physician the extent of the resident's head injury.An interview on [DATE] at 10:19 am with the Physician revealed that he remembered RN BB calling him and stating that R1 had fallen, and he thought she had said that R1 refused to go to the ER. He gave instructions to watch R1 closely and was concerned that R1 would not go to the ER. The Physician stated that RN BB told him neurological checks were started, but she did not tell him about the resident being on Plavix. He stated that he was not called about the R1 showing signs of confusion, and he did not give an order for a urinalysis sample, nor did the Nurse Practitioner (NP). The Physician further revealed that he read the nurse's note for [DATE], and his expectation that residents on an anticoagulant with a visible head injury should be monitored and taken to the ER for evaluation. However, the investigation revealed that there was no evidence that R1 had refused to go to the ER. The physician was informed that there was no documentation of R1 refusal. The only refusal identified was R4, who declined a surgical repair for a fractured hip.

Based on record review, staff interviews, the facility failed to ensure that staff nurses assessed and completed neurological checks for one of 10 Residents (R1) who had a fall (5/15/2025) with a head injury and sustained a hematoma. The census was 60. On August 12, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Interim Director of Nursing, Director of Nursing, MDS (Minimum Data Set) Coordinator, and Registered Nurse Wound Care were informed of the Immediate Jeopardy on August 12, 2025, at 4:07 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on May 15, 2025. An Acceptable IJ Removal Plan was received on 8/14/2025. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 8/15/2025. The facility remained out of compliance while the facility continues to develop and implement a Plan of Correction (POC). This oversight process includes analyzing the facility's staff's conformance with the facility's policies and procedures related to ensuring resident safety, including staff education, care plan review and interventions, fall risk assessments, resident neurological checks, and quality assurance. Findings include:Review of the medical record for R1 revealed diagnoses that included, but were not limited to, traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, dated 5/23/2025.Review of the Medication Administration Record (MAR) dated 5/1/2025 through 5/31/2025 revealed an order for clopidogrel bisulfate [generic Plavix (a medication used to prevent blood clotting)] oral tablet 75 milligrams (mg) by mouth one time a day related to essential primary hypertension. Further review revealed the medication was documented as administered daily as ordered. Review of the Progress Notes for R1 revealed an entry dated 5/15/2025 at 1:47 pm documented that R1 was found lying on the floor on his back with his walker (rollator) next to him. R1 had a hematoma [a localized collection of blood outside of a blood vessel caused by trauma or injury] to the top of his head. It was noted that the physician was notified of the fall, and neurological checks (neuro checks) were started per the facility's fall protocol. Continued review revealed an entry dated 5/21/2025 at 7:43 pm that R1 was noted to be on the floor in his room. The resident was unable to give a description of the incident and was assisted to a chair via a two-person assist. The nurse returned to the room, and the resident was not responding to commands. Staff were unable to get the resident to respond to any commands. The resident was sent out via Emergency Medical Services (EMS) for evaluation. Review of the facility-provided document titled Neurological Assessment Flow Sheet for R1 indicated the neuro checks were to be completed every 15 minutes for two hours, every 30 minutes for two hours, and every shift for 72 hours. Further review of the document revealed that the neuro checks were initiated on 5/15/2025 at 1:30 pm. Continued review revealed no evidence that the neurological checks were completed on the 5/17/2025 night shift (11:00 pm to 6:00 am), 5/18/2025 for each of the three shifts, and 5/19/2025 day shift (7:00 am to 3:00 pm). The Vitals section of the document revealed a blood pressure of 99/58 on 5/15/2025 at 2:30 pm, 104/58 at 3:30 pm, and 108/58 at 4:30 pm. There was no documented evidence that the physician was notified of the blood pressure readings. Review of the Georgia Death Certificate for R1 revealed the Immediate Cause of death was a Subdural Hematoma, and the approximate interval between onset and death was weeks. date of death [DATE].In an interview on 8/5/2025 at 1:14 pm, Licensed Practice Nurse (LPN) AA revealed that she came to work on 5/21/2025, and that she received a report that R1 had a previous fall on 5/15/2025. She noticed that the resident had a knot on his head that was getting larger, and his head looked warped. She stated that the Director of Nursing (DON) was aware of the knot. She further stated that R1 was more confused. He had a fall in his room and was placed in his bed. She stated she left the room to call the physician, returned to R1's room, saw him unresponsive, and sent him to the hospital via EMS services.In an interview on 8/5/2025 at 2:02 pm, Registered Nurse (RN) BB revealed the R1 fell on 5/15/2025. She stated that the resident stood and tumbled while going into his room and fell backward. His head hit the door as he was falling. In an interview on 8/6/2025 at 9:52 am, Certified Nurse Aide (CNA) DD revealed that before his fall with injury, R1 was able to go to the shower, dress, and feed himself. He was ambulatory with a walker and would place his clothes over the walker. He had a walker with wheels (rollator). She stated that he was still his usual self and was not a bed person. CNA DD further stated that R1 changed after the fall and before he had the last fall. She stated he started urinating on himself, had to be encouraged to come to the dining room, started taking off his clothes, and would sleep a lot, which were not his usual behaviors. She stated that after the last fall, when he came back from the hospital, he was not talking, could not open his eyes, and was not eating. He was pretty much a vegetable. In an interview on 8/7/2025 at 1:24 pm, LPN II revealed that after a fall on 5/15/2025, R1 started needing some assistance with dressing and had some confusion. LPN II stated she was unable to recall if she conducted the neuro checks for R1 after the fall. In an interview on 8/11/2025 at 9:27 am. RN BB revealed that she witnessed the fall on 5/15/2025. She stated she was in the hallway close to the resident's room. She stated she called the physician about the fall and told him the resident seemed fine. In an interview on 8/11/2025 at 10:19 am, the physician revealed that he recalled RN BB calling him and telling him the R1 had fallen and that R1 refused to go to the emergency room (ER). He gave instructions to watch closely and was concerned about the resident not going to the ER. The physician stated RN BB told him that neuro checks were started, but she did not tell him the resident was on Plavix. He stated he was not called about the resident showing signs of confusion. He stated his expectation was that residents are to go to the ER for a visible head injury, and if on an anticoagulant. He further stated that residents were to be monitored closely and that documentation was to be completed. In an interview on 8/11/2025 at 2:01 pm, RN WW, Interim DON, and RN XX, newly hired DON, confirmed R1 was on Plavix and sustained a head injury. The nurse should have informed the physician that the resident received Plavix, neurological checks should have been assessed for differences, and R1 monitored for changes.

Based on record review, staff interviews, and a review of the facility-provided Administrator and Director of Nursing (DON) Job Description, the Administration failed to provide oversight and supervision related to assessments of post fall monitoring and neurological checks by licensed nurses and failed to ensure safety measures implemented were effective for R1, who suffered head trauma after a fall, resulting in death.On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Interim Director of Nursing (DON), Director of Nursing, MDS (Minimum Data Set) Coordinator, and Registered Nurse Wound Care were informed of the Immediate Jeopardy on [DATE], at 4:07 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance while the facility continues to develop and implement a Plan of Correction (POC). This oversight process includes analyzing the facility's staff's conformance with the facility's policies and procedures related to ensuring resident safety, including staff education, care plan review and interventions, fall risk assessments, resident neurological checks, and quality assurance. Findings include: Review of the Administrator job description dated [DATE]. Purpose of Your Job Position. The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. Duties and Responsibilities. Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. Review of the Director of Nursing job description dated [DATE]. Position Purpose. Planning, organizing, developing, and directing the overall operations of the Nursing Service Department in accordance with local, state, and federal standards and regulations, established facility policies and procedures, and as may be directed by the Administrator and the Medical Director, to provide appropriate care to the residents. Major Duties and Responsibilities. Interprets and communicates policies and procedures to nursing staff, and monitors staff practices and implementation. Participates in daily or weekly management team meetings to discuss census changes, resident changes in status, complaints or concerns. Performs rounds to observe residents and ensure nursing needs are being met. Facility Administration, specifically the Administrator and DON, failed to ensure resident safety and effectively oversee areas of the facility that were included in their job descriptions. 1.The facility Administration failed to provide supervision and oversight of R1, who had a history of multiple falls; failed to ensure monitoring of R1, who was on Plavix and had a head trauma from a fall on [DATE] and a second fall on [DATE] with head trauma resulting in death on [DATE]. Cross-reference F689 2.The facility failed to ensure safety measures implemented were effective for R1 who had a head trauma from a fall on [DATE] and [DATE].Cross-reference F689, 726, F835 3.The facility failed to ensure R1 had accurate and completed neurological checks post-fall ([DATE]) protocol for head injury. R1 had a hematoma located on the left side of the head and was receiving Plavix daily.Cross-reference F835 4.The facility failed to ensure that staff nurses assessed and completed neurological checks for R1, who was on Plavix and had a fall ([DATE]), which resulted in a hematoma to the left side of the head.Cross-reference F689, F835 Review of R1's fall history for 2025 revealed he had had a total of 10 falls prior to his death. A previous fall on [DATE] resulted in a compressed fracture of the lumbar spine. R1 fell on [DATE], revealing a hematoma (nurse's note) to the top of his head. And on [DATE], a fall that put R1 in a state of unconsciousness and expired on [DATE]. A review of the progress note (nursing) dated [DATE] revealed R1 was noted to be on the floor in his room. R1 had discoloration from a previous fall ([DATE]). The nurse noted she attempted to notify the physician and the emergency contact. She returned to R1's room to do neurological checks, and R1 was not responding to commands. The resident was in a state of sleep, and she was unable to get the resident to respond. R1 was sent out via Emergency Medical Services (EMS) for an evaluation. The nurse noted that she had received a call from the hospital that his diagnosis was a brain bleed with a midline shift. On [DATE], R1 returned from the hospital on hospice care. R1 expired in the facility on [DATE]Review of the Georgia Death Certificate revealed Immediate Cause of death was a Subdural Hematoma with a week's onset. date of death [DATE].There was a discrepancy in time intervals between the last 15 minutes and the beginning of the 30-minute neurological checks for R1. There was no evidence that the neurological check assessments were completed for the [DATE] night shift (11:00 pm to 6:00 am), [DATE] for each of the three shifts, and [DATE] day shift (7:00 am to 3:00 pm).There was no evidence of Performance Assessment Review (PAR) meetings being held weekly. The facility was unable to provide documentation from the former Director of Nursing (DON) regarding PAR meetings. Review of the hospital emergency room (ER) documentation dated [DATE] revealed that R1 was sent to the closest hospital. The resident was noted to have an unwitnessed fall and was on Plavix. EMS stated the hematoma was on the back of the head. R1 received a Computed Tomography (CT) scan, which revealed a right-sided subdural and epidural bleed. R1 emergency contact reversed the DNR (Do Not Resuscitate) and requested that any intervention be done to the patient. R1 had a blunt fall epidural hemorrhage. R1 was unconscious. The CT dated [DATE] revealed there are acute bilateral tentorial subdural hemorrhages (a type of brain bleed located beneath the dura mater and adjacent to the tentorium cerebelli, a [NAME] fold in the brain) present, left greater than right, measuring up to 6 centimeters (cm). There is a 14 millimeter (mm) right-to-left midline shift. A chronic left subdural hematoma is present, measuring up to 1 cm in thickness. Right subdural hematoma, measuring up to 2.1 cm, with mass effect upon the right cerebral. An interview on [DATE] at 2:01 pm with the Interim DON and the newly hired DON ([DATE]) revealed that R1 was on Plavix and had a head injury. The nurse should have informed the physician of the Plavix; neurological checks should have been assessed for differences and monitored for changes. Both DONs stated that for the effectiveness of the care plan, the R1 should have undergone a re-evaluation by therapy, assessed for changes, had their shoes checked to ensure proper footwear, and documented that education was provided and the educational content taught. Re-educate, reiterate fall precautions, and evaluate equipment. When Resident 1 fell, the nurse needed to have a clear picture of what had happened, the resident's background, and pertinent medications. An interview on [DATE] at 2:59 pm with the Administrator revealed that for fall accidents, he expects nurses to assess the residents, deem them okay, document the incident, and implement selected interventions. The Administrator further stated that the physician and the party responsible are to be notified. The nurses were to provide supervision of R1, and the documentation should provide information on what took place and dispel what isn't there.An interview on [DATE] at 10:19 am with the Physician revealed that he remembered RN BB calling him and stating that R1 had fallen. The Physician stated that RN BB told him neurological checks were started, but she did not tell him about the resident being on Plavix. He stated that he was not called about the R1 showing signs of confusion. The Physician further revealed that he read the nurse's note for [DATE], and his expectation that residents on an anticoagulant with a visible head injury should be monitored and taken to the ER for evaluation.

Based on record review, staff and resident interviews, and review of the facility policy titled Documentation in Medical Record, the facility failed to ensure the medical record documentation was complete and accurate for one of 10 sampled residents (R) (R5). Specifically, staff documented the presence of maggots between the left great toe and the second toe for R5.Findings include:Review of the facility policy titled Documentation in Medical Record, dated 1/13/2025, revealed: Policy Explanation and Compliance Guidelines: 4. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident-centered.Review of the admission record revealed that R5 was admitted to the facility with diagnoses including, but not limited to, type 2 diabetes mellitus, unspecified dementia, peripheral vascular disease, and severe morbid obesity.Review of the 6/30/2025 Wound Care Physician note indicated the resident had a wound to the left medial leg that was being treated with medical-grade honey and a two-layer compression wrap every Monday, Wednesday, and Thursday.Review of the 7/2/2025 Wound Care Physician note indicated the order was changed to cleanse with wound cleanser, pat dry, apply collagen, and cover with ABD [abdominal] pad every Monday, Wednesday, and Thursday.Review of the 7/17/2025 progress notes documented the Wound Care Nurse and the Wound Care Nurse Practitioner (NP) were in the resident's room for weekly rounds. It was noted the left foot was noted to have non-skin abnormalities. There was no redness or open areas noted. The Physician and the Director of Nursing were notified.Review of the Physician's Order for R5 revealed an order dated 7/17/2025 to cleanse the left foot with normal saline, pat dry, soak in Dakin's solution for five to ten minutes, pat dry, apply calcium alginate to left foot digits, and apply nystatin powder. Remove calcium alginate in the am. One-time, only for one day order.During an interview with Registered Nurse (RN) EE on 7/23/2025 at 3:37 pm, she stated that she had seen maggots between the resident's left foot toes. She stated that there was no open area between her toes. She stated there were about 10 maggots for about two to three days. She also stated she did not document the maggots on the resident's foot because she was instructed not to write maggots in her documentation.During an interview with the NP Wound Consultant on 8/5/2025 at 10:55 am, she stated the resident had maggots between the toes, and she did not document the maggots in her report because the maggots were not in the wounds. She stated she was seeing the resident for wounds.During an interview with RN BB on 8/5/2025 at 11:08 am, she stated that the Wound Care NP told her that the resident had maggots between her toes and feet. The Wound Care NP asked her if she had seen the maggots. She stated that if she had seen the maggots, she would have documented that in the resident's chart.During an interview with Licensed Practical Nurse (LPN) GG on 8/5/2025 at 12:39 pm, she stated the maggots were in the resident's left toes and that she was standing near RN BB and RN EE and overheard the conversation about the resident having maggots.

Based on observation, interview, and facility policy review, the facility failed to date, label, and/or cover food in refrigeration and freezer storage, failed to discard food in refrigeration storage with expired use by dates or signs of spoilage, and ensure scoops were not stored in containers of sugar, flour, and corn meal. The facility also failed to keep the kitchen's oven, large manual can opener, and metal exhaust hood vents clean. This failure had the potential to create an environment for food-borne illnesses which could affect 57 of 57 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Food Receiving and Storage, with a revision date of ,d+[DATE], indicated, . Food shall be received and stored in a manner that complies with safe food handling practices . 7. All food stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) . Review of the facility's undated policy titled, Leftover Food, indicated, . 3. Leftover foods will be stored in approved containers and labeled with the name of the item and the date prepared. 4. Refrigerated leftover food items must be used within 48 hours of original preparation and frozen leftover food items must be used within two months. 5. All refrigerated or frozen leftover food items that are improperly stored, stored for a time period longer than allowed, or appear spoiled or of poor quality, will be discarded . Review of the facility's undated policy titled, Food Storage, indicated, . 6. Scoops must be provided for flour, sugar, cereals, dried vegetables, and spices. Scoops are not to be stored in the food containers, but are kept covered in a protected area near the containers . Review of the facility's undated policy titled, Sanitation/Infection Control, indicated, . 4. To maintain high environmental sanitation standards, the following practices are suggested, but are not all-inclusive: . d. Hoods and ducts are cleaned at least monthly to prevent grease build up, which creates a fire hazard as well as a sanitation problem. Ducts are professionally cleaned every six months . f. All cooking equipment, door seals, and surfaces of grills, burners, and ovens are wiped off daily and thoroughly cleaned regularly . 1. Observation of kitchen food storage areas on [DATE] from 8:15 AM to 8:45 AM, during the initial kitchen inspection, with Dietary [NAME] (DC)1 present, revealed the following concerns: a. Observation of food stored in the kitchen's walk-in refrigerator revealed three large packages of cole slaw mix, which contained cabbage, purple cabbage and carrots, with expired use by dates of [DATE], one undated opened 128 ounce container of buttermilk dressing, one unlabeled and undated plastic bag of Swiss cheese slices, 20 undated loaves of thawed bread, 27 half pint cartons of whole milk with expired use by dates of [DATE], 12 tomatoes stored in a box that were very mushy and appeared rotten, three undated and unlabeled wrapped peanut butter and jelly sandwiches that had very hard bread, and four undated and unlabeled dishes of left over peach crisp. b. Observation of food stored in the kitchen's walk-in freezer revealed one 9.75-pound box of dinner rolls, one 20-pound box of cookie dough, and one 13.5-pound box of French toast that were not closed, and the food stored inside each box was unprotected from possible contamination. c. Observation of food stored in the kitchen's dry storage room revealed three large plastic containers which contained sugar, flour, and corn meal that had scoops stored inside each of these containers. The scoops were in direct contact with the food and the handles of the scoops were embedded in the flour, sugar, and corn meal stored in these containers. During an interview on [DATE] at 8:45 AM, DC1 confirmed the above observed concerns with food stored in the kitchen's walk-in refrigerator, walk-in freezer, and dry storage room. DC1 stated scoops should not be stored in food bins, food should be dated and labeled when opened and completely covered when stored, and any food with expired use by dates or signs of spoilage should be discarded. During an interview on [DATE] at 11:15 AM the Dietary Manager (DM) stated bread products should be dated by staff when taken out of freezer storage and placed in refrigeration storage to thaw and should be discarded if not used within 14 days after they were thawed. 2. Observation on [DATE] from 8:15 AM to 8:45 AM, during the initial kitchen inspection, with DC1 present, revealed the kitchen's only oven was unclean with heavy accumulated blackened and dried food spills on its interior cooking compartment, the large manual can opener's blade and table base attachment were unclean with accumulated dried and sticky substances, and the kitchen's metal exhaust hood vents, located directly above the kitchen's stove top where food was prepared, were unclean with a greasy residue and black dust. During an interview on [DATE] at 8:45 AM, DC1 confirmed the kitchen's oven, manual can opener and its' base attachment, and the kitchen's exhaust hood vents were unclean. DC1 stated the kitchen's oven and manual can opener was on the kitchen's weekly cleaning schedule. DC1 was unsure when the kitchen's metal exhaust hood vents were last cleaned. During an interview on [DATE] at 2:15 PM, the DM stated the kitchen's metal exhaust hood vents should be cleaned weekly or as needed. The DM stated she had worked at the facility since the end of [DATE] and to her knowledge the kitchen's exhaust hood vents had not been cleaned since she started working at the facility.

Based on observation, interview, record review, and policy review, the facility failed to implement interventions to aid in the healing of pressure ulcers for two of two residents (Resident (R) 45 and R48) reviewed for pressure ulcers out of a total sample of 21. This had the potential to cause delay in the healing of the residents' pressure ulcers. Findings include: Review of the facility's policy Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated April 2018, revealed, . The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers, for example immobility, recent weight loss, and a history of pressure ulcer(s) . The nurse should describe, document, and report: a full assessment of the pressure ulcer, including stage, length, width, depth, presence of exudate (drainage) or necrotic (dead) tissue; pain assessment; resident's mobility status; current treatments, including support surfaces, and all active diagnoses. The physician would assist the staff to identify the type and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer . The physician would help identify factors that contribute or predispose residents to skin breakdown; for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer, or sepsis causing a catabolic state, and macerated or friable skin . The physician would order pertinent wound treatments, including pressure reduction surfaces, wound cleansing, and debridement approaches, dressings, and application of topical agents . The physician guided the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . Review of the facility's policy titled, Wound Care, dated October 2010, revealed clinical documentation should include, . Any change in the resident's condition, all assessment data, for example, wound bed color, size, and drainage, obtained when inspecting the wound . 1. Review of R45's Census tab of the electronic medication record (EMR) revealed R45 was admitted to the facility on [DATE]. Review of R45's Diagnosis tab of the EMR revealed R45 had diagnoses that type 2 diabetes with neuropathy (nerve pain) and left leg below the knee amputation. Review of R45's Care Plan, dated 11/26/24 and located under the Care Plan tab of the EMR, revealed, . Resident has potential/actual impairment to skin integrity related to fragile skin, impaired mobility causing sheering, and unstable DM [diabetes mellitus]. The goal was, Resident will maintain or develop clean and intact skin by the review. Review of R45's Braden Scale for Predicting Pressure Sore Risk, dated 12/10/24 and located under the Assessment tab in the EMR, revealed R45 scored an 18, which was indicative of being at low risk for the development of pressure ulcers. Review of R45's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/21/24 and located under the MDS tab of the EMR, revealed R45 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. It was recorded R45 required supervision or touching assistance for upper and lower body dressing and personal hygiene, was independent with repositioning in bed and from going from sitting to lying, lying to sitting, and transferring from his wheelchair to bed and to the toilet. It was recorded that R45 did not have pressure or stasis ulcers present. Review of R45's Progress Note, dated 02/11/25 at 8:23 PM, written by Licensed Practical Nurse (LPN)3, and located under the Progress Notes tab in his EMR revealed a Certified Nursing Assistant (CNA) had assisted R45 with his shower and noticed a red area to his right heel, and the CNA reported the area to LPN3. It was recorded LPN3 assessed, cleaned, and applied a dressing to his right heel. It was recorded that R45's physician had been notified at 8:30 PM. Review of the DON's logs of non-pressure wounds, dated 02/11/25 and provided by the DON, included R45's wound listed as diabetic. The wound to his right heel had initial measurements of 2.8 centimeters (cm) by 2.5 cm. The depth could not be measured. There was tissue present described as slough. The treatment was Medi-honey/Island ointment covered with a dressing to be changed daily. Review of R45's Care Plan, revised 02/12/25 and located under the Care Plan tab of the EMR, revealed, . Resident has open area noted to right lower extremity. MD notified with treatment in progress, float heel while in bed, in house wound care, MD to eval [evaluate] on next visit and treat till healed. Review of R45's clinical record, dated 02/11/25 through 02/16/25, revealed no documented evidence that R45 was encouraged to elevate his right foot while in bed. There was no documentation that pressure relieving devices for the foot were provided or used while the resident was up in his wheelchair. During an observation and interview on 02/16/25 at 3:00 PM, R45 was observed in his wheelchair in the dining room. His wheelchair only had one pedal on the right. His right foot rested on the pedal in a slanted way which put pressure on the outside area and bottom of his right heel. There was a surgical shoe protector on his right foot. There were areas on the shoe protector that had stains of what appeared to be light-colored blood. R45 stated he had a sore on his right heel, and he did not know how he got it. He stated he had been instructed to keep his foot on a pillow when he was in bed, but no one had helped him, and he did not have an extra pillow in his room. During an observation on 02/17/25 at 10:55 AM, Licensed Practical Nurse (LPN)2 completed a dressing change for R45's right heel wound. There were dried drainage spots on his sheets and on the surgical shoe cover he had over the dressing. The old dressing was wet with a bloody appearing drainage. The wound was open with a large amount of thick stringy tissue hanging out of the wound. There was a foul odor from the wound. A wound cleanser was used on a gauze pad and only the area around the wound was cleansed before the new dressing was applied. During the dressing change observation, there were no extra pillows observed in the room to elevate his right foot on, he had a regular mattress, and there were no heel protector boots noted in his room. When R45 laid down in bed so that his dressing change could be completed, his right foot was turned so that pressure was applied in the location of the room. R45 stated this was how his right foot rested on his mattress when he was sleeping. During an interview on 02/19/25 at 8:45 AM, the DON stated she did not think R45's wound was a pressure ulcer because he had a diagnosis of diabetes. She stated she had not thought of it as a pressure ulcer because of the diabetes diagnosis. The DON stated the wound had declined rapidly and the wound care doctor was supposed to see the resident on 02/18/25 but was unable to make it The DON confirmed she had not assessed whether R45 put pressure on the heel area when he was in bed or in the wheelchair. The DON stated she had provided R45 a Prevalon boot (padded knee high boot which provides pressure relief to the heel) last night. During an interview on 02/19/25 at 10:34 AM, CNA3 stated she did not have access to R45's care plan to see what interventions she was supposed to provide for the resident. She stated she was not aware of what assistance R45 needed to help with the healing of his right heel wound. She stated the CNAs documentation only focused on how much assistance a resident needed. During a phone interview on 02/19/25 at 2:40 PM, LPN3 stated the CNA had reported to her on the evening shift on 02/11/25 that R45 had a wound on his right heel. She stated when she assessed his right heel, it felt squishy to touch. LPN3 stated there was not a blister as it was not clear fluid but infection looking fluid. She stated it had a smell to it but no drainage. LPN3 stated she placed a non-stick gauze pad and a folded over ABD (thick abdominal dressing) pad on the wound and wrapped it in gauze. She stated she had let the staff on duty that evening know R45 should keep his right foot elevated, but she had not written it down so all the staff would know. She stated she had instructed R45 to elevate his leg, and she thought he had an extra pillow to put his leg on. 36190 2. Review of R48's annual MDS, with an ARD of 11/13/24 and located in the EMR under the MDS tab, revealed an admitted [DATE]. R48 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R48 was cognitively intact. It was recorded R48 had impairment on both sides of the lower extremities, required supervision or touching assistance to roll left and right, required substantial/maximal assistance for chair/bed-to-chair transfer, was always incontinent of bowel and bladder, had a stage four pressures ulcer, and had diagnoses of type 2 diabetes mellitus without complications, peripheral vascular disease, and a fracture of the tibia or fibula in the left leg after an orthopedic implant is inserted. Review of R48's Health Status note, dated 08/08/24 and located in the EMR under the Progress Note tab, revealed, When applying zinc to areas noted active bright red bleeding. New order was received to D/C [discontinue] zinc to areas and do Vaseline dressing daily to area or as needed until healed. Measurements to right upper buttocks 1cm [centimeter] X 1cm x 0 . Resident is aware of areas and treatment orders. Review of R48's Skin/Wound note, dated 08/27/24 and located in the EMR under the Progress Note tab, revealed, . [Medical Doctor (MD) 2] in facility and eval [evaluated] wounds, new order as following . Wound to upper right buttocks, clean with wound cleanser, pat dry, apply medi honey to area, cover with island dressing secure with tape, change daily and as needed until resolved. Measurements: 5.2 x 4 x 0.2cm area is unstageable due to necrosis, resident is aware of new orders and measurements. Review of R48's Care Plan, dated 08/27/24 and located in the EMR under the Care Plan tab revealed, . Resident has potential/actual impairment to skin integrity r/t [related to] incontinence and impaired mobility . Interventions included, . In house wound care MD to follow weekly until healed, enablers placed on both sides of bed to assist with turning and repositioning, supplements per MD orders and . Res. [resident] refused wound care Encouraged to allow nurse to change dressing . The care plan did not address repositioning or limiting time in the wheelchair. Review of R48's Wound Physician notes, located in the EMR under the Miscellaneous tab revealed on 09/17/24, 12/17/24 01/21/25, and 02/11/25, the wound physician had recommended to limit sitting to 60 minutes, to off-load wound, and to reposition per facility protocol: Review of R48's Progress Notes, dated from 02/17/24 to 02/17/25 and located in the EMR under the Progress Note tab, revealed the only entry mentioning repositioning was on 11/01/24. Only four entries of R48 refusing wound care were on 09/02/24, 09/10/2024, 12/03/24, and 01/07/25. No entry was found encouraging R48 to limit his time in the wheelchair. During an interview on 02/18/25 at 3:50 PM, the Director of Nursing (DON) was asked about R48's pressure sore. The DON stated R48's wound was in-house acquired, and R48 was seen weekly by the wound doctor and measures were taken then. The DON stated R48 had a gel cushion in his wheelchair and a pressure-reducing mattress on his bed, but the mattress was not an air mattress. The DON stated the events that had led to R48's pressure sores began with R48 gaining weight after he fractured his foot in 2023. The DON stated R48 underwent surgery and had become less mobile. On 02/19/25 at 9:25 AM, R48 was awake in bed lying on his back playing a game on his cell phone. R48 was asked if his pressure sores hurt and R48 stated, No. R48 was asked if staff helped reposition him and he said, Yes sometimes but he could reposition himself. During an interview on 02/19/25 at 9:30 AM, Licensed Practical Nurse (LPN)2 was asked what interventions were in place for R48's pressure sores. LPN2 stated, We try to get [R48] to reposition, and he refuses, we try to use pillows and a cushion, but he takes them off. LPN2 stated R48 did not have any feeling in his lower extremities. During an interview on 02/19/25 at 10:23 AM, Certified Nurse Aide (CNA)2 was asked if R48 needed to be repositioned. CNA2 stated, No, he does that himself. CNA2 was asked if she had to remind him to reposition and CNA stated, No. During a follow up interview on 02/19/25 at 10:56 AM, the DON was asked what pressure sore interventions were in place since R48's mobility was reduced. The DON stated [R48] needed to be repositioned by staff and more staff help mostly because of his size. The DON was asked if R48 needed more help, why did his CNA say he did not need to be repositioned or reminded to change positions in bed. The DON stated, That's because [R48] knows already when he needs to be repositioned but R48 does refuse to be repositioned and wound treatments at times. The DON stated R48 did not need to be reminded because he knew when to be repositioned and had enablers on his bed. The DON was asked if R48 needed help, how does he get repositioned. The DON stated R48 needed to be encouraged to reposition. The DON stated R48 should be repositioned every two hours. The DON was asked how CNAs knew what kind of care R48 should receive as the care plan or the Kardex did not include repositioning. The DON stated she did not know what the Kardex was, and the CNAs did not have access to the care plan. The DON was asked if there were any recommendations from the wound doctor. The DON stated, To offload. The DON was asked if she was aware of the recommendation to limit time in the wheelchair. The DON stated, Yes but she was unaware of the time limit. The DON was informed that the recommendation was for 60 minutes. During a telephone interview on 02/19/25 at 2:51 PM, LPN3 was asked if R48 needed to be repositioned in bed. LPN3 stated, Yes, but [R48] can do it himself but he does need assistance. LPN3 went on to say [R48] will do it himself and he has not asked to be repositioned. LPN3 stated [R48] is always sitting up in his bed playing video games and he needs a donut to sit on. LPN3 stated she encourages him to get out of bed. LPN3 was asked if there was a time-limit for R48 to be in his wheelchair. LPN3 stated, No, [R48] will let someone know when he wants to get in bed. During a telephone interview on 02/19/25 at 3:37 PM, Medical Director (MD)1 was asked about R48's pressure sore. MD1 stated [R48] was up and about the home and is paraplegic. MD1 was asked what his expectation was for repositioning R48. MD1 stated that R48 could move about in his wheelchair and would be able to move in his bed but needed to be checked on. MD1 stated R48 was somewhat non-compliant. MD1 stated it was his right to refuse treatment, and he did refuse. MD1 stated R48 should not need to be in the wheelchair more than two hours at a time. MD1 stated R48 should be encouraged to get off his pressure sore and he needed to be encouraged to be off his back in bed and off his buttocks. During a telephone interview on 02/19/25 at 3:52 PM, Wound Care Physician (MD)2 was asked about R48's pressure sore interventions. MD2 stated, To offload but [R48] was non-compliant and wet constantly. MD2 stated he wanted [R48] to stay off his bottom but doesn't. MD2 stated he has tried stem cell and ultrasound treatment. MD2 was informed staff were not aware of the 60-minute limit in the wheelchair. MD2 stated R48 was cognitive intact, and he knew the 60-minute limit in his wheelchair. MD2 was asked if he expected staff to read his recommendations in his notes. MD2 stated he I think so, I have them for a reason. On 02/19/25 at 10:21 AM to 4:19 PM, R48 was observed in his wheelchair, dressed, and groomed and wheeling himself about the facility.

Based on record review, interviews, and facility policy review, the facility failed to ensure a resident's wish for a Do Not Resuscitate (DNR) code status as specified in the resident's Physician Orders For Life-Sustaining Treatment (POLST, this is a Physician's Order guided by the patient's medical condition and based upon personal preferences verbalized to the physician or expressed in an Advanced Directive) was ordered and accurately documented in the resident's medical record for one of two residents (Resident (R) 54) reviewed for advanced directives in a total sample of 21 residents. This failure created the potential for residents not to have their wishes followed should they suffer a health emergency. Findings include: Review of the facility policy titled, Advanced Directives, revised on ,d+[DATE], indicated, Policy Statement Advanced directives will be respected in accordance with state law and facility policy. 1. Upon Admission, the resident will be provided with written information concerning the right to refuse or accept medical treatment and to formulate an advanced directive if he or she chooses to do so . 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advanced directive, the information may be provided to the resident's legal representative . 6. Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directives. 7. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record . 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive . 18. The interdisciplinary team will review annually with the resident his or her advanced directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument . 20. The director of nursing services or designee will notify the attending physician of advanced directives so that appropriate orders can be documented in the resident's medical record and plan of care. The attending physician will not be required to write orders for which he or she has an ethical or conscientious objection. Review of R54's Admission Record, located in the front of the resident's hard medical record/chart, revealed R54 was admitted to the facility on [DATE] with diagnoses that included dementia, schizophrenia, major depression, and bipolar disorder. The resident was listed as her own responsible party and under the Advanced Directive section CPR [Cardiopulmonary Resuscitation] was listed. Review of R54's Dashboard, located under the Dash tab in the electronic medical record (EMR), revealed the resident's code status was noted as CPR. Review of R54's current care plan, located under the Care Plan tab in the EMR and with a creation date of [DATE] and a most recent review date of [DATE], contained a Focus which specified, Resident has a Full Code Status. The care plan's Goal indicated, Request to be honored thru review date. Target Date: [DATE]. Care plan Interventions, specified, Full Code status, Notify MD [physician] and Family as needed, and transfer to ER [emergency room ] as needed. Review of R54's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] and located under the MDS tab in the resident's EMR, indicated R54 had a Brief Interview for Mental Status (BIMS) score of 08 out of fifteen, which indicated R54 had moderate cognitive impairment. Review of 54's POLST form, located under the Miscellaneous tab of the EMR, indicated the document was signed by the resident on [DATE] and signed by a physician on [DATE]. Under section A Code Status Cardiopulmonary Resuscitation (CPR)/Patient has no pulse and is not breathing Allow Natural Death (AND)- Do Not Attempt Resuscitation was checked. Review of R54's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], located under the MDS tab in the residents EMR, indicated, R54 had a Brief Interview for Mental Status (BIMS) score of 04 out of fifteen, which indicated R54 was cognitively impaired. Review of R54's February 2025 physician orders, located under the Orders tab of the EMR, revealed an order for Full Code with a start date of [DATE]. During an interview on [DATE] at 1:06 PM, Licensed Practical Nurse (LPN)2 was asked what she would do if R54 coded. LPN 2 stated she would check the resident's EMR to see what her code status was on her face sheet. LPN2 then checked the resident's EMR and stated R54 was a Full Code, so, if R54 coded she would initiate CPR by starting compressions on the resident and she would continue compressions until the emergency medical transport (EMT) staff arrived at the facility. During an interview on [DATE] at 1:15 PM, the Director of Nursing (DON) reviewed R54's EMR and stated the resident was noted as being a Full Code which was on the resident's home page, so if the resident coded the staff would initiate CPR. The DON then reviewed the resident's [DATE] POLST information and confirmed it specified the resident had chosen Allow Natural Death (AND)- Do Not Attempt Resuscitation. The DON confirmed the resident's specified wishes on the POLST form were different from what was on the resident's face sheet and as ordered by the physician. The DON stated the facility's Social Services Director (SSD) was responsible for processing changes in a resident's code status. During an interview on [DATE] at 1:40 PM, the SSD stated she worked at the facility as the SSD when R54 was admitted to the facility on [DATE]. The SSD stated when R54's POLST was signed by the MD on [DATE], the MD would have faxed her the POLST form to the facility and she was responsible for notifying the nursing staff of the resident's choosing to Allow Natural Death (ARD)- Do Not Attempt Resuscitation on her POLST form and the nursing staff was responsible for writing the DNR order. The SSD stated there was a failure to communicate the change in the resident's code status, so the resident's code status was not changed from a Full Code to a DNR on [DATE]. The SSD also confirmed R54's current care plan also incorrectly specified the resident was a Full Code. The SSD stated the care plan team was expected to review the resident's code states at each quarterly care plan meeting and correctly update the care plan when needed, but the interdisciplinary team (IDT) failed to update R54's care plan from a Full Code to a DNR when her code status was changed on [DATE]. During an interview on [DATE] at 2:50 PM, one of R54's family members (F)54 stated she would have been surprised if R54 did not want to be resuscitated. F54 stated she attended R54's care plan meeting in February 2024 and R54's code status was not discussed during this meeting. F54 stated if it had been discussed she would have asked R54 if she wanted to be a DNR and abided by the residents' wishes. During an interview on [DATE] at 5:02 PM, R54 stated when she was admitted to the facility she did not recall staff going over any regarding whether she wanted to be resuscitated if she was unable to breathe. When R54 was asked if she would want to be revived or resuscitated the resident stated, I do not know if I would. During an interview on [DATE] at 5:20 PM, the SSD stated she was involved with R54's admission on [DATE] and she went over the admission paperwork with the resident. The SSD stated there was no family involved or present when R54 was admitted . The SSD stated she recalled when she discussed the resident's code status with R54, the resident stated, When I am dead I am dead and chose to select DNR as her code status. The SSD stated when R54 was admitted on [DATE], she was her own responsible party and was more cognizant and more capable of making her preferences known than she is currently. During an interview on [DATE] at 6:00 PM, the MDS Coordinator (MDSC) stated when R54 was admitted to the facility on [DATE] she was assessed as having moderately impaired cognition. The MDSC stated the care plan team will go over a resident's code status during the resident's care plan meetings. The MDSC explained R54's care plan was inaccurate because it reflected the resident was a Full Code instead of a DNR. The MDSC stated, I do not know what to tell you. It just fell through the cracks regarding R54's care plan inaccurately specifying the resident was a Full Code since [DATE].

Based on interview, record review, and facility policy review, the facility failed to provide written notification of a facility-initiated transfer to the resident/responsible party (RP) for two of three residents (Resident (R) R7 and R41) reviewed for hospitalization. The failure had the potential to affect the residents and/or their representative concerning the resident's appeal rights. Findings include: Review of the facility's policy titled Transfer or Discharge, Facility-Initiated, dated 10/2022, revealed The resident and representative are notified in writing of the following information: .d. An explanation of the resident's rights to appeal the transfer or discharge to the state, including: (1) the name, address, email and telephone number of the entity which receives such appeal hearing requests; (2) information about how to obtain an appeal form; and (3) how to get assistance in completing and submitting the appeal hearing request; f. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; . 1. Review of R7's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 01/12/25, in the Electronic Medical Record (EMR) located in the MDS tab, revealed an admission date of 01/06/20. R7 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R7 was cognitively intact and had diagnoses of anxiety, depression, and schizophrenia. Review of R7's Behavior Note, dated 04/11/24, located in the EMR under the Progress Note tab revealed Resident walked to nurses' station and stated she busted her window out in her room with her table. Resident stated, the people on the 3rd floor keeps shaking my window, and I told them to stop but they wouldn't. Review of R7's Health Status note, dated 04/11/24 located in the EMR under the Progress Note tab revealed Resident transported via DON [Director of Nursing] and other staff member to [name] Hospital ER [emergency room] for labs [laboratory] to be admitted in Behavioral Health Center in [City, State]. RP [Responsible Party] is aware of transport. Review of R7's Assessment note, dated 04/18/24 located in the EMR under the Progress Note revealed . R7 was transferred to the hospital Sent To: [name] Behavior Unit Date: 4/11/2024 13:0 Sent From: [facility name] Unit: 2 Reason(s) for Transfer: Behavioral symptoms (e.g. agitation, psychosis). It was a Discharge. A Hospital Transfer Form (HTF) was completed in [EMR]. For further information please see the HTF. Review of R7's Hospital Transfer Form, dated 04/18/24, located in the EMR under the Assessment tab revealed no appeal information or that the resident/representative was provided with a written notice of transfer. The form included the Next of kin was telephoned with no telephone number listed. During an interview on 02/18/25 at 10:15 AM, the DON was asked about the R7's hospital transfer notice for 04/11/24. The DON stated notice of transfer was explained to the Resident Representative (RP). The DON stated a transfer form was in the EMR, but it did not include the appeals rights. The DON stated the notice was placed in the discharge packet to the hospital which was given to the EMT [emergency medical technician]. The DON stated the hospital staff would have given the notice to R7 but had no way of confirming it. On 02/19/25 at 4:20 PM, R7 was awake and dressed while lying in her bed. R7 was asked when she went to the hospital last year, did she receive any paperwork about her transfer. R7 stated she did not get any papers. 2. Review of R41's quarterly MDS with an ARD date of 12/02/24, in the EMR located in the MDS tab, revealed an admission date of 06/09/21, had no BIMS score and was severely impaired. R41 had diagnoses of cancer, Down syndrome, and anxiety. Review of R41's Health Status note, dated 05/16/24, located in the EMR under the Progress Note tab revealed During morning medication pass with writer observed resident in bed, noted cough with congestion, skin cool to touch, resident refused morning meal. V/S [vital signs] obtain BP [blood pressure]- 64/6, P [pulse]-76, R [respiration]-24, T [temperature]-98.0, 02 [oxygen] level 80% room air. [name] NP in facility, new order to apply 02 and to send resident out for eval [evaluation] obtain verbally. @ [at] 9:05 am 911 called and report giving for transport. @9:15am EMT in facility to transport resident via stretcher to [hospital] General. Bed hold policy and medication list, with face sheet given to EMT on arrival. This writer called and gave report to ER nurse at [hospital] General. RP [responsible party] was called and given detail on resident's condition and new orders. Review of R41's Health Status note, dated 05/16/24, located in the EMR under the Progress Note tab revealed Resident was also noted to have discoloration with small open area to left forehead. No bleeding noted. When asked what happened [the] resident stated, leave me alone [the] roommate stated [the] resident fell, got up, and went back to bed. [The] Nurse practitioner in facility and made aware. RP notified. Review of R41's Health Status note, dated 05/16/24, located in the EMR under the Progress Note tab revealed This writer spoke with [name] RN at [hospital] ER [emergency room] in [City, State]. Report was given that resident was transferred to [hospital] in [City, State] to ER for admission with DX [diagnosis]: Pneumonia and Septic, resident's RP made aware. Review of 41's hospital transfer form, dated 05/23/24, located in the EMR under the Assessment tab revealed no appeal information or that the resident/representative was provided with a written notice of transfer. The form included the Next of kin was telephoned. During an interview on 02/18/25 at 10:15 AM, the DON asked about R41's hospital transfer notice for 05/16/24. The DON stated notice of transfer was explained to the RP. The DON stated a transfer form was in the EMR but it didn't included the appeals rights. The DON stated the notice was placed in the discharge packet to the hospital which was given to the EMT. The DON stated the hospital staff would have given the notice to the RP but had no way of confirming it. During an interview on 02/18/25 at 10:35 AM, the Social Service Director (SSD) confirmed she sends the ombudsman monthly notice of transfers/discharges. However, a written transfer form that included the time, location, reason for the discharge/transfer and the appeal rights was not given to residents or their RP when transferred to the hospital.

Based on observation, interview, record review, and policy review, the facility failed to implement the comprehensive plan of care for one resident ((R) 29) of three residents reviewed for nutrition out of 21 sampled residents. The facility's failure to assist R29 with meals as indicated in the resident's plan of care placed R29 at risk for weight loss and nutritional complications. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised on 03/2022, indicated, Policy Statement A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and nutritional needs is developed and implemented for each resident. Policy interpretation and Implementation 1. The interdisciplinary team (IDT) in conjunction with the resident and his/her family of legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Review of R29's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R29 was admitted to the facility on [DATE] with diagnoses which included psychosis, Alzheimer's disease, other specified eating disorder, and anxiety disorder. Review of R29's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/27/24 and located in the MDS tab of the EMR, revealed R29 had severely impaired cognitive skills for daily decision making, had short term and long-term memory impairment, and required set up or clean up assistance with eating. Review of R29's care plan dated 11/30/24, located in the Care Plan tab of the EMR, revealed a focus of Resident requires assistance with ADLs [Activities of Daily Living] related to impaired cognition. Resident is able to make her simple needs known at times, but her needs are predominantly anticipated and met per staff. Resident uses a wheelchair for locomotion. An Intervention directed staff to, Setup tray and assist resident as needed with meals. Observation on 02/16/25 at 12:58 PM revealed R29 was seated in her wheelchair at a table in the facility's assisted dining room eating her lunch meal with no staff at her table. Observation of the resident's meal tray revealed she was served a chopped fish sandwich, green beans, and French fries. Chewed foods were observed next to the resident's plate, on the table, and on the floor next to the resident. Continuous observations of R29 from 12:58 PM to 1:13 PM revealed R29 remained seated at the dining room table, and she used her fingers to bring food from her plate to her mouth. R29 was observed to place food in her mouth, chew it up, and throw it back onto her plate, onto the table next to her plate, or onto the floor. R29 was observed to repeatedly use her fingers to pick up food from her plate and table that she had previously chewed and spit out, place it back into her mouth, spit the food back into her fingers, and throw it back onto her plate, table or floor. During this continuous observation, a staff member was observed in the dining room seated at a table assisting another resident to eat, but this staff member, nor any other staff member, did not offer to assist R29 with her meal. On 02/16/24 at 1:13 PM staff was observed to roll R29 in her wheelchair from the dining room. Observation on 02/16/24 at 1:13 PM of the R29's finished lunch meal revealed there was a large accumulation of chewed up green beans, pieces of fish, French fries, and bun on the resident's plate, table and on the floor around her table. During an observation and interview on 02/16/25 at 1:15 PM, the Administrator confirmed the large amount of food spillage on the table and floor around where R29 ate her lunch meal. The Administrator stated R29 preferred to eat her meals with her fingers instead of using utensils. During an interview on 02/19/25 at 2:25 PM, the Regional Director (RDG) confirmed R29's care plan specified for staff to assist her at meals.

Based on interview, record review, and review of the facility's policy, the facility failed to review and revise the care plan for one of two residents reviewed for care plans (Resident (R) 48). R48's care plan was not revised to reflect repositioning and/or limiting the resident's time in her wheelchair per the physician's order. This failure placed the resident at risk for unmet care needs and worsening of a pressure ulcer. Findings include: Review of R48's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 11/13/24, located in the EMR under the MDS tab revealed an admitted [DATE]. R48 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R48 was cognitively intact. Continued review of the MDS revealed the facility assessed the resident to have impairment on both sides of the lower extremities, required supervision or touching assistance to roll left and right, required substantial/maximal assistance for chair/bed-to-chair transfer, always incontinent of bowel and bladder, had a stage four pressures ulcer, and had diagnoses of type 2 diabetes mellitus without complications, peripheral vascular disease, and a fracture of the tibia or fibula in the left leg after an orthopedic implant is inserted. Review of R48's Skin/Wound note, dated 08/27/24, located in the EMR under the Progress Note tab revealed [ Medical Doctor (MD) 1] in [the] facility and eval [evaluate] wounds, new order as following: .Wound to upper right buttocks, clean with wound cleanser, pat dry, apply medi honey to area, cover with island dressing secure with tape, change daily and as needed until resolved. Measurements: 5.2 x 4 x 0.2cm area is unstageable due to necrosis, resident is aware of new orders and measurements. Review of R48's Care Plan, dated 08/27/24 and located in the EMR under the Care Plan tab revealed Resident has potential/actual impairment to skin integrity r/t [related to] incontinence and impaired mobility. Interventions included In house wound care MD to follow weekly until healed, enablers placed on both sides of bed to assist with turning and repositioning, supplements per MD orders and Res. [resident] refused wound care Encouraged to allow nurse to change dressing. The care plan did not address repositioning or limiting time in the wheelchair. Review of R48's Wound Physician notes, dated 02/11/24, located in the EMR under the Miscellaneous tab revealed stage 4 pressure wound of the right buttock full thickness, wound size (L [length] x W [width] x D [depth]): 3.2 x 5.5 x 0.2 cm, Exudate: light serous, granulation tissue: 40 %, recommendations: Limit sitting to 60 minutes; Off-Load Wound; Reposition per facility protocol. Review of R48's Kardex [system for organizing information], dated as of 02/19/25, located in the EMR under the Care Plan tab did not include positioning or limiting time in the wheelchair to 60 minutes. During an interview on 02/19/25 at 3:13 PM, the MDS Coordinator (MDSC) was asked who was responsible for updating R48's care plan. The MDSC stated was. The MDSC stated she obtained her information to update the care plan by reviewing notes, talking with staff and the Director of Nursing (DON) reviewing physician notes. The MDSC was asked why the care plan and Kardex didn't include repositioning. The MDSC stated she didn't know as the Kardex was automatically generated. The MDSC was asked why the Kardex or care plan did not include the 60-minute time limit for R48 to be in his wheelchair according to the wound doctor's recommendations. The MDSC stated she was not aware of the 60 minutes limit.

Based on observation, interview, record review, and facility policy review, the facility failed to provide eating assistance for one of three residents (Resident (R) 29) reviewed for nutrition out of 21 sampled residents. This failure had the potential to cause weight loss and/or nutritional complications for this resident. Findings include: Review of the facility's policy titled, Assistance with Meals, revised on 03/2022, indicated, Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident . Dining Room Residents: . 2. Facility staff will serve resident trays and will help residents who require assistance with eating . Review of R29's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R29 was admitted to the facility on [DATE] with diagnoses which included psychosis, Alzheimer's Disease, other specified eating disorder, and anxiety disorder. Review of R29's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/27/24 and located in the MDS tab of the EMR, revealed R29 had severely impaired cognitive skills for daily decision making, had short term and long-term memory impairment, and required set up or clean up assistance with eating. Review of R29's care plan dated 11/30/24, located in the Care Plan tab of the EMR, revealed a focus of Resident requires assistance with ADLs [Activities of Daily Living] related to impaired cognition. Resident is able to make her simple needs known at times, but her needs are predominantly anticipated and met per staff. Resident uses a wheelchair for locomotion. A care plan Intervention directed staff to Setup tray and assist resident as needed with meals. Observation on 02/16/25 at 12:58 PM revealed R29 was seated in her wheelchair at a table in the facility's assisted dining room eating her lunch meal with no staff at her table. Observation of the resident's meal tray revealed she was served a chopped fish sandwich, green beans, and French fries. Chewed foods were observed next to the resident's plate, on the table, and on the floor next to the resident. Continuous observations of R29 from 12:58 PM to 1:13 PM revealed R29 remained seated at the dining room table, and she used her fingers to bring food from her plate to her mouth. R29 was observed to place food in her mouth, chew it up, and throw it back onto her plate, onto the table next to her plate, or onto the floor. R29 was observed to repeatedly use her fingers to pick up food from her plate and table that she had previously chewed and spit out, place it back into her mouth, spit the food back into her fingers and throw it back onto her plate, table, or floor. During this continuous observation, a staff member was observed in the dining room seated at a table assisting another resident to eat, but this staff member, or any other staff member, did not offer to assist R29 with her meal. On 02/16/24 at 1:13 PM staff was observed to roll R29 in her wheel chair from the dining room. Observation on 02/16/24 at 1:13 PM of the R29's finished lunch meal revealed there was a large accumulation of chewed up green beans, pieces of fish, French fries, and bun on the resident's plate, table, and on the floor around her table. During an observation and interview on 02/16/25 at 1:15 PM, the Administrator confirmed the large amount of food spillage on the table and floor around where R29 ate her lunch meal. The Administrator stated R29 preferred to eat her meals with her fingers instead of using utensils. Observation on 02/18/25 at 12:46 PM revealed R29 was seated at a dining room table being assisted by Certified Nurse Aide (CNA)1 to eat her lunch meal. Continuous observations on 02/18/25 from 12:46 PM to 1:03 PM revealed CNA1 assisted and prompted R29 to eat her lunch meal and redirected R29 when she used her fingers to eat food and spit them out. R29 was observed to readily accept the assistance provided by CNA1 during this meal. Observation on 02/18/25 at 1:03 PM revealed CNA1 assisted R29 from the dining room. Observation of R29's finished lunch meal revealed there was minimal food spillage which included only five partially chewed lima beans that were on the table where R29 ate her lunch meal. During an interview on 02/18/25 at 1:23 PM, CNA1 stated R29 needed staff assistance and redirection to eat her meals. CNA1 stated R29 would accept food and fluids when offered by staff at meals. During an interview on 02/18/25 at 1:32 PM, the Director of Nursing (DON) stated that R29 would eat food and spit it out at meals, and she required staff assistance with cueing and redirection at meals. The DON stated a staff member should be with R29 to assist her at meals and confirmed that during the 02/16/25 lunch meal R29 should have received staff assistance.

Based on interview and record review, the facility failed to report abnormal blood sugar levels to the physician for one of two residents reviewed for laboratory services (Resident (R)32). This deficient practice could lead to serious health complications for R32 such as nerve damage, kidney disease, vision problems, heart disease, and even diabetic coma. Findings include: Review of the facility policy titled Obtaining a Fingerstick Glucose Level, dated 10/11, provided by the facility, revealed 1. Report results promptly to the supervisor and the Attending Physician. Review of the facility policy titled Lab and Diagnostic Test Results- Clinical Protocol, revised 11/18, provided by the facility revealed 3. A nurse will identify the urgency of communicating with the Attending Physician based on the physician request, the seriousness of any abnormality, and the individual's current condition. 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the physician has requested to be notified as soon as a result is received. Whether the results should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). Review of R32's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/24 and located in the resident's Electronic Medical Record (EMR) under the MDS tab, revealed an admitted [DATE]. R32 had a Brief Interview for Mental Status (BIMS) score of nine out of 15 indicating R32's cognition was moderately impaired. The MDS also indicated the resident received insulin, and had diagnoses of type 2 diabetes mellitus with other specified complication and dementia. Review of R32's Care Plan, undated, located in the EMR under the Care Plan tab revealed Resident is at risk for alterations in FSBS [finger-stick blood sugar] due to DX [diagnosis] of DM [diabetes mellitus]. Resident is noncompliant with diet. Interventions included FSBS as indicated, medications as ordered, and notify MD [physician] as needed. Review of R32's Physician Order, dated 08/09/22, located in the EMR under the Order tab revealed Check blood sugar BID [twice daily] & as needed two times a day for DM and Notify MD for blood sugar less than 60 or greater than 500. Review of R32's Physician's Order, dated 10/29/23, located in the EMR under the Order tab revealed Gvoke Kit Subcutaneous Solution 1 MG [milligram]/0.2ML [milliliter] (Glucagon) Inject 1 mg subcutaneously every 6 hours as needed for Give for BS [blood sugar] 60 or less related to type 2 diabetes mellitus with other specified complication. Review of R32's Blood Sugar located in the EMR under the Weights & Vitals tab revealed R32's blood sugar was measured on 09/22/24 at 50.0 mg/dL[milligrams per deciliter], on 10/12/24 at 46.0 mg/dL, on 10/22/24 at 46.0 mg/dL, and on 02/11/24 at 561.0 mg/dL. Review of R32's Progress Notes, located in the EMR under the Progress Note tab revealed on 09/22/24, 10/12/24, 10/22/24, and 02/11/25, there was no entry or documentation notifying the physician of the abnormal blood sugar levels, whether R32 was displaying signs/symptoms of hyperglycemia/hypoglycemia, or if treatment was provided. Review of R32's September and October 2024 Medication Administration Record (MAR) located in the EMR under the Order tab revealed Glucagon was not administered on 09/22/24 for a blood sugar of 50.0 mg/dL, on 10/12/24 for blood sugar of 46.0 mg/dL, and on 10/22/24 for a blood sugar of 46.0 mg/dL. During an interview on 02/17/25 at 1:08 PM, the Director of Nursing (DON) was asked if the physician should have been notified for the blood sugar of 561 on 02/11/25. The DON checked the EMR and confirmed there was no note the physician was notified. The DON then stated, Yes, the doctor was most likely called. The DON went on to say Medical Director usually wants to know if R32 was symptomatic and R32 wasn't. Otherwise, it would be documented that the Medical Director was called. DON confirmed there was no documentation of signs/symptoms or that the physician was call/notified. During an interview on 02/18/25 at 8:36 AM, the DON was asked about the September and October 2024 MAR for R32's blood sugar. The DON acknowledged the nurse didn't document her interventions for the low blood sugars of 46 and 50.0 mg/dL. The DON reviewed the EMR and confirmed the glucagon should have been documented as given and acknowledged it wasn't. The DON was asked if the nurse didn't document the glucagon, how do you know the physician was notify of the abnormal BS. The DON stated, The nurse said she gave a snack but again it wasn't documented. The DON stated, The nurse called the physician, but she didn't document it. The DON was asked if the blood sugar was out of range, should the nurse have rechecked it. The DON said, Yes. The DON stated the nurse said she documented the blood sugar of 561 in error. During a telephone interview on 02/19/25 at 2:39 PM, LPN3 was asked about R32's blood sugar of 561 on 02/11/25. LPN3 stated she thought she tapped it in wrong as R32 doesn't normally get up that high. LPN3 was asked about the low blood sugars on 9/22/24 and 10/12/24. LPN3 stated she would have contacted the physician, but she forgot to document it. LPN3 was asked why the glucagon order wasn't utilized as there was no document in the September and October 2024 MAR. LPN3 stated because she gave R32 orange juice and chocolate pudding. LPN was asked if she rechecked R32's blood sugar after the orange juice and pudding. LPN3 stated, Yes, but she did not document it. LPN3 was asked when she would utilize the glucagon order if she gave food and beverage first. LPN3 stated, If the orange juice didn't work. During a telephone interview on 02/19/25 at 3:43 PM, MD1 was asked what his expectation was when R32's blood sugar was out of range and was he notified about R32's recent blood sugars. Medical Director stated staff should notify him and they have been good about that. The Medical Director stated he had only been the Medical Director since November 2024 and would have to review his notes. The Medical Director stated staff should document the physician had been notified.

Based on observation, interview, and record review, the facility failed to accurately document in the medical record that insulin was not administered when blood sugars were 250 ml/dl (milligrams per deciliter) or less for one (Resident (R)32) of one resident reviewed for resident records. The failure had the potential to result in overlooking proper care and diabetic complications. Findings include: Review of the facility policy titled Charting and Documentation, dated 07/2017, provided by the facility revealed All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. l. Documentation in the medical record may be electronic, manual or a combination 2. The following information is be documented in the resident medical record: Objective observations; Medications administered; Treatments or services performed; Changes in the resident's condition; . Review of the facility's policy titled Obtaining a Fingerstick Glucose Level, dated 10/2011, provided by the facility, revealed The person performing this procedure should record the following information in the resident's medical record: . 6. The blood sugar results. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage and/or physician intervention is needed to adjust insulin or medication dosages), etc. Review of R32's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 11/03/24, in the Electronic Medical Record (EMR) under the MDS tab revealed an admitted [DATE]. R32 had a Brief Interview for Mental Status (BIMS) score of nine out of 15 indicating R32's cognition was moderately impaired. The MDS also indicated the resident received insulin, and had diagnoses of type 2 diabetes mellitus with other specified complication and dementia. Review of R32's Physician Order, dated 07/26/24, located in the EMR under the Order tab revealed Novolog Injection Solution 100 unit/ml [millimeter] (Insulin Aspart) Inject 10 unit subcutaneously in the morning for uncontrolled blood sugar related to type 2 diabetes mellitus with other specified complication (E11.69) Hold insulin if blood sugar is 250 or below. Review of R32's Care Plan, undated, located in the EMR under the Care Plan tab revealed Resident is at risk for alterations in FSBS [finger-stick blood sugar] due to DX [diagnosis] of DM [diabetes mellitus]. Resident is noncompliant with diet. Interventions included FSBS as indicated, medications as ordered, and notify MD [physician] as needed. Review of R32's January and February 2025 Medication Administration Record (MAR) located in the EMR under the Order tab revealed an order to hold the Novolog insulin if R32's blood sugar (BS) was 250 or below. Check marks were present that indicated 10 units was administered on 01/02/25 with a BS of 147, 01/05/25 with a BS of 116, on 01/08/25 with a BS of 121, 01/16/25 with a BS of 225, 01/18/25 with a BS of 162, 01/25/25 with a BS of 136, 01/27/25 with a BS of 168, on 02/01/25 with a BS of 196, on 02/08/25 with a BS of NA [not applicable], and on 02/13/25 with a BS of 102. During an interview and record review on 02/17/25 at 3:32 PM, Licensed Practical Nurse (LPN) 4 was asked if a check mark was present on the MAR for R32's Novolog insulin, did that indicate the insulin was administered. LPN4 stated she was not sure because the insulin should not be administered if his BS was 250 or below. LPN4 was shown the January 2025 MAR and that she had coded the 01/27/25 MAR with a check mark when the BS was 168. LPN4 reviewed the MAR ledger, and the check mark indicated the medication was administered. LPN4 was then asked if the check mark meant she administered the insulin. LPN4 stated she wasn't sure about the meaning of the check mark, but she did not administer the Novolog insulin, and the Director of Nursing (DON) would need to be asked about the codes. During an interview on 02/17/25 at 4:56 PM, the DON was asked about the February 2025 MAR that included check marks on 02/01/25, 02/02/25, 02/08/25, and 02/13/25, indicating Novolog was given and X marks on 02/15/25 and 02/16/25, in the spaces for BS. The DON stated the nurse probably checked it by mistake. The DON was asked if mistakes should occur multiple times. The DON had no comment. The DON was also asked about the X marks in the space instead of BS. The DON stated the check and X marks meant the BS was done. The DON was asked if the insulin was administered at these times that were checked. The DON stated, No but understands how it looks unclear. During an interview on 02/17/25 at 6:03 PM, the DON provided a detailed printout of the insulin administration for January and February 2025. The DON was asked about the 0coding that indicated 10 units of Novolog insulin were administered for blood sugars less than 250 for the days of 01/05/25, 01/08/25, 01/16/25, 01/18/25, 01/25/25, 01/27/25, 02/01/25, 02/02/25, 02/08/25, and 02/13/25. DON stated she did the blood sugar on 02/13/25 and she documented the wrong code indicating she administered insulin but she in fact did not. The DON was asked about the other days. DON stated, I can't dispute that it appears it was administered but it wasn't. During a follow up interview on 02/18/25 at 8:36 AM, the DON provided more clarification on the check marks on the January and February 2025 MAR. The DON stated the nurse checked, Yes, in the drop-down box so as to say, I see the order. The DON stated, there is confusion among the staff with the [EMR program] and they don't know what the 'yes or no' means. During an interview on 02/18/25 at 8:53 AM, LPN1 was asked about R32's morning order for Novolog and to hold if the BS was below 250. LPN1 was asked about the N/A [not applicable] she documented instead of listing a BS on 02/08/25 MAR and documented a check mark indicating 10 units of insulin was given. LPN1 reviewed the EMR and stated she used N/A because she didn't give the insulin. LPN1 stated she documented for the injection location/site also as N/A because she didn't give it. LPN1 then crossed checked the BS for 02/08/25 and confirmed it was 92 and she didn't give the insulin. LPN1 dropped down the menu in the EMR and confirmed there was confusion as how to code the MAR. During a telephone interview on 02/19/25 at 3:43 PM, the Medical Director stated he had only been the Medical Director since November 2024. The Medical Director was asked about his expectation in documenting in the EMR for R32's morning insulin order. The Medical Director stated if the order says to give the insulin, it should be documented according to the order.

Based on observation, interview, and record review, the facility failed to include in the binding arbitration agreement that it was not a requirement to sign the agreement to continue to receive care at the facility and be allowed to communicate with federal, state, local officials and the ombudsman for two of three residents (Resident (R)32 and R42) reviewed for arbitration out of 21 sampled residents. This placed residents at risk of unknowingly giving up their constitutional rights. Findings include: Review of the facility's arbitration agreement, undated, provided by the facility revealed no statement that it was not a requirement to sign the agreement to continue to receive care at the facility and residents and their representatives were allowed to communicate with federal, state, local officials and the ombudsman. 1. Review of R32's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 11/03/24, in the Electronic Medical Record (EMR) located in the MDS tab, revealed an admitted [DATE]. Review of R32's Binding Arbitration Agreement, provided by the facility, revealed R32's name and signature, dated 08/09/22. R32's arbitration agreement did not include in the agreement that it was not required to receive care by the facility and the resident, or their representative were allowed to communicate with federal, state, local officials, and the ombudsman. 2. Review of R42's quarterly MDS with an ARD date of 12/18/24, located in the MDS tab of the EMR, revealed an admitted [DATE]. Review of R42's Binding Arbitration Agreement, provided by the facility, revealed R42's name and signature, dated 09/07/22. R42's arbitration agreement did not include in the agreement that it was not required to receive care by the facility and the resident, or their representative were allowed to communicate with federal, state, local officials and the ombudsman. During an interview on 02/19/25 at 8:34 AM, the SSD stated she was aware of the items included in the agreement and explained the agreement as written. The SSD stated she had not received any education regarding the regulatory requirements related to arbitration agreements.

Based on staff interviews, record reviews, and a review of the facility's policies titled Abuse Prevention Policy & Procedure and Identifying Sexual Abuse and Capacity to Consent policy, the facility failed to protect Resident (R) 4's right to be free from sexual abuse by R5. The facility sample size was 21. On 8/8/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Minimum Data Set (MDS) Nurse, and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 8/8/2024 at 11:25 am. The noncompliance related to the IJ was identified to have existed on 7/7/2024. An Acceptable IJ Removal Plan was received on 8/15/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 8/12/2024. Findings include: The facility had an Abuse Prevention Policy & Procedure, with revision date of 2/26/2019. The policy included a definition of sexual abuse as any abuse that is of a sexual nature, including harassment, coercion or assault. The facility had an Identifying Sexual Abuse and Capacity to Consent policy, dated September 2022. The policy's statement documented that a resident's consent to sexual activity is not valid if obtained from a resident who lacks the capacity to consent, or if consent was obtained through intimidation, fear or coercion. Review of R4's clinical record revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Alzheimer's Disease, unspecified psychosis, and anxiety disorder. Review of the 6/17/2024 Brief Interview for Mental Status (BIMS) form revealed that R4 was assessed as having cognitive impairment, with a score of 0 out of 15, indicating severe cognitive impairment. Review of a 3/12/2024 social services quarterly review note revealed that R4 was alert with marked confusion and oriented to person only. The note also documented that R4 required assistance with activities of daily living (ADLs) and used a wheelchair for mobility. Review of R5's clinical record revealed that he was admitted to the facility on [DATE] had diagnoses that included, but were not limited to, hypertension, chronic obstructive pulmonary disease, bipolar disorder, and generalized anxiety disorder. Review of a 7/1/2024 social services quarterly review note revealed that R5 was alert and oriented x2, with a BIMS score of 13 (out of 15). The note further documented that R5 had no behaviors (during the review period), was supervised with ADLs and independent with ambulation. Review of a 7/8/2024 BIMS form revealed that R5 scored a 14 out of 15 on the cognitive assessment, indicating he was cognitively intact. Further review of R4's clinical record revealed a 7/7/2024 Medication Administration Note, made by Licensed Practical Nurse (LPN) DD, that documented R4 was observed in the dining area by a staff member having inappropriate sexual behavior with another resident. Further review of 5's clinical record revealed a 7/7/2024 Medication Administration Note, made by LPN DD, that documented R5 was observed in the dining area before breakfast by a staff member having inappropriate sexual behavior. A 7/7/2024 Behavior Note, made by the Director of Nursing (DON), documented that R5 was observed by LPN BB in the dining room involved in inappropriate sexual behavior with another resident. The note also included that LPN BB asked R5 what he was doing, and he stated nothing and went to sit down. LPN BB notified the DON. During an interview on 7/17/2024 at 2:05 pm, LPN BB recalled the incident that occurred between R4 and R5 on 7/7/2024. LPN BB stated that she was walking up the hallway and observed R5 on the left side of the dining room, and he is normally on the right side of the dining room. R5 was standing up close to R4's wheelchair, and LPN BB stepped in to get a closer look. R5's shirt was out of his pajama pants, and his penis was exposed. R5 pushed R4's head twice onto his penis. LPN BB stated she became really stern and called out R5's name and yelled What are you doing? You know you can't do that. R5 immediately stepped away (from R4) and said he was not doing anything. LPN BB stated she told LPN DD what had happened. LPN BB stated that R4 and R5 were LPN DD's residents that day. LPN BB stated that while LPN DD called the Administrator, she made sure the residents were separated. LPN BB stated that she also called the DON on 7/7/2024 and reported the incident to her, and also notified the physician. LPN BB stated she asked R5 if he knew what he had done was wrong and he said he did not remember. During a phone interview on 7/23/2024 at 11:18 am, LPN DD recalled the events of 7/7/2024. LPN DD stated that she did not witness the incident between R4 and R5, that she was at her medication cart getting it ready. She heard LPN BB say something like stop that and then LPN BB walked up to her and told her what had happened (between R4 and R5). LPN DD confirmed that she notified the Administrator and that he came to the facility. LPN DD also stated that she checked both residents out and that R4 remained in the dining room, and R5 was redirected back to his room. Following the 7/7/2024 sexual abuse occurrence, further review of R5's clinical record, including physician's orders, Medication Administration Records (MARs), and behavioral health notes revealed that R5 was started on Zoloft 50 milligrams (mg), one and a half tablets daily for hypersexuality, on 7/9/2024. The behavioral health Nurse Practitioner (NP) also visited on 7/9/2024 and assessed and counseled R5 on his behavior. Further review of R5's clinical record also revealed that the behavioral health NP assessed R4 on 7/9/2024 with no changes in mood or behavior noted at that time. During an interview on 8/8/2024 at 4:20 pm, the behavioral health NP confirmed that she saw R4 and R5 on 7/9/2024. She stated that R5 had no history of sexual behaviors prior. The facility implemented the following actions to remove the IJ: 1. Resident 5 put on one-on-one monitoring on 8/8/2024 to monitor behaviors. Resident 4 was moved to another room and the opposite hall away from Resident 5 on 7/26/2024. All Residents including R4 and R5 were assessed by the Medical Director's Nurse Practitioner on 8/8/2024. No negative outcomes were noted. Residents R4 and R5 were given a head-to-toe skin assessment on 8/8/2024 by nursing staff. The head-to-toe assessment revealed that R4 and R5 had no bruising, or signs of abuse. This was to ensure that no harm to the residents had occurred. Both R4 and R5 had been on behavior monitoring every shift since 6/2024. Mental Health services evaluated R4 and R5 on 7/9/2024 with no negative outcomes noted. Secondary to the mental health evaluation a pharmacological intervention, Zoloft 75mg daily was ordered for R5 on 7/8/2024. 2. The Social Worker provided Inservice on 8/8/2024 to 35 cognitively intact residents (Brief interview of Mental Statue (BIMS) score of 9 and above) including R5 that no one should touch others in any sexual manner without their permission. The Inservice also informed residents that if anyone makes you feel uncomfortable with unwanted touch report to any staff immediately. The Social Worker provided education on 8/8/2024 to all cognitively intact residents (Brief interview of Mental Statue (BIMS) score of 9 and above) that the facility Abuse Coordinator is the Administrator. The residents were also educated on the location of the bulletin boards where contact information is posted, which included: Facilities Abuse Coordinator, State Survey Agency, Local Police, State Ombudsman, and Adult Protective Service. A copy of all the facility policies titled Abuse and Neglect and Residents Rights was given to all cognitively intact residents. The resident's education included that no abuse of any kind would be acceptable. Residents are educated to tell staff immediately about abuse or neglect including mistreatment, exploitation, misappropriation of property, injury of unknown origin, resident to resident altercation, and suspicions of crime affecting them or other residents. On 8/8/2024 through 8/9/2024, the Social Worker, Registered Nurse (RN), Licensed Practical Nurse (LPN), interviewed all cognitively intact residents regarding abuse. The interview questions included: are you afraid to stay at this facility, if so, why? Do you feel safe here at the facility? Do you know who tell if someone scares you? Has anyone hurt you at this facility? The findings showed all cognitively intact residents felt free from abuse of any kind. On 8/8/2024 the Social Worker and Administrator interviewed all cognitive intact residents. The interview question consists of: Has anyone ever hurt you? Or have you ever seen anyone hurt someone else in the facility? Who would you tell if you saw someone hurting another resident or yourself? When would you tell if you saw someone hurting another resident or yourself? These interviews were given to reinforce with residents when to report allegations of abuse. What to report, who to report to and how to report. The facility has 25 cognitively impaired Residents with a Brief interview Mental Status (BIMS) score of below 9. On 8/8/2024 LPN nurse performed a head-to-toe assessment to assess for signs of abuse or neglect. No signs of abuse of any kind were observed. In addition, the Social Worker assessed (which included visual observation for negative facial expression, review of medical records for changes in behaviors, along with verbal conversation with each resident). The observation findings were that 25 of 25 cognitively impaired residents had no change in mood. The residents did not have negative facial expressions, or behaviors. On 8/9/2024 the business Officer Manager mailed 36 of 36 responsible parties and or guardian a copy of the facility policies titled Abused and Neglect and Resident Rights, In addition the responsible party or guardian were also provided a copy of the contact information for the facility Abuse Coordinator (Administrator), State Ombudsman, Adult Protective Services, Local Police, and State Survey Agency. On 8/9/2024 the Business Manager called the 36 responsible parties or guardian to inform them that they will receive the Policies mailed regarding Abuse and Neglect along with contact information for who to report abuse of any kind to. The responsible party or guardian were asked if they had any questions regarding Abuse of any kind, such as who to contact, how to contact, what to report. And when to report abuse. On 8/9/2024, Medical Records provided the 9 residents that are their own responsible party with a copy of the facility policies, Abuse and Neglect and Resident Rights. Each of the residents were educated and shown the location of the bulletin boards that have the contact information for the facility. Abuse Coordinator (Administrator), State Ombudsman, Adult Protective Services, Local Police. And State Survey Agency. The residents were questioned to confirm their understanding regarding Abuse and Neglect, location of contact information, who to contact, how to contact, and what abuse and neglect is, including abuse of any kind of other residents. On 8/9/2024, The Social Worker and Activity Director held an additional Residents Council meeting to reinforce the education, that Abuse of any kind including sexual, mistreatment, exploitation, misappropriation of property. Injury of unknown origin. Resident to resident altercation, and suspicions of crime. The education also included that the facility abuse coordinator is the Administrator and that the contact numbers the Administrator, State Survey Agency, Adult Protective Agency, Local Police, and State Ombudsman is located on the 300-hall dining room bulletin board and the bulletin board across from the front office. The Resident were educated to not only report allegations of abuse that occurs to them, but also to report allegation abuse to other resident, The resident was educated to immediately report abuse to Administrator, State Survey Agency, Adult Protective Agency, Local Police, and State Ombudsman. 3. The Administrator was educated by The Regional Director of operation on 8/8/2024 On Recognizing Signs and Symptoms of Abuse, including sexual exploitation and rape. Education on Abuse includes Mental, Physical, and sexual, and verbal abuse. He was also educated on Abuse Policy and Procedures. The Education on Abuse included Sexual abuse, Physical Abuse, and Verbal abuse. The administration was also educated that Allegation of any kind of sexual abuse, Injury of unknown Injury, Resident Falls with severe injury, Resident with missing money. The administrator was also educated that a full investigation must begin immediately after receiving knowledge of the incident. If the allegation is against employee-suspend immediately pending investigation. If resident to resident allegation, immediately separate residents. Obtain statements from all employees in facility at time of incident and 24 hours. The Administrator was also Inservice by the Chief Operating Officer on 8/8/2024 on Allegation of any kind of sexual abuse, Injury of unknown Injury, Resident Falls with severe injury, Resident with missing money. The administrator was also educated that a full investigation must begin immediately after receiving knowledge of the incident. If the allegation is against employee-suspend immediately pending investigation. If resident to resident allegation, immediately separate residents. Obtain statements from all employees in the facility at time of incident and 24 hours. the Chief Operating Officer also educated the Administrator on all residents must be free of Abuse of any kind. All residents with abusive behaviors, including physical, sexual, or verbal must have interventions implemented, all care plans must be reviewed to ensure appropriate intervention were updated, effectiveness of care plans for recognition of instances of abuse, as well as receive appropriate treatment and/or services, including. intervention was updated, effectiveness of care plans for recognition of instances of abuse, as well as receive appropriate treatment and/or services. The Administrator educated staff on 8/8/2024 - 8/9/2024 on the following education: that abuse, and neglect includes mistreatment, exploitation, misappropriation of property, injury of unknown origin, resident to resident altercation, suspicions of crime including sexual and physical abuse. The Staff were educated on recognizing and identifying abuse and neglect, The Staff was educated that the facility Abuse coordinator is the Administrator and all allegation of abuse must be reported immediately to Administrator. The following staff received this education: 1of 1 Director of Nursing, 1of 1 Social Worker, 1of 1 Maintenance Director, 2 of 2 Activity Directors, 8 of 8 Registered Nurses, 9 of 10 Licensed Practical Nurses, 27 of 27 Certified Nurse Assistants, 9 of 9 housekeeping staff, 11 of 12 Dietary Staff, 1 of 1 Business Office Manager, and 6 of 6 Therapists. The staff not present will be educated prior to returning to work by the Director of Nursing. No staff will be allowed to work until educated. As of 8/11/2024 no new staff hired. On 8/10/2024 the staff was given a screen test on sexual abuse to test knowledge of sexual abuse protocol. 76 of 78 staff (totaling 98%) were educated on abuse. 4. The process for when a resident displays aggressive abusive behavior is nursing staff will separate residents immediately. Residents will then be assessed for injury by nurse on duty. The resident's physician will be notified by the nurse on duty and nurse will follow MD orders. The responsible party will be notified by nurse on duty. The aggressor must be put on one-on-one observation immediately, meaning one staff member will be assigned to that resident at all times. The other resident involved will be placed on 15 minute observation. This is to continue until the environment is safe. The nurse on duty must then notify the Administrator immediately and will document in the residents' progress notes. The nurse will document the behavior along with all steps taken to protect all residents from abuse. The Administrator will then start the investigation process and follow through to ensure the safety of all residents. The Administrator will also notify the State Survey Agency of all allegations of abuse within 2 hour time requirement. As of 8/8/2024, the Social Worker, Director of Nursing, and Licensed Nurse Supervisor will audit progress notes daily of all residents displaying verbal and physical aggressive behaviors, sexual inappropriate behaviors, escalation in behavior, and resident to resident physical and verbal behaviors, to ensure that all residents are free from abuse. The Social Worker, Director of Nursing, Licensed Nurse and Supervisor will monitor daily using the audit tool titled, Behavior QAPI Tool, which identifies each aggressive behavior, new interventions, such as one on one observation, mental health services, activities, environmental changes, medications reviews, and pain assessment. This monitoring will occur daily. The monitoring tool will be discussed daily in morning meeting beginning 8/9/2024. The care plan will be revised during the meeting by Minimum Data Nurse (MDS). Any problems or concerns will be immediately addressed by DON and communicated to the Administrator. 5. On 8/8/2024 the Quality Assurance Committee, including Administrator, DON, MDS, Dietary Manager, Business Office Manager, Nurse Aide, Rehab Manager, Social Worker, Housekeeping Manager, Maintenance Director, and Activity Director reviewed the facility 4 Immediate jeopardy tags. The Medical Director was called by DON on 8/8/2024 and notified of 4 immediate jeopardy tags. The Quality Assurance Committee reviewed and determined the root cause of F600. The facility failed to ensure that R4 was free from sexual abuse from another resident. The facility failed to provide protection for R4 as she resides in the facility. The Quality Assurance Committee reviewed the policies titled, Abuse Policy and Procedure, (revised 05/2017) and Abuse Investigation and Reporting (revised 7/2017) with no further revisions to policies being made. Review of the police determined the need for 100% staff education on Abuse Policy including mistreatment, exploitation, misappropriation, injury of unknown origin, physical abuse, sexual abuse, and protecting residents from abuse. The Quality Assurance Committee implemented and added a tool titled, Behavior QAPI Tool. The tool will be brought to QA daily. 6. All Correction actions were completed on 8/11/2024. 7. The immediacy of the IJ was removed on 8/12/2024. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Verified via review of an 8/8/2024 physician's order for R5 for 1:1 monitoring related to sexual behaviors and the accompanying Resident Location Check sheet. R4's room change was verified via review of a communication form, dated 7/26/2024, that documented a room change for R4. R4 was observed in the new room on 7/29/2024 at 4:20 pm. Nurse Practitioner (NP) assessments were verified via review of clinical records, including 8/8/2024 nurse's notes entries, made by the Director of Nursing (DON), in R4's and R5's clinical records that documented the Nurse Practitioner was at the facility doing rounds, with no issues or concerns noted and no new orders for R4 and R5. Review of the skin assessment forms for R4 and R5, dated 8/8/2024, verified they had been completed with no new areas noted. Per review of physician's orders and Medication Administration Records (MARs), R4 and R5 had been on behavior monitoring every shift since June 2023 (the entry of 6/2024 in the AOC is a typing error). Review of behavioral health NP notes from 7/9/2024 for R4 and R5 verified that she visited and assessed them. During an interview on 8/8/2024 at 3:56 pm, the NP confirmed that she saw R4 and R5 on 7/9/2024. Review of R5's physician's orders and July 2024 MAR confirmed that Zoloft 50 milligrams (mg), 1.5 tablets (75 mg) by mouth daily was started on 7/9/2024 to address hypersexual behavior. 2. Verified via review of the Concern and Comment form signed by the Social Services Director and Administrator. The form documented that on 8/8/2024, the Social Services Director educated residents with BIMS of 9 or greater on residents' rights, abuse and reporting, name of the abuse coordinator, and location of the bulletin boards with contact information for the ombudsman, abuse coordinator, law enforcement, and state regulatory agency. The form also documented that residents were given a copy of the residents' rights and abuse policy. Review of the following information: 35 Sexual Abuse Education for Resident forms, that included a signature for each of the 35 cognitively intact residents, the list of contact names and information on who to report abuse to, copy of the Residents' Rights policy, copy of the Abuse and Neglect- Clinical Protocol, an 8/8/2024 in-service education sign in sheet titled Abuse and Neglect and Residents Rights with 35 resident signatures or names (two residents refused to sign and one was blind), and review of the interview questionnaire forms, one for each resident with their documented answers, also confirmed the residents received the education and information. During an interview on 8/19/2024 at 1:14 pm, the Social Services Director confirmed she provided education and information to the 35 cognitively intact residents. Also, during an observation on 8/18/2024 at 12:52 pm and 12:57 pm, the bulletin boards near the dining room and at the end of the 300 halls were observed to include posted contact information on the state survey agency, law enforcement, state ombudsman, and the abuse coordinator, along with a copy of residents' rights. In addition, during an interview on 8/19/2024 at 2:55 pm the Administrator confirmed interviewing residents and stated, I was fully involved and commented that the resident interviews went well. Also, during interviews on 8/18/2024 at 12:57 pm with R15, at 1:04 pm with R2, and at 1:06 pm with R3 and on 8/19/2024 at 2:25 pm with R17, at 2:47 pm with R18, at 3:35 pm with R9, at 3:38 pm with R21, at 3:40 pm with R19, and at 3:45 pm with R20, the residents were able to verify being interviewed and educated about abuse by staff and who to report concerns to. None of the interviewed residents expressed concerns related to abuse. A review of skin assessment forms revealed that head-to-toe skin assessments were completed on all 60 residents from 8/8/2024 through 8/9/2024. Verified via review of a list identifying 25 residents with a BIMS score of less than 9, dated 8/8/2024, and review of the F557 Resident Dignity and Respect Audit Tool completed on the 25 residents. The audit tool documented that progress notes had been reviewed for moods and behaviors on 8/8/2024 by the Social Services Director. Verified via review of the individual forms that had pictures of facial expressions that were completed on each of the 25 residents and signed by the Minimum Data Set (MDS) Coordinator and dated 8/8/2024. During an interview on 8/19/2024 at 1:14 pm with the Social Services Director and on 8/19/2024 at 2:45 pm with the MDS Coordinator, both confirmed that the residents had been assessed for negative facial expressions/responses and records reviewed for changes in behaviors. Verified via review of copies of individually stamped and addressed envelopes to 35 resident responsible parties. There were 35 responsible parties for 36 residents because two residents (R3 and R20), who were related, had the same responsible party. During an interview on 8/19/2024 at 1:40 pm the Business Office Manager confirmed mailing information to residents' responsible parties. Verified via review of the list of 36 residents who have a responsible party along with the progress notes made on 8/9/2024 that documented calls or call attempts to the responsible parties to notify them of the information being mailed out. During an interview on 8/19/2024 at 1:40 pm the Business Office Manager confirmed calling the responsible parties to notify them of the information being mailed. She stated that she the ones she was able to speak to seemed appreciative of the call and did not have any abuse concerns or questions. Verified via review of the Abuse and Neglect-Clinical Protocol, Residents' Rights policy and list of contact information for the facility abuse coordinator, state contacts, and law enforcement. Review of the list of residents who are their own responsible party revealed there were 24 residents, not nine as listed in the AOC. During an interview on 8/16/2024 at 2:30 pm the Regional Director of Operations confirmed that the 9 was a typing error and that 24 residents had been provided with the information. During an interview on 8/19/2024 at 1:40 pm the Business Office Manager confirmed that she was also over medical records. She confirmed that she provided abuse information to the 24 residents who were their own responsible parties. During interviews with residents who were listed as their own responsible party on 8/18/2024 at 12:57 pm with R15, on 8/19/2024 at 2:25 pm with R17, at 3:35 pm with R9 and at 3:40 pm with R19, the residents verified they received information on abuse. During the interview on 8/19/2024 at 2:25 pm with R17, the paperwork she had received was visible on the nightstand in her room. During the interview on 8/19/2024 at 3:40 pm, R19 confirmed receiving paperwork from staff but stated she did not keep it. Verified via review of the resident council meeting notes, dated 8/9/2024 and signed by the Social Services Director. The meeting information included eight residents attended. In addition, 18 residents who were gathered outside for a smoke break, were also informed. During an interview on 8/19/2024 at 1:14 pm, the Activity Director and Social Services Director confirmed the resident council meeting was held, that the meeting went well, and the residents understood the information. During an interview on 8/19/2024 at 2:25 pm, the resident council president (R17) confirmed the meeting was held on 8/9/2024. During interviews on 8/18/2024 at 1:06 pm with R3 and on 8/19/2024 at 3:45 pm with R20, the residents (who were included in the list of 18 residents who were gathered for smoke break and educated on 8/9/2024) confirmed receiving information on abuse and resident's rights. 3. Verified via review of the in-service and training sign-in sheet titled Recognizing Signs and Symptoms of Abuse. The educator was listed as the Regional Director of Operations and the form was signed by the Administrator and dated 8/8/2024. Verified via review of the Recognizing Signs and Symptoms of Abuse/Neglect policy and accompanying information on the reporting timeline to the state survey agency and immediate action once notified of a reportable incident. Verified via review of the Event Management Abuse Policy and Procedure power point slide copies which were signed and dated 8/8/2024 by the Regional Director of Operations. Verified via review of the in-service and training sign-in sheet titled Abuse Investigation and Reporting which listed the educator as the Regional Director of Operations and was signed by the Administrator and dated 8/8/2024, along with the accompanying education information on abuse reporting and immediate interventions. Verified via review of the in-service education titled Abuse Policy and Procedure which was dated 8/8/2024 and sign by the Administrator and Regional Director of Operations. During an interview on 8/19/2024 at 2:45 pm, the Regional Director of Operations confirmed educating the Administrator on 8/8/2024. Review of the in-service education form titled Abuse Prevention Policy and Procedure and the accompanying abuse education information which was signed by the Administrator and Chief Operating Officer and dated 8/8/2024. Verified via review of the in-service education form titled Identifying Sexual Abuse and Capacity to Consent that was signed and dated 8/8/2024 by the Administrator and Chief Operation Officer, along with the Identifying Sexual Abuse and Capacity to Consent policy and Abuse Prevention Policy and Procedure. During an interview, via phone, on 8/19/2024 at 3:17 pm, the Chief Operation Officer confirmed providing in-service education to the Administrator and stressed the importance of the information. During an interview on 8/19/2024 at 2:55 pm the Administrator confirmed receiving in-service education from the Chief Operating Officer on 8/8/2024 related to abuse policy and procedures, investigations, and reporting. A master list of staff was cross-referenced with the sexual abuse screening quiz questions that were completed individually by staff to verify that they did receive the information. Verified via review of in-service education sign in sheets labeled with Abuse and Neglect, recognizing signs and symptoms of abuse, Abuse Coordinator, Reportables must be reported in 2 hours, along with the accompanying education information, dated 8/8/2024 and 8/9/2024. The staff signature sheets included a total of 79 staff were educated. During an interview with the Regional Director of Operations and MDS Coordinator on 8/19/2024 at 12:06 pm, it was clarified that 12 of 12 dietary staff were in-serviced and 5 of 6 therapy staff were in-serviced. They confirmed that one LPN and one therapy staff were out on leave and would be educated upon return to work. Staff interviews conducted on 8/18/2024 at 12:40 pm with LPN DD, at 12:49 pm with housekeeper BBB, at 12:55 pm with RN JJ, on 8/19/2024 at 11:30 am with the Housekeeping Manager, at 11:38 am with housekeepers SSS and CCC, at 12:15 pm with the Dietary Manager, at 12:20 pm with the Maintenance Director, at 1:02 pm with activity assistant MM, at 1:14 pm with the Social Services Director and Activity Director, at 1:32 pm with CNA DD, at 1:35 pm with dietary staff EEE and FFF, at 1:40 pm with the Business Office Manager, and at 2:45 pm with the MDS Coordinator confirmed they had received education that abuse and neglect and what it included, recognizing signs of abuse and neglect, that the Abuse Coordinator is the Administrator and that all allegations of abuse must be reported immediately. During an interview on 8/19/2024 at 2:55 pm the Administrator confirmed providing the in-service education information on 8/8/2024 and 8/9/2024. 4. Interviews conducted with nursing staff on 8/18/2024 at 12:40 pm with LPN DD, at 12:55 pm with RN JJ, and on 8/19/2024 at 1:32 pm with CNA DD, and at 2:45 pm with the MDS Coordinator confirmed they were knowledgeable of the process for when a resident displays aggressive abusive behavior. Verified via review of the Behavior Quality Assurance Performance Improvement (QAPI) Tool dated daily from 8/8/2024 through 8/25/2024 that documented all residents were audited with no aggressive behaviors noted. Interviews conducted on 8/19/2024 at 1:14 pm with the Social Service Director, at 2:35 pm with the DON, and at 2:45 pm with the MDS Coordinator and Regional Director of Operations confirmed that audits of resident progress notes were done daily to identify any residents displaying aggressive or inappropriate behaviors or an escalation in behaviors. Verified via interview on 8/19/2024 at 2:45 pm with the MDS Coordinator related to the revision of care plan during the morning meeting as needed for residents displaying behaviors. 5. Verified via review of the 3rd Quarterly Monthly QA/PI Meeting Agenda form, dated 8/8/2024 that documented an ad hoc meeting was held and the Immediate Jeopardy and abuse policies were reviewed. The signature[TRUNCATED]

Based on staff interviews, record reviews, and review of the policy titled Abuse Prevention Policy & Procedure, the facility failed to ensure that allegations of abuse or injury of unknown origin were reported to the State Survey Agency in a timely manner for four Residents (R) (R4, R5, R3, and R8), failed to ensure that an allegation of sexual abuse involving two residents (R4 and R5) was reported to law enforcement in a timely manner, and failed to ensure that the initial and follow up reports to the State Survey Agency, for an allegation of sexual abuse involving two residents (R4 and R5), contained complete and accurate information, from a total sample of 21 residents. On 8/8/2024 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Minimum Data Set (MDS) Nurse, and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 8/8/2024 at 11:25 am. The noncompliance related to the IJ was identified to have existed on 7/7/2024. An Acceptable IJ Removal Plan was received on 8/15/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 8/12/2024. Findings include: The facility had an Abuse Prevention Policy & Procedure, with revision date of 2/26/2019. The policy's statement included that any allegation of abuse is reported immediately to the state agency and to all other agencies as required, per state and federal guidelines. The policy defined sexual abuse as any abuse that is of a sexual nature, including harassment, coercion, or assault. Verbal abuse was defined as any use of oral, written, or gestured language that willfully included the disparaging and derogatory terms to residents, their families or within hearing distance. An example of verbal abuse included saying or doing something with intent to frighten a resident or otherwise make him/her feel unsafe or insecure. Mental abuse included, but was not limited to, humiliation, harassment, threats of punishment or deprivation. Section 5 of the policy Reporting/Investigation/Response Policy included that the Administrator or designee shall call local police when sexual abuse is suspected and/or confirmed by investigation. 1. Review of R4's clinical record revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Alzheimer's Disease, unspecified psychosis, and anxiety disorder. Review of the 6/17/2024 Brief Interview for Mental Status (BIMS) form revealed that R4 was assessed as having cognitive impairment, with a score of 0 out of 15, indicating severe cognitive impairment. Review of a 3/12/2024 social services quarterly review note revealed that R4 was alert with marked confusion and oriented to person only. The note also documented that R4 required assistance with activities of daily living (ADLs) and used a wheelchair for mobility. Review of R5's clinical record revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, hypertension, chronic obstructive pulmonary disease, bipolar disorder, and generalized anxiety disorder. Review of a 7/1/2024 social services quarterly review note revealed that R5 was alert and oriented x2, with a BIMS score of 13 (out of 15). The note further documented that R5 had no behaviors (during the review period), was supervised with ADLs and independent with ambulation. Review of a 7/8/2024 Brief Interview for Mental Status form revealed that R5 scored a 14 out of 15 on the cognitive assessment, indicating he was cognitively intact. Further review of R4's clinical record revealed a 7/7/2024 Medication Administration Note, made by Licensed Practical Nurse (LPN) DD, that documented R4 was observed in the dining area by a staff member having inappropriate sexual behavior with another resident. Further review of 5's clinical record revealed a 7/7/2024 Medication Administration Note, made by LPN DD, documented R5 was observed in the dining area before breakfast by a staff member having inappropriate sexual behavior. A 7/7/2024 Behavior Note, made by the Director of Nursing (DON), documented that R5 was observed by LPN BB in the dining room involved in inappropriate sexual behavior with another resident. The note also included that LPN BB asked R5 what he was doing, and he stated nothing and went to sit down. LPN BB notified the DON. During an interview on 7/17/2024 at 2:05 pm, LPN BB recalled the incident that occurred between R4 and R5 on 7/7/2024. LPN BB stated that she was walking up the hallway and observed R5 on the left side of the dining room, and he is normally on the right side of the dining room. R5 was standing up close to R4's wheelchair, and LPN BB stepped in to get a closer look. R5's shirt was out of his pajama pants and his penis was exposed. R5 pushed R4's head twice onto his penis. LPN BB stated she became really stern and called out R5's name and yelled What are you doing? You know you can't do that. R5 immediately stepped away (from R4) and said he was not doing anything. LPN BB stated she went and told LPN DD what had happened. LPN BB stated that R4 and R5 were LPN DD's residents that day. LPN BB stated that while LPN DD called the Administrator, she made sure the residents were separated. LPN BB stated that she also called the DON on 7/7/24 and reported the incident to her, and also notified the physician. LPN BB stated she asked R5 if he knew what he had done was wrong and he said he did not remember. During a phone interview on 7/23/2024 at 11:18 am, LPN DD recalled the events of 7/7/2024. LPN DD stated that she did not witness the incident between R4 and R5, that she was at her medication cart getting it ready. She heard LPN BB say something like stop that and then LPN BB walked up to her and told her what had happened (between R4 and R5). LPN DD confirmed that she notified the Administrator and that he came to the facility. LPN DD also stated that she checked both residents out, and R4 remained in the dining room, and R5 was redirected back to his room. Although the Director of Nursing and Administrator were both aware of the sexual abuse occurrence on the day that it occurred, on 7/7/2024, an initial report to the state survey agency was not submitted until 7/8/2024. In addition, the initial report to the state survey agency contained inaccurate information. Review of the Facility Incident Report Form, dated 7/8/2024 and submitted to the state survey agency by the DON, revealed that the sexual abuse occurrence between R4 and R5 was correctly documented as having occurred on 7/7/2024. However, the details of the incident included in the report incorrectly documented that the incident was reported to the DON and Administrator by staff on 7/8/2024 at 1:07 pm. During interviews on 7/16/2024 at 4:15 pm and 4:25 pm, the Administrator confirmed that he was made aware of the incident between R4 and R5 on 7/7/2024, and he then he reported that he came to the facility, and spoke with R4 and R5's nurse, LPN DD. During the interview on 7/16/2024 at 4:25 pm, the DON stated that she found out about the incident on 7/8/2024, when she was reviewing incident notes, which was something she did as part of risk management. However, during an additional interview on 7/17/2024 at 2:43 pm, when questioned about the nurse's note entry she made in R5's clinical record, dated 7/7/2024, the DON confirmed that LPN BB called her on 7/7/2024 and reported the inappropriate sexual act that had occurred between R4 and R5. The DON also stated that she spoke with the Administrator on 7/7/2024. During an interview on 7/31/2024 at 10:55 am, the DON was questioned as to why the initial report to the state survey agency included that she and the Administrator were made aware of the incident on 7/8/2024, but they both knew about it on 7/7/2024. The DON stated that when LPN BB called her on 7/7/2024 and told her about the incident, she called the Administrator. The Administrator then called her back and said that it turned out not to be what it was. However, when she pulled the report the next day and read it, it was inappropriate sexual behavior. Review of the facility's follow-up report, submitted to the state survey agency revealed that the result of the facility's investigation was inconclusive, even though it was witnessed by LPN BB. The follow- up report also omitted the information that the Administrator and DON were aware of the incident on the date it occurred, 7/7/2024. During an interview on 7/16/2024 at 4:25 pm, the Regional Director of Operations stated that she was not aware the Administrator knew of the incident on 7/7/2024 and that she was the person who completed the 5-day follow-up summary to the state survey agency. During a subsequent interview on 7/18/2024 at 3:25 pm, the Regional Director of Operations stated that not too long after the 7/7/2024 incident, the DON was out for a few days. The 5-day follow-up report to the state survey agency was coming due, so she did the report based off what was told to her at that time by staff. There was no evidence that the resident-to-resident sexual abuse incident involving R4 and R5 was reported to law enforcement. During the interview on 7/17/2024 at 2:43 pm, the DON stated no police were contacted. During an interview on 7/23/24 at 1:25 pm, when asked if law enforcement should have been notified, the Regional Director of Operations responded yes. After surveyor inquiry, the sexual abuse incident between R4 and R5 was reported to law enforcement. During an interview on 7/23/2024 at 2:15 pm the Regional Director of Operations reported the incident to Patrol Officer EE. 2. R3 was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, generalized anxiety disorder, type 2 diabetes, gout, low back pain, cerebral infarction, and hypertension. Review of the 6/22/2024 Quarterly Minimum Data Set (MDS) assessment revealed that R3 was assessed as being cognitively intact with a BIMS score of 15 out of 15. During an interview on 7/18/2024 at 10:28 am, Ombudsman CC stated that she spoke with R3 on 5/30/2024 at the facility, and R3 complained to her that Registered Nurse (RN) AA had threatened to give him an injection and would not let him go outside. R3 did not specify when the incident had occurred. Ombudsman CC stated that she reported the allegation to the Administrator on 5/30/2024. She made another in-person visit to the facility on [DATE], and R3 told her that the Administrator had come to talk to him about his allegation (against RN AA) and asked him to report any concerns immediately. During an interview on 7/22/2024 at 2:05 pm, R3 stated that about three months ago, they (staff) kept bringing him food he said he was not going to eat. RN AA told him if he kept acting up, she would give him a shot. R3 said RN AA would not let him go back to his room or outside to cool down. He confirmed that he spoke with Ombudsman CC about it on 5/30/2024 but had not reported it to anyone prior to that. R3 also confirmed that the Administrator had talked to him about it, after the Ombudsman. However, there was no evidence that the allegation of RN AA's verbal threat to give R3 an injection was reported to the State Survey Agency. During an interview on 7/22/2024 at 3:05 pm, the Administrator confirmed he was aware of R3's allegation and stated that he went to talk to R3 on 5/30/2024, immediately after Ombudsman CC reported the allegation. However, R3 could not recall any information when they went to talk to him about it. 15650 4. Review of the 7/13/2024 at 1:48 pm Health Status Note for R8 revealed documentation that a Certified Nursing Assistant (CNA) reported a large area of bruising to the resident's right side. The Licensed Practical Nurse (LPN) observed the area and asked the resident if she fell . The resident shook her head no. Although the LPN documented she notified the Director of Nursing (DON) on 7/13/2024, review of the 7/14/2024 Health Status Note revealed documentation the DON was notified of the bruising 7/14/2024, not on 7/13/2024. Review of the 7/13/2024 skin assessment noted bruising to the left and right iliac crest and under the right breast. Review of the 7/15/2024 Facility Incident Report Form revealed an incorrect date of the incident as 7/15/24 and indicated bruising was noted the resident's diaphragm and left breast area. During an interview with Licensed Practical Nurse (LPN) DD on 7/24/2024 at 12:05 pm, she stated although she observed the bruising to the resident on 7/13/2024 she did not report the bruising to the DON until 7/14/2024. During an interview with the DON on 7/24/2024 at 11:45 am, she confirmed although the LPN reported the bruising to her on 7/14/2024, the State Survey Agency was not notified until 7/15/2024. The facility implemented the following actions to remove the IJ: 1. Resident 8 was transferred to the hospital on 7/15/2024 then transferred from the hospital to another facility on 7/22/2024. Resident 5 was put on one-on-one monitoring on 8/8/2024 to monitor for sexual behaviors. R4 was moved to another room on the opposite hall away from R5 on 7/26/2024. Resident 4, 5, 8, 3 and all other residents were assessed by the Medical Director's Nurse Practitioner on 8/8/2024. No adverse effects were noted. All Residents were given a head-to-toe skin assessment on 8/8/2024 and 8/9/2024 by nursing staff. The head-to-head assessment revealed that 60 out of 60 residents had no bruising or signs of abuse. This was to ensure that no harm to the residents had occurred. Both R4 and R5 had been on behavior monitoring every shift since 6/2024. Mental Health services evaluated R4 and R5 on 7/9/2024 with no adverse effects noted. Secondary to the Mental Health evaluation a pharmacological intervention, Zoloft 75mg daily was ordered for R5 on 7/8/2024. 2. On 8/8/2024 the Administrator audited reportable events (abuse and neglect) which includes mistreatment, exploitation, misappropriation of property, injury of unknown origin, resident to resident altercations, and suspicions of sexual crimes) using the audit tool titled, New Reportable Audit for Events for the last 30 days. The audit identified 4 reportable events with 3 of the 4 initial reportable events were not reported within the 2 hour time requirement per federal guidelines. The 4 final summaries were completed on 7/12/2024, 7/19/2024, and 7/30/2024. The Administrator added a new QAPI tool titled, New Reportable Audit for Events, which audits reportable events with date and time, report to supervisor, employee involvement including suspension date, date investigation starts and ends, report to state initial date and time, report to state final date and time, and date of care plan revision. Effective use of QAPI tool will ensure that the facility reports reportable events within the federal guidelines. The Administrator will be notified of any allegations of abuse, mistreatment, exploitation, misappropriation of property, injury of unknow origin, resident to resident altercation, and suspicions of sexual crimes; by the licensed nurse, immediately, to ensure timely reporting to the state agencies. The result of the audit will be presented daily in morning meeting and any problems will be addressed immediately. 3. The Administrator educated staff on 8/8/2024 -8/9/2024 on the following education: abuse and neglect includes mistreatment, exploitation, misappropriation of property, injury of unknown origin, resident to resident altercation, suspicions of crime including sexual and physical abuse. The staff were educated on recognizing and identifying abuse and neglect. The staff was educated that the facility Abuse Coordinator is the Administrator and all allegations of abuse must be reported immediately to the Administrator. The staff was educated to report allegations immediate to the Administrator due to the 2 hour requirement for the Administrator to report to the State Agency of all allegations of abuse. The following staff received this education: 1of 1 Director of Nursing, 1of 1 Social Worker, 1 of 1 Maintenance Director, 2 of 2 Activity Directors, 8 of 8 Registered Nurses, 9 of 10 Licensed Practical Nurses, 27 of 27 Certified Nurse Assistants, 9 of 9 housekeeping staff, 11 of 12 Dietary Staff, 1of 1 Business Office Manager, and 6 of 6 Therapists. The staff not present will be educated prior to returning to work by the Director of Nursing. No staff will be allowed to work until educated. As of 8/11/2024 no new staff hired. 76 of 78 staff (totaling 98%) were educated on abuse. 4. The Administrator was educated on 8/8/2024 that all reportables must be reported within 2 hours which includes sexual abuse, injury of unknow origin, and any allegations of abuse. Immediate actions to be taken once notified of reported abuse are make sure residents are safe, if resident on resident abuse immediately separate, if allegations are against an employee suspend immediately pending investigation, obtain statements from all employees in facility at time of incident and 24 hours prior to incident occurrence. Notify physician of residents involved, call police, responsible party, and Ombudsman. 5. As of 8/9/2024 the Administrator will audit each new event to ensure timely reporting to the State Survey Agency with the tool titled New Reportable Audit for Events. The Administrator will bring the New Reportable Audit for Events tool to the morning meeting daily (Monday-Friday) for review beginning on 8/9/2024 and weekends will be reviewed on Monday in morning meeting through 8/11/2024 with no new negative findings. If the tool identifies that an event was not reported in a timely manner, the staff and Administrator will be reeducated on timely reporting by the Regional Director of Operations immediately. 6. On 8/9/2024 the Quality Assurance committee reviewed the facility's 4 cited immediate jeopardy (IJ) tags. The committee determined the root cause of F609. The root cause was the facility failed to ensure that allegations of abuse and injury of unknown origin were reported to the state survey agency in a timely manner for 4 residents (R4, R5, R3, and R8) and failed to identify that an allegation of sexual abuse involving R4 and R5 contained inaccurate information or omitted information. The facility failed to timely investigate allegations of abuse and failed to investigate resident to resident sexual abuse. The facility failed to recognize patterns in behaviors and failure to protect all residents. The Quality Assurance committee reviewed the facility policies titled, Investigating Injuries revised 2016 and Protection of Residents During Abuse Investigation revised April 2017. No further revisions to policies were made. The Medical Director viewed the policy on 8/9/2024 with no revisions suggested. Review of policy determined the need for 100% staff education for investigating allegations of abuse in a timely manner. 7. All corrections were completed 8/11/2024. 8. The immediacy of the IJ was removed on 8/12/2024. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Verified transfer to hospital via review of R8's clinical record. Verified via review of the 8/8/24 physician's order for R5 and the accompanying monitoring forms. Review of R5's clinical record revealed that 75 mg of Zoloft was started on 7/9/2024. R4's room change was verified via review of a communication form, dated 7/26/2024, that documented a room change to a different hall. R4 was observed in the new room on 7/29/2024 at 4:20 pm. Review of R3, R4 and R5's clinical records revealed that the Nurse Practitioner visited and assessed them on 8/8/24. A review of skin assessment forms revealed that a skin assessment was completed on 60 residents from 8/8/24-8/9/24. 2. Verified via review of the Audit of Reportable Events form, dated 8/8/2024 and review of the New Reportable Audit for Events for July 2024, which included four events involving R4, R5, R8 and R16. The events involving R4, R5, and R8 were already known to surveyors. A record review on R16 for an injury of unknown origin was conducted which verified the information on the audit form was correct and the incident was reported to the state survey agency in a timely manner. During an interview on 8/15/2024 at 4:15 pm the Regional Director of Operations clarified that the QAPI tool titled New Reportable Audit for Events was a form that was already in use. The new tool developed is titled Daily Reportable Log and provided a copy to review. The Regional Director stated that the Administrator brings the tool to the daily morning meetings Monday through Friday. During an interview on 8/19/2024 at 2:55 pm the Administrator confirmed the use of the Daily Reportable Log tool during morning meetings. Verified the tool had been implemented via review of the Daily Reportable Log that included documentation of reviews 8/9/2024-8/15/2024. 3. Confirmation of in-service education sign in sheets labeled with Abuse and Neglect, Recognizing signs and symptoms of abuse, Abuse Coordinator, Reportables must be reported in 2 hours, along with the accompanying education information, dated 8/8/2024 and 8/9/2024. The staff signature sheets included a total of 79 staff were educated. During an interview with the Regional Director of Operations and MDS Coordinator on 8/19/2024 at 12:06 pm, it was clarified that 12 of 12 dietary staff were in-serviced and 5 of 6 therapy staff were in-serviced. They confirmed that one LPN and one therapy staff were out on leave and would be educated upon return to work. Staff interviews conducted on 8/18/2024 at 12:40 pm with LPN DD, at 12:49 pm with housekeeper BBB, at 12:55 pm with RN JJ, on 8/19/2024 at 11:30 am with the Housekeeping Manager, at 11:38 am with housekeepers SSS and CCC, at 12:15 pm with the Dietary Manager, at 12:20 pm with the Maintenance Director, at 1:02 pm with Activity Assistant MM, at 1:14 pm with the Social Services Director and Activity Director, at 1:32 pm with CNA DD, at 1:35 pm with dietary staff EEE and FFF, at 1:40 pm with the Business Office Manager, and at 2:45 pm with the MDS Coordinator confirmed they had received education that abuse and neglect and what it included, recognizing signs of abuse and neglect, that the Abuse Coordinator is the Administrator and that all allegations of abuse must be reported immediately. They were also knowledgeable about the 2-hour requirement for the Administrator to report to the state survey agency. During an interview on 8/19/2024 at 2:55 pm the Administrator confirmed provide the in-service education information on 8/8/2024 and 8/9/2024. 4. Verified via review of the in-service and training sign-in sheet titled Recognizing Signs and Symptoms of Abuse. The educator was listed as the Regional Director of Operations and the form was signed by the Administrator and dated 8/8/2024. Verified via review of the Recognizing Signs and Symptoms of Abuse/Neglect policy and accompanying information on the reporting timeline to the state survey agency and immediate action once notified of a reportable incident. Verified via review of the Event Management Abuse Policy and Procedure power point slide copies which were signed and dated 8/8/2024 by the Regional Director of Operations. Verified via review of the in-service and training sign-in sheet titled Abuse Investigation and Reporting which listed the educator as the Regional Director of Operations and was signed by the Administrator and dated 8/8/2024, along with the accompanying education information on abuse reporting and immediate interventions. Verified via review of the in-service education titled Abuse Policy and Procedure which was dated 8/8/2024 and signed by the Administrator and Regional Director of Operations. During an interview on 8/19/2024 at 2:45 pm, the Regional Director of Operations confirmed educating the Administrator on 8/8/2024. During an interview on 8/19/2024 at 2:55 pm the Administrator confirmed receiving in-service education from the Regional Director of Operations on 8/8/2024 and that he was aware of the requirements of reporting to the state survey agency and law enforcement. 5. During an interview on 8/15/2024 at 4:15 pm the Regional Director of Operations clarified that the QAPI tool titled New Reportable Audit for Events was a form that was already in use. The new tool developed is titled Daily Reportable Log and provided a copy to review. The Regional Director of Operations stated that the Administrator brings the tool to the daily morning meetings Monday through Friday. During an interview on 8/19/2024 at 2:55 pm the Administrator confirmed the use of the Daily Reportable Log tool during morning meetings. Verification that the tool had been implement via review of the Daily Reportable Log that included documentation of reviews from 8/9/2024 through 8/15/2024. During an interview on 8/19/2024 at 2:45 pm, the Regional Director of Operations confirmed that if concerns were identified related to events not reported in a timely manner, re-education would be provided. She stated that she would oversee the completion of the QA audit forms for accurate information. 6. Verified via review of the 3rd Quarterly Monthly QA/PI Meeting Agenda form, dated 8/8/2024 that documented an ad hoc meeting was held and the Immediate Jeopardy and abuse policies were reviewed. The signatures of the QA committee members were included along with copies of the completed Immediate Jeopardy Templates and copies of the Investigating Injuries policy and Protection of Residents During Abuse Investigations policy. Interviews conducted on 8/19/2024 at 11:30 am with the Housekeeping Supervisor, at 12:15 pm with the Dietary Manager, at 12:20 pm with the Maintenance Director, at 1:14 pm with the Activity Director and Social Services Director, at 1:40 pm with the Business Office Manager, at 2:35 with the DON, at 2:45 pm with the MDS Coordinator and Regional Director of Operations, and at 2:55 pm confirmed that they held a QA meeting on 8/8/2024, reviewed policies, and reviewed and determined the root cause of F609. During an interview on 8/12/2024 at 1:04 pm the Medical Director confirmed knowledge of the Immediate Jeopardy.

Based on interviews, record reviews, and review of the Abuse Prevention Policy & Procedure, the facility failed to conduct an investigation and implement protective measures in a timely manner following an allegation of resident-to-resident sexual abuse involving two Residents (R) (R4 and R5) from a total sample of 21 residents. On 8/8/2024 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Minimum Data Set (MDS) Nurse, and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 8/8/2024 at 11:25 am. The noncompliance related to the IJ was identified to have existed on 7/7/2024. An Acceptable IJ Removal Plan was received on 8/15/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 8/12/2024. Findings include: The facility had an Abuse Prevention Policy & Procedure, with revision date of 2/26/2019. Section 4 of the policy titled Resident-To-Resident Policy documented that it is the policy of the facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from physical and verbal abuse from other residents. Number 8 of the Procedure portion of the Resident-to-Resident Policy documented all incidents are to be documented in the resident's medical record with intense monitoring to continue for at least 72 hours. Section 5 of the policy titled Reporting/Investigation/Response Policy documented that if the incident has resulted in an injury or a suspected sexual assault, the resident will be transferred to the hospital emergency room . Review of R4's clinical record revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Alzheimer's Disease, unspecified psychosis, and anxiety disorder. Review of the 6/17/2024 Brief Interview for Mental Status (BIMS) form revealed that R4 was assessed as having cognitive impairment, with a score of 0 out of 15, indicating severe cognitive impairment. Review of a 3/12/2024 social services quarterly review note revealed that R4 was alert with marked confusion and oriented to person only. The note also documented that R4 required assistance with activities of daily living (ADLs) and used a wheelchair for mobility. Review of R5's clinical record revealed that he was admitted to the facility on [DATE] had diagnoses that included, but were not limited to, hypertension, chronic obstructive pulmonary disease, bipolar disorder, and generalized anxiety disorder. Review of a 7/1/2024 social services quarterly review note revealed that R5 was alert and oriented x2, with a BIMS score of 13 (out of 15). The note further documented that R5 had no behaviors (during the review period), was supervised with ADLs and independent with ambulation. Review of a 7/8/2024 BIMS form revealed that R5 scored a 14 out of 15 on the cognitive assessment, indicating he was cognitively intact. Further review of R4's clinical record revealed a 7/7/2024 Medication Administration Note, made by Licensed Practical Nurse (LPN) DD, that documented R4 was observed in the dining area by a staff member having inappropriate sexual behavior with another resident. Further review of 5's clinical record revealed a 7/7/2024 Medication Administration Note, made by LPN DD, that documented R5 was observed in the dining area before breakfast by a staff member having inappropriate sexual behavior. A 7/7/2024 Behavior Note, made by the Director of Nursing (DON), documented that R5 was observed by LPN BB in the dining room involved in inappropriate sexual behavior with another resident. The note also included that LPN BB asked R5 what he was doing, and he stated nothing and went to sit down. LPN BB notified the DON. During an interview on 7/17/2024 at 2:05 pm, LPN BB recalled the incident that occurred between R4 and R5 on 7/7/2024. LPN BB stated that she was walking up the hallway and observed R5 on the left side of the dining room, and he is normally on the right side of the dining room. R5 was standing up close to R4's wheelchair, and LPN BB stepped in to get a closer look. R5's shirt was out of his pajama pants and his penis was exposed. R5 pushed R4's head twice onto his penis. LPN BB stated she became really stern and called out R5's name and yelled What are you doing? You know you can't do that. R5 immediately stepped away (from R4) and said he was not doing anything. LPN BB stated she went and told LPN DD what had happened. LPN BB stated that R4 and R5 were LPN DD's residents that day. LPN BB stated that while LPN DD called the Administrator, she made sure the residents were separated. LPN BB stated that she also called the DON on 7/7/2024 and reported the incident to her, and also notified the physician. LPN BB stated she asked R5 if he knew what he had done was wrong and he said he did not remember. During a phone interview on 7/23/2024 at 11:18 am, LPN DD recalled the events of 7/7/2024. LPN DD stated that she did not witness the incident between R4 and R5, that she was at her medication cart getting it ready. She heard LPN BB say something like stop that and then LPN BB walked up to her and told her what had happened (between R4 and R5). LPN DD confirmed that she notified the Administrator and that he came to the facility. LPN DD also stated that she checked both residents out and that R4 remained in the dining room and R5 was redirected back to his room. However, review of R4's clinical record revealed no skin assessment documented until 7/10/2024. Review of R5's clinical record revealed no skin assessment documented until 7/11/2024. R4 was also not sent to the hospital for an examination. In addition, although the DON and Administrator were both aware of the sexual abuse incident on the day that it occurred, on 7/7/2024, and the Administrator came to the facility, he failed to initiate a timely investigation and interview the only witness, LPN BB, or obtained a written statement from her until 7/8/2024. During interviews on 7/16/2024 at 4:15 pm and 4:25 pm, the Administrator confirmed that he was made aware of the incident between R4 and R5 on 7/7/2024, came to the facility, and spoke with R4 and R5's nurse, LPN DD. During the interview on 7/17/2024 at 2:26 pm, LPN BB stated that the Administrator did not talk with her on 7/7/2024, and she was not sure what LPN DD told him. Review of R4 and R5's clinical records revealed that both residents were already on behavior monitoring every shift, related to psychotropic medication use, since June 2023. The behavior monitoring was documented on the Medication Administration Records (MARS). After 7/7/2024, additional nurses' notes entries related to behavior monitoring were also documented on R4 and R5 one to two times daily in their clinical records through 7/12/2024. Review of R4's clinical record revealed nurses' notes entries on 7/8/2024 at 1:35 am and 9:29 pm, on 7/9/2024 at 1:05 am, on 7/10/2024 at 6:36 am and 8:26 pm, on 7/11/2024 at 3:19 am and 7:54 pm, and on 7/12/2024 at 1:48 am and 8:29 pm documented R4 continued on behavior charting and/or no behaviors noted at that time. Review of R5's clinical record revealed nurses' notes entries on 7/8/2024 at 1:34 and 9:28 pm, on 7/10/2024 at 6:29 am and 8:28 pm, on 7/11/2024 at 3:17 am and 7:53 pm, and on 7/12/2024 at 1:46 am and 8:34 pm documented R5 continued on behavior charting and/or no behaviors noted at that time. However, there was no evidence of intense monitoring until 7/29/2024. Review of R5's physician's orders revealed an order for one hour checks every shift for any inappropriate behaviors. In addition, both R4 and R5 continued to reside in rooms that were on the same end of the hall, in close proximity to each other until 7/26/2024. Review of R4's clinical record revealed a 7/28/2024 social services note that documented R4 was relocated to another room on a different hall on 7/26/2024. During an interview on 7/31/2024 at 10:55 am, when asked if any additional frequent checks/monitoring or intense monitoring was implemented on R4 or R5 after 7/7/2024 and prior to the one-hour checks were ordered on 7/29/2024 for R5, the DON stated no. The DON did say that the staff have made sure R4 and R5 were on different sides of the dining room. During an interview on 7/31/2024 at 11:25 am, when asked about R4 and R5 continuing to reside on the same hall with their rooms in close proximity to each other until 7/26/2024, the Administrator responded that there was no proof that R5 wandered into resident rooms. When asked if any intense monitoring or frequent monitoring was implemented and documented for R4 or R5 before the q1h was ordered on 7/29/2024, the Regional Director of Operations responded that she knew the staff were monitoring. The facility implemented the following actions to remove the IJ: 1. Resident 5 was put on one-on-one monitoring on 8/8/2024 to monitor behaviors. R4 was moved to another room on the opposite hall away from R5 on 7/26/2024. All Residents including R4 and R5 were assessed by the Medical Director's Nurse Practitioner on 8/8/2024. No negative outcomes were noted. Residents R4 and R5 were given a head-to-toe skin assessment on 8/8/2024 and 8/9/2024 by nursing staff. The head-to-toe assessment revealed that R4 and R5 had no bruising or signs of abuse. This was to ensure that no harm to the residents had occurred. Both R4 and R5 had been on behavior monitoring every shift since 6/2024. Mental Health services evaluated R4 and R5 on 7/9/2024 with no negative outcomes noted. Secondary to the Mental Health Evaluation a pharmacological intervention, Zoloft 75mg daily was ordered for R5 on 7/8/2024. 2. Because the facility failed to conduct an investigation, prevent, and correct alleged violations, the Administrator and DON were educated on abuse investigations to protect all residents. If an incident or suspected incident of abuse is reported, the administrator will assign the investigation to DON. The Administrator will provide any supporting documents related to the alleged incident to DON who's in charge of the investigation. The Administrator will keep the resident and responsible party informed of the progress of the investigation. The Administrator will suspend immediately any employee who has been accused of resident abuse pending the outcome of the investigation and interview other residents to whom the accused employee provided during the time of the alleged incident, this is to ensure safety and protection of the resident. If resident-to-resident abuse is reported, staff will immediately intervene and separate residents to protect and prevent them from further abuse. The DON will review the residents' medical records to determine events leading up to the incident. The DON will interview the person reporting the incident. The DON will interview any witnesses of the incident. The DON will interview the resident if medically appropriate. The DON will interview staff on all shifts who worked during the time of the alleged incident. The DON will interview the resident's roommate and any other resident whom the accused employee provided care for during the period of the alleged incident. The DON will obtain written witness statements. The DON will notify the Ombudsman that an abuse investigation is being conducted. Upon conclusion of the investigation, the results of the findings will be provided to the resident, responsible party, Ombudsman, and medical director. 8/8/2024, the Administrator audited reportable events (abuse and neglect which includes mistreatment, exploitation, misappropriation of property, injury of unknown origin, resident to resident altercation, and suspicions of sexual crimes) using the audit titled New Reportable Audit for Events daily and will bring to morning meeting daily. The audit identified 4 reportable events with 3 of 4 initial reportable that were not reported timely. The 3 reportables was reported and finalized 7/12/2024, 7/19/2024 and 7/30/2024. The administrator added a new QAPI tool titled New Reportable Audit for Events, which audits reportable events with date and time, report to supervisor, employee involvement including suspension date, date investigation starts and ends, report to state initial date and time, report to state final date and time and date of care plan revision. Effective use of QAPI tool will ensure that the facility reports reportable events within the federal guidelines. The Administrator will be notified of any allegations of abuse, mistreatment, exploitation, misappropriation of property, injury of unknown origin, resident to resident altercation, and suspicions of sexual crime by the licensed nurse immediately to ensure timely reporting to the state agencies. The result of the audit will be presented by the Administrator to the morning meeting daily. If any problems or issues are identified, they will be addressed immediately by the Administrator. 3. The Administrator in-serviced staff from 8/8/2024 through 8/9/2024. The staff was educated that the facility abuse coordinator is the Administrator and all allegations of abuse and neglect must be reported immediately to the administrator due to the 2 hour requirement for the administrator to notify the State Survey Agency of all allegations of abuse. The following staff received this education: 1 of 1 Director of Nursing, 1 of 1 Social Worker, 1 of 1 Maintenance Director, 2 of 2 Activity Directors, 8 of 8 Registered Nurses, 9 of 10 Licensed Practical Nurses, 27 of 27 Certified Nurse Assistants, 9 of 9 housekeeping staff, 11 of 12 Dietary Staff, 1 of 1 Business Office Manager, and 6 of 6 Therapists. The staff not present will be educated prior to returning to work by the Director of Nursing. No staff will be allowed to work until educated. As of 8/11/2024 no new staff hired. 76 of 78 staff (totaling 98%) were educated on abuse. 4. As of 8/9/2024 the Administrator will audit each new event to ensure timely reporting to the State Survey Agency with the tool titled New Reportable Audit for Events. The Administrator will bring the New Reportable Audit for Events tool to the morning meeting daily (Monday-Friday) and the weekends will be reported on Monday morning in our morning meeting for review beginning on 8/9/2024. The Administrator will continue to complete the New Reportable Audit for Event tool daily through 8/11/2024 with no new negative findings. If the tool identifies that an event was not reported in a timely manner, the staff and Administrator will be reeducated on timely reporting by the Regional Director of Operations immediately. 5. On 8/8/2024 the Quality Assurance committee which consist of Administrator, DON, MDS, Dietary Manager, Business Office Manager, Nurse Aide, Rehab Manager, Social Worker, Housekeeper Manager, Maintenance Director, and Activity Manager reviewed the facility 4 cited immediate jeopardy (IJ) tags. The committee determined the root cause of F610. The facility failed to conduct an investigation and provide protective measures in a timely manner following an incident of resident-to-resident sexual abuse involving R4 and R5 that occurred on 7/7/2024. The Quality Assurance committee reviewed the facility policies titled Investigation of Injuries revised 2016 and Protection of Residents during Abuse Investigation revised April 2017. No further revisions to policies were made. The Medical Director was notified of the policy on 8/9/2024 with no changes or suggestions. Review of policy determined the need for 100% staff education for investigating allegations of abuse in a timely manner. Quality Assurance committee implemented a new QAPI tool New Reportable Audit for Events. and Behavior QAPI tools will be brought to morning meeting daily (Monday-Friday) and the weekends will be addressed on Monday. The committee includes the Administrator, DON, MDS, Dietary Manager, Business Office Manager, Nurse Aide, Rehab Manager, Social Worker, Housekeeping Manager, Maintenance Director, and Activity Manager. 6. All corrections actions were completed on 8/11/2024. 7. The immediacy of the (IJ) tag was removed on 8/12/2024. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Verified via review of an 8/8/2024 physician's order for R5 for 1:1 monitoring related to sexual behaviors and the accompanying Resident Location Checksheet(s). R4's room change was verified via review of a communication form, dated 7/26/2024, that documented a room change to a different hall. R4 was observed in the new room on 7/29/2024 at 4:20 pm. Nurse Practitioner (NP) assessments were verified via review of clinical records, including 8/8/2024 nurse's notes entries, made by the Director of Nursing (DON), in R4's and R5's clinical records that documented the Nurse Practitioner was at the facility doing rounds, with no issues or concerns noted and no new orders for R4 and R5. Review of the skin assessment forms for R4 and R5, verified completed with no new areas noted. Per review of physician's orders and Medication Administration Records (MARs), R4 and R5 had been on behavior monitoring every shift since June 2023 (the entry of 6/2024 in the AOC is a typing error). Review of behavioral health NP notes from 7/9/2024 for R4 and R5 verified that she visited and assessed them. During an interview on 8/8/2024 at 3:56 pm, the NP confirmed that she saw R4 and R5 on 7/9/2024. Review of R5's physician's orders and July 2024 MAR confirmed that Zoloft 50 milligrams (mg), 1.5 tablets (75 mg) by mouth daily was started on 7/9/2024 to address hypersexual behavior. 2. Verified via interview on 8/19/2024 at 2:35 pm with the DON and with the Administrator on 8/19/2024 at 2:55 pm. Verified via review of the Audit of Reportable Events form, dated 8/8/2024 and review of the New Reportable Audit for Events for July 2024, which included four events involving R4, R5, R8 and R16. The events involving R4, R5, and R8 were already known to surveyors. A record review on R16 for an injury of unknown origin was conducted which verified the information on the audit form was correct. During an interview on 8/15/2024 at 4:15 pm the Regional Director of Operations clarified that the QAPI tool titled New Reportable Audit for Events was a form that was already in use. The new tool developed is titled Daily Reportable Log and provided a copy to review. The Regional Director stated that the Administrator brings the tool to the daily morning meetings Monday through Friday. During an interview on 8/19/2024 at 2:55 pm the Administrator confirmed the use of the Daily Reportable Log tool during morning meetings. Verified the tool had been implemented via review of the Daily Reportable Log that included documentation of reviews 8/9/2024-8/15/2024. 3. Verified via review of in-service education sign in sheets labeled with Abuse and Neglect, recognizing signs and symptoms of abuse, Abuse Coordinator, Reportables must be reported in 2 hours, along with the accompanying education information, dated 8/8/2024 and 8/9/2024. The staff signature sheets included a total of 79 staff were educated. During an interview with the Regional Director of Operations and MDS Coordinator on 8/19/2024 at 12:06 pm, it was clarified that 12 of 12 dietary staff were in-serviced and 5 of 6 therapy staff were in-serviced. They confirmed that one LPN and one therapy staff were out on leave and would be educated upon return to work. Staff interviews conducted on 8/18/2024 at 12:40 pm with LPN DD, at 12:49 pm with housekeeper BBB, at 12:55 pm with RN JJ, on 8/19/2024 at 11:30 am with the Housekeeping Manager, at 11:38 am with housekeepers SSS and CCC, at 12:15 pm with the Dietary Manager, at 12:20 pm with the Maintenance Director, at 1:02 pm with activity assistant MM, at 1:14 pm with the Social Services Director and Activity Director, at 1:32 pm with CNA DD, at 1:35 pm with dietary staff EEE and FFF, at 1:40 pm with the Business Office Manager, and at 2:45 pm with the MDS Coordinator confirmed they had received education that abuse and neglect and what it included, recognizing signs of abuse and neglect, that the Abuse Coordinator is the Administrator and that all allegations of abuse must be reported immediately. They were also knowledgeable about the 2-hour requirement for the Administrator to report to the state survey agency. During an interview on 8/19/2024 at 2:55 pm the Administrator confirmed provide the in-service education information on 8/8/2024 and 8/9/2024. 4. During an interview on 8/15/2024 at 4:15 pm the Regional Director of Operations clarified that the QAPI tool titled New Reportable Audit for Events was a form that was already in use. The new tool developed is titled Daily Reportable Log and provided a copy to review. The Regional Director stated that the Administrator brings the tool to the daily morning meetings Monday through Friday. During an interview on 8/19/2024 at 2:55 pm the Administrator confirmed the use of the Daily Reportable Log tool during morning meetings and that new events will be audited to ensure timely reporting and investigation. Verified the tool had been implemented via review of the Daily Reportable Log that included documentation of reviews 8/9/2024-8/15/2024. 5. Verified via review of the 3rd Quarterly Monthly QA/PI Meeting Agenda form, dated 8/8/2024 that documented an ad hoc meeting was held and the Immediate Jeopardy and abuse policies were reviewed. The signatures of the QA committee members were included along with copies of the completed Immediate Jeopardy Templates and copies of the Investigating Injuries policy and Protection of Residents During Abuse Investigations policy. Interviews conducted on 8/19/2024 at 11:30 am with the Housekeeping Supervisor, at 12:15 pm with the Dietary Manager, at 12:20 pm with the Maintenance Director, at 1:14 pm with the Activity Director and Social Services Director, at 1:40 pm with the Business Office Manager, at 2:35 with the DON, at 2:45 pm with the MDS Coordinator and Regional Director of Operations, and at 2:55 pm confirmed that they held a QA meeting on 8/8/2024, reviewed policies, and reviewed and determined the root cause of F610. During an interview on 8/12/2024 at 1:04 pm the Medical Director confirmed knowledge of the Immediate Jeopardy.

Based on interviews, record reviews, and review of the job descriptions for Nursing Home Administrator and Director of Nursing (DON), facility Administration failed to ensure that all components of the facility's abuse prevention system were implemented in a thorough and timely manner to address allegations of abuse or injury of unknown origin for four Residents (R) (R4, R5, R3, and R8), from a total sample of 21 residents. On 8/8/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Minimum Data Set (MDS) Nurse, and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 8/8/2024 at 11:25 am. The noncompliance related to the IJ was identified to have existed on 7/7/2024. An Acceptable IJ Removal Plan was received on 8/15/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 8/12/2024. Findings include: The facility had a job description for the Nursing Home Administrator. The general purpose of the Administrator was to lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. The description included job duties and responsibilities for the categories of facility management, compliance management, facility staff and retention, business management, marketing and revenue management, community relations, and other duties. The category of Compliance Management included to maintain a working knowledge of and confirm compliance with all governmental regulations. The category of Other Duties included to protect residents from neglect, mistreatment, and abuse. The facility had a job description for the Director of Nursing. The general purpose of the DON was to manage the overall operations of the nursing department in accordance with company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs. The description included job duties and responsibilities included administrative functions, meeting functions, personnel functions, nursing care functions, safety and sanitation, equipment and supply functions, care plan and assessment functions, documentation, and budget and planning functions. The category of Administrative Functions included to organize, develop, and direct the administration and resident care of the nursing service department. The category of Nursing Care Functions included to perform nursing services and deliver resident care services in compliance with corporate policies and state and federal regulations. Also, inform state of any reportable incidents within appropriate time frames, and complete investigative analysis as required. Facility Administration failed to consistently and effectively oversee areas of the facility that were included in their job descriptions. 1. Administration failed to maintain an environment free from sexual abuse for one resident (R5). The sexual abuse was caused by another resident. Cross refer to F600 2. Administration failed to ensure that abuse allegations or injury of unknown origin were reported to the state survey agency in a timely manner for four residents (R3, R4, R5, and R8) Cross refer to F609 3. Administration failed to ensure that an allegation of sexual abuse involving two residents (R4 and R5) was reported to law enforcement in a timely manner. Cross refer to F609 4. Administration failed to ensure that the initial and follow-up reports to the state survey agency for an allegation of sexual abuse involving R4 and R5 contained accurate and complete information. Cross refer to F610 5. Administration failed to ensure that an allegation of sexual abuse involving two residents (R4 and R5) was thoroughly investigated, and corrective actions implemented, including protection of the resident, in a timely manner. Cross refer to F610 During an interview on 7/31/2024 at 10:55 am, the DON stated that she started working at the facility at the end of May 2024. When questioned about the sexual abuse incident that occurred between R4 and R5 on 7/7/2024, the DON responded that she had never dealt with that situation before. She stated that the training she had at the facility was minimal to none. When asked if she knew what her role was and what she was supposed to do when that situation occurred, she responded no. During an interview on 7/31/2024 at 11:25 am, the Administrator confirmed he was the facility's Abuse Coordinator. When questioned about what he does when there is an allegation of abuse, the Administrator left the interview and returned a short time later and stated that the first thing to do is to decode the information. He then provided a copy of a paper in-service titled In-Service Allegation of Abuse or Sexual Act, that included the protocol for staff to follow when a sexual act or abusive act was observed. The Administrator stated that he gave a copy to everyone in the building and would give a copy to new employees during orientation. The in-service information did not include what the Administrator's role was in the protocol. The facility implemented the following actions to remove the IJ: 1. R 8 was discharged to the hospital from our facility on 7/15/2024 and then was transferred from the hospital to another facility on 7/22/2024. Resident 5 put on one-on one monitoring on 8/8/2024 to monitor behaviors. R4 was moved to another room on the opposite hall away from R5 on 7/26/2024. Residents 3, 4, 5, and all other residents was assessed by the Medical Director's Nurse Practitioner on 8/8/2024. No adverse effects were noted. All residents were given head-to-toe skin assessments on 8/8/2024-8/9/2024 by nursing staff. The head-to-toe assessments revealed that 60 out 60 residents had no bruising or signs of abuse. This was to ensure that no harm to the residents had occurred. Mental Health services evaluated R4 and R5 on 7/9/2024 no adverse effects were noted. The regional Director of Operations reviewed job duties with the Administrator and the Director of Nursing on 8/10/2024. 2. The Administrator was in-service on 8/8/2024 by the Chief Operations Officer. The Director of Nursing was in-serviced on 8/9/2024 by the Regional Director of Operations, on protecting all residents from abuse and neglect. The education included that abuse and neglect includes mistreatment, exploitation, misappropriation of property, injury of unknown origin, resident to resident altercation, and sexual abuse. Recognizing and Identifying Abuse and Neglect, The Administrator and Director of Nursing, education included notification of all state agencies that consist of Police, State Ombudsman, State Survey Agency, and Adult Protective Services. The education included the importance of timely and effective investigation of events with final summary submitted to the State Agency within the five-day time frame. The Administrator's education included protecting all residents from abuse and neglect. Job duties were reviewed with the Administrator and DON in addition to the in-service that was provided. 3. The Administrator in-serviced staff from 8/8/2024 through 8/9/2024, the staff was educated that the facility abuse coordinator is the Administrator and all allegations of abuse and neglect must be reported immediately to the Administrator. Staff were educated to report allegations of abuse immediately to the Administrator due to the 2-hour requirement for the administrator to notify the State Agency of all allegations of abuse. The following staff received this education: 1 of 1 Director of Nursing, 1of 1 Social Worker, 1of 1 Maintenance Director, 2 of 2 Activity Directors, 8 of 8 Registered Nurse, 9 of 10 Licensed Practical Nurse, 27 of 27 Certified Nurse Assistants, 9 of 9 housekeeping staff, 11 of 12 Dietary Staff, 1 of 1 Business Office Manager, and 6 of 6 Therapists on protecting all residents from abuse and neglect. This includes all full-time, part-time and as needed staff. No contract or agency staff used. The staff not present will be educated prior to returning to work by the Director of Nursing. No staff will be allowed to work until educated. As of 8/11/2024 no new staff have been hired. A total of 98% of total staff were educated on abuse. 4. As of 8/9/2024 the Administrator will audit each new event to ensure timely reporting to the State Survey Agency with the tool titled New Reportable Audit for Events. The Administrator will bring the New Reportable Audit for Events tool to the morning meeting daily (Monday-Friday) for review beginning on 8/9/2024 and weekend will be reviewed on Monday in morning meeting. The Administrator will continue to complete the New Reportable Audit for Event tool daily through 8/11/2024 with no new negative findings. If the tool identifies that an event was not reported in a timely manner, the staff and Administrator will be reeducated on timely reporting by the Regional Director of Operations immediately. 5. 8/8/2024, the Quality Assurance committee reviewed the facility 4 cited immediate jeopardy (IJ) tags. The committee consists of the Administrator, DON, MDS, Dietary Manager, Business Office Manager, Nurse Aide, Rehab Manager, Social Worker, Housekeeper Manager, Maintenance Director, Activity Manager met to review and determine the root cause of F835. The findings were the Administrator failed to ensure that all components of the facility's abuse policy to address allegations of abuse and injuries of unknown origin for R4, 5, 3, and 8 were implemented in a thorough and timely manner. The committee determined the root cause of F835 also includes the facility's failure to timely investigate allegations of abuse and failed to investigate resident to resident sexual abuse. The facility also failed to recognize patterns and behaviors and failed to protect all residents. The administration failed to ensure that all components of the facility abuse policy addressed allegations of abuse of injury of unknown origin for 4 residents. The Quality Assurance Committee reviewed the facility's policies entitled Investigating Injuries revised 2016 and Protection of Residents during Abuse Investigations revised April 2017. No further revisions were made. Review of policy determined the need for 100% staff education for investigation allegations of abuse in a timely manner. The tool will be brought to daily morning meeting (Mon-Friday) and then the weekend days will be reviewed on Monday mornings. 6. Ala corrections actions were completed 8/11/2024. 7. The immediacy of the (IJ) was removed on 8/12/2024. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Verified transfer to hospital via review of R8's clinical record. Verified via review of the 8/8/2024 physician's order for R5 and the accompanying monitoring forms. Verified via review of an 8/8/2024 physician's order for R5 for 1:1 monitoring related to sexual behaviors and the accompanying Resident Location Checksheet. R4's room change was verified via review of a communication form, dated 7/26/2024, that documented a room change to a different hall. R4 was observed in the new room on 7/29/2024 at 4:20 pm. Review of R3, R4 and R5's clinical records revealed that the Nurse Practitioner visited and assessed them on 8/8/2024. A review of skin assessment forms revealed that a skin assessment was completed on 60 residents from 8/8/2024-8/9/2024. Validated review of job duties via review of in-service education information and sign-in sheet, dated 8/10/2024 and titled Job Duties which was signed by the Administrator, DON, and Regional Director of Operations. Interviews on 8/19/2024 at 2:35 pm with the DON, 2:45 pm with the Regional Director of Operations, and at 2:55 with the Administrator confirmed that the Administrator and DON's job duties had been reviewed with them and they acknowledged understanding. 2. Also, verified via review of in-service education information provided by the Regional Director of Operations titled Abuse and Neglect, which was signed by the Administrator, DON, and dated 8/8/2024. During interviews on 8/19/2024 at 2:35 pm with the DON and at 2:55 pm with the Administrator, they confirmed receiving the in-service education information from the Regional Director of Operations. The Administrator also confirmed receiving inservice education from the Chief Operating Officer on 8/8/2024 related to abuse policy and procedures, investigations, and reporting. 3. Verified via review of in-service education sign in sheets labeled with Abuse and Neglect, Recognizing signs and symptoms of abuse, Abuse Coordinator, Reportables must be reported in 2 hours, along with the accompanying education information, dated 8/8/2024 and 8/9/2024. The staff signature sheets included a total of 79 staff were educated. During an interview with the Regional Director of Operations and MDS Coordinator on 8/19/2024 at 12:06 pm, it was clarified that 12 of 12 dietary staff were in-serviced and 5 of 6 therapy staff were in-serviced. They confirmed that one LPN and one therapy staff were out on leave and would be educated upon return to work. Staff interviews conducted on 8/18/2024 at 12:40 pm with LPN DD, at 12:49 pm with housekeeper BBB, at 12:55 pm with RN JJ, on 8/19/24 at 11:30 am with the Housekeeping Manager, at 11:38 am with housekeepers SSS and CCC, at 12:15 pm with the Dietary Manager, at 12:20 pm with the Maintenance Director, at 1:02 pm with activity assistant MM, at 1:14 pm with the Social Services Director and Activity Director/Manager, at 1:32 pm with CNA DD, at 1:35 pm with dietary staff EEE and FFF, at 1:40 pm with the Business Office Manager, and at 2:45 pm with the MDS Coordinator confirmed they had received education that abuse and neglect and what it included, recognizing signs of abuse and neglect, that the Abuse Coordinator is the Administrator and that all allegations of abuse must be reported immediately. 4. During an interview on 8/15/2024 at 4:15 pm the Regional Director of Operations clarified that the QAPI tool titled New Reportable Audit for Events was a form that was already in use. The new tool developed is titled Daily Reportable Log and provided a copy to review. The Regional Director stated that the Administrator brings the tool to the daily morning meetings Monday through Friday. During an interview on 8/19/2024 at 2:55 pm the Administrator confirmed the use of the Daily Reportable Log tool during morning meetings and that new events will be audited to ensure timely reporting and investigation. Verified the tool had been implemented via review of the Daily Reportable Log that included documentation of reviews 8/9/2024-8/15/2024. 5. Verified via review of the 3rd Quarterly Monthly QA/PI Meeting Agenda form, dated 8/8/2024 that documented an ad hoc meeting was held and the Immediate Jeopardy and abuse policies were reviewed. The signatures of the QA committee members were included along with copies of the completed Immediate Jeopardy Templates and copies of the Investigating Injuries policy and Protection of Residents During Abuse Investigations policy. Interviews conducted on 8/19/2024 at 11:30 am with the Housekeeping Supervisor, at 12:15 pm with the Dietary Manager, at 12:20 pm with the Maintenance Director, at 1:14 pm with the Activity Director/Manager and Social Services Director, at 1:40 pm with the Business Office Manager, at 2:35 with the DON, at 2:45 pm with the MDS Coordinator and Regional Director of Operations, and at 2:55 pm confirmed that they held a QA meeting on 8/8/2024, reviewed policies, and reviewed and determined the root cause of F835. During an interview on 8/12/2024 at 1:04 pm the Medical Director confirmed knowledge of the Immediate Jeopardy.

Based on record review, staff, resident, and family interviews, and review of the facility policy titled, Abuse Prevention Policy & Procedure the facility failed to ensure that residents were free from physical abuse from Resident (R) #1, and the facility failed to protect residents from continued abuse for 11 of 23 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16) reviewed for abuse. On 1/29/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and Social Services Director were informed of the Immediate Jeopardy on 1/29/2020 at 10:26 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/26/19. Immediate Jeopardy is outlined as follows: Resident (R) #1, a [AGE] year-old ambulatory male resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 had been prescribed [MEDICATION NAME] (an antipsychotic medication) since 2012. When R#1 was admitted to the facility this medication was discontinued because the Attending Physician/Medical Director did not complete the required online training required by the prescribing pharmacy in order to administer this medication. In addition, this medication required a laboratory test (ANC-Absolute [DIAGNOSES REDACTED] Count) be obtained and there was no evidence the required laboratory test was obtained. In addition, R#1 had a Preadmission Screening/Resident Review (PASSR) Level II dated 8/9/2019, that recommended medication management and on-going psychiatric care and treatment. There was no evidence the facility provided R#1 with any psychiatric services from the time of his admission on 8/15/19, until a new Behavior Health provider began providing psychiatric/behavioral health services on 1/9/2020. Record review revealed that R#1 started refusing his medications and on 9/26/2019, R#1 attacked R#5 and pushed him to the floor and kicked him. From 9/26/2019 until 1/18/2020, R#1 attacked 11 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16). Two of these eleven residents (R#3 and R#2) had to be sent to the emergency room for evaluation and treatment. R#3 had an acute/chronic displaced nasal fracture and R#2 received a laceration that required Dermabond to close. Record review revealed R#1 was sent out to a Behavioral Health Unit on 10/3/2019, 11/4/2019, 12/3/2019, 12/24/19, and although the facility was not able to meet his needs for medication management and ongoing psychiatric services the facility continued to readmit R#1 back to the facility. Although the facility was aware of R#1's aggressive behavior the facility failed to put measures in place to protect residents from R#1. In addition, the facility failed to provide psychiatric services for other residents in the facility with Level II PASSRs that had recommendations for psychiatric services from October of 2019 until January of 2020. On 1/18/2020, after R#1 was in a physical altercation with another resident R#1 was sent out of the facility to a Behavioral Health Facility. The facility did not have any plans to readmit R#1 after he was sent out of the facility on 1/18/2020. The immediate jeopardy is outlined as follows: 42 CFR 483.12 (a)(1) Abuse and Neglect, F600, Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; C.F.R. 483.15(a) Admissions policy, F620 Scope/Severity: K; 42 CFR 483.20(k)(1)-(3) PASARR Screening for MD & ID, F645 Scope/Severity: J; 42 CFR 483.21(b) Comprehensive Care Plans,42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision, F657 Scope/Severity: K; 42 CFR 185.25 Quality of Care, F684 Scope/Severity: J;42 CFR 483.25 Quality of Care, F684; 42 CFR 483.40 Behavioral Health, F740 Scope/Severity: K; 42 CFR 483.40(a) Sufficient/Competent Staff-Behavioral Health Needs,F741 Scope/Severity: K; 42 CFR 483 40(d) Provision of Medically Related Social Services; F745 Scope/Severity: J; 42 CFR 483.70 Administration, F835 Scope/Severity: K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; 42 CFR 483.25 Quality of Care, F684 Scope/Severity: J; and 42 CFR 483 40(d) Provision of Medically Related Social Services, F745 Scope/Severity: J. At the time of the exit on February 3, 2020, the Immediate Jeopardy remained ongoing. Findings include: Review of the facility policy titled, Abuse Prevention Policy & Procedure (revised 2/26/19) revealed that the purpose of this written Resident Abuse, Neglect and Misappropriation Prevention Program (RANMP) is to outline the preventative steps taken by this facility to reduce the potential for the mistreatment, neglect and abuse of residents and the misappropriation of resident property, and to review those practices and omissions, which if allowed to go unchecked, could lead to abuse. The scope of this program should apply to the prevention of abuse committed by anyone, including but not limited to, staff, other residents, consultants, volunteers and staff of other agencies serving the individual, family members, legal guardians, friends, or other individuals. The Policy Statement reads, This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical, and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Though it cannot guarantee that such occurrences will not occur at this facility, preventative steps will be taken to reduce the potential for such occurrences. Report all allegation of abuse immediately to the Director of Nursing and Administrator. Any allegation of abuse is reported immediately to the state agency and to all other agencies as required, per state and federal guidelines. 1. Record review revealed that R#1 was admitted on [DATE] to the nursing home facility, from an acute care hospital, with the following [DIAGNOSES REDACTED]. His discharge medication list from the acute care hospital included [MEDICATION NAME] (only antipsychotic medication approved by the FDA for treatment-resistant [MEDICAL CONDITION]. This medication is used after all other medications have failed). The most recent Minimum Data Set (MDS) for R#1 was an Admission assessment dated [DATE] and under Section C - Cognitive Patterns his cognitive level was assessed to be 10 out of 15 indicating that R#1 was moderately cognitively impaired. Investigation revealed that the following 11 residents were physically assaulted by R#1: 2. R#2 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Significant Change assessment dated [DATE] revealed a Brief Mental Status Interview (BIMS) score of 3, indicating severe impairment. The MDS Section G Functional Status revealed R#2 walked unsteady, had no upper or lower impairment, and used a wheelchair for mobility. Review of the facility Progress Notes dated 10/4/19 through 1/14/2020 revealed on 12/3/19 R#2 had an open area over his left eye. The Physician came to the facility and wanted R#2 sent to the emergency room (ER) for a Computed Tomography (CT) scan and evaluation. A later entry on the same day, documented that R#2 returned from the ER with no new orders. R#2 had facial contusions and laceration, bruising to the left eye and swollen left jaw. Review of the Emergency Record dated 12/3/19 revealed R#2 was assaulted at nursing home by another patient and fell hitting his face on a bedside table during this altercation. Patient is currently on [MEDICATION NAME] and is a poor historian. The CT scan of the head, cervical spine and the Maxillofacial area were negative for fractures. The discharge instructions dated 12/3/19 revealed R#2 had a closed head injury. And to follow up with primary care Physician in 2-3 days. During an interview on 1/15/2020 at 11:44 a.m. R F stated he witnessed R#1 hitting R#2. He stated that R#2 was walking that day. R#1 stood up and knock the Hell out of R#2. R F continued to say that he tried to help break up the fight. R F stated that he had gotten out of his wheelchair to get R#2 away from R#1. The nurses then came and took over. Everything got quiet after R#1 and R#2 were separated. During an interview on 1/15/2020 at 12:26 p.m. Certified Nurse Aide (CNA) FF revealed that R#2 got jumped on by another resident that she identified R#1 as the attacker and that R#1 had busted R#2's forehead open. R#2 had a deep gash above his left eyebrow. CNA FF stated she grabbed a towel and applied pressure. CNA FF stated that R#1 is dangerous and he will walk up to anybody and start hitting them. During an interview on 1/16/2020 at 12:17 p.m. LPN JJ revealed that R#1 had assaulted R#2. And that R#2 had two black eyes. During an interview on 1/16/2020 at 3:41 p.m. LPN LL revealed R#1 hit R#2 in the face and R#2 was sent to the ER for a laceration. 3. Record review revealed that R#3 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed a BIMS score of 13 indicating cognitition intact. The MDS Section G Functional Status revealed R#3 could walk unsteady but able to stabilize without help; had impairment of upper and lower extremities on one side and did not use a device for mobility. Review of the facility Progress Notes dated 11/5/19 through 1/22/2020 revealed on 11/9/19, the residents were standing in line to go outside to smoke, when R#3 suddenly began crying and hollering. R#1 had punched R#3 in the face, head and neck. R#3 was extremely upset and complained of severe pain to the left jaw, neck and shoulder areas and the left jaw area appeared to have swelling. This incident was witnessed by R#7. R#3 was sent to the ER for evaluation. The guardian was unsuccessfully notified. (sic) Review of an Emergency Medical System (EMS) report dated 11/9/19 revealed that the EMS had responded to the location due to an assault per dispatch. Nursing staff advised EMS that patient was punched by a male patient. Review of the Emergency Department Triage dated 11/9/19 revealed R#3 had pain to her neck, right side of face. Patient was assaulted by another patient in the nursing home. The CT scan of the maxillofacial area revealed acute/chronic nondisplaced bilateral nasal bone fractures. Review of the hospital Request for Accident Information (Non-MVA) form for R#3 dated 11/9/19 revealed patient was assaulted. During an interview on 1/15/2020 at 11:11 a.m. R#3 revealed that she was going out for a smoke break at night time and she was trying to get out the door when a tall man in front of her (R#1) was holding the door and the light from inside was shining outside. R#3 said the man hit her right shoulder, side of the neck, and that he hit her so hard that all she could say was ouch. She didn't fall but she staggered. R#3 stated that her face was swollen and that she went to the hospital. R#3 said she tries to keep her distance from R#1 because she is afraid that he may hurt her. During an interview on 1/16/2020 at 3:41 p.m. LPN LL revealed that R#1 hit R#3 on the side of the face and she was sent to the emergency room and that she was afraid of R#1. LPN LL continued to state that she has not had any training on how to care for residents with psychiatric diagnoses/mental illnesses and that she did not know what to do. LPN LL stated, when you call the police, the police could not take him and that R#1 does not listen to anybody. During an interview on 1/21/2020 at 11:36 a.m. the Attending Physician/Medical Director revealed he was aware that R#3 had been hit by R#1. However, the CT report for acute/chronic bilateral nasal fracture, means that reader could not decide if it was acute or chronic, and the Attending Physician/Medical Director stated he didn't read the report. 4. Review of the nursing facility Admission Record revealed R#4 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed BIMS score of 4 indicating severe cognitive impairment. The MDS Section G Functional Status revealed R#4 could not walk in corridor or unit, had lower extremity impairment on one side and used a wheelchair for mobility. Review of the facility Progress Notes dated 8/29/19 through 1/8/2020 revealed an incident that occurred on 9/29/19 documented that R#1 hit R#4 without any reason and that R#1 stated R#4 had a body odor and was walking too close to him. There were not any injuries noted. 5. Review of the nursing facility Admission Record revealed R#5 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed BIMS score of 14 indicating the resident was cognitively intact. The MDS Section G Functional Status revealed R#5 could walk unsteady but able to stabilize without help, did not have any impairment and did not use a device for mobility. Review of the facility Progress Notes dated 9/24/19 through 1/16/2020 revealed an incident that occurred on 9/26/19 with R#1 that a nurse heard a commotion in the dining room and observed R#1 push R#5 down. There were not any injuries noted. 6. Review of the nursing facility Admission Record revealed R#6 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed BIMS score of 9 indicating moderate impaired cognitition. The MDS Section G Functional Status revealed R#6 could walk unsteady but able to stabilize without help, had no upper or lower extremity impairment and used a walker for mobility. Review of the nursing Progress Notes date 11/13/19 through 12/11/19 revealed R#6 was roommates with R#1 on 11/17/19, it is documented that R#1 kicked R#6 out of the shared room. R#6 was afraid of R#1 and made a permanent room change. There were not any injuries noted. During an interview on 1/15/2020 at 12:26 p.m. CNA FF revealed that R#6 was R#1's roommate and that when R#6 came out of the room to the nursing station R#6 told the nurses that that he was afraid of R#1. During an interview on 1/15/2020 at 1:14 p.m. CNA HH stated that R#6 was roommate with R#1. R#6 was moved to another room after R#1 kicked him out and that they (CNAs) do not know what to do with R#1. No one has told them what to do. 7. Review of the nursing facility Admission Record revealed R#7 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed a BIMS score of 13 indicating cognitition intact. The MDS Section G Functional Status revealed R#7 could walk unsteady but able to stabilize without help, had no upper or lower extremity impairment and used a wheelchair for mobility. Review of the nursing facility Progress Notes dated 12/12/19 through 1/23/2020 revealed on 12/27/19 that R#7 reported to the nurse that another resident had fallen on him and that he pushed the other resident off him. The other resident turned around and hit him in the face. R#7 sustained a small superficial laceration beneath the left eyebrow. During the investigation, R#1 was identified as being the resident that hit R#7 in the face. Review of the Skin assessment dated [DATE] revealed R#7 had an abrasion to the left side of the forehead. During an interview on 1/15/2020 at 11:44 a.m. R#7 (BIMS 13 indicating cognitition intact) revealed that R#1 swung at him and knocked him out his wheelchair shortly after Christmas. He hurt his knee, this happened near the nursing station. When R F stated that he wasn't afraid, but he was mad that R#1 knocked him out of his wheelchair. 8. Review of the facility Admission Record revealed R#8 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed BIMS score of 9 indicating moderate cognitive impairment. Review of the facility Progress Notes dated 12/22/19 through 1/14/2020 revealed on 1/1/2020 that R#8 reported a resident had hit her in the face and eye. There were not any injuries noted. During an interview on 1/16/2020 at 3:35 p.m. LPN KK revealed that R#8 told her that R#1 hit her in the eye. And LPN KK stated that staff and residents are afraid of R#1. During an interview on 1/21/2020 at 1:13 p.m. the former DON revealed that R#8 had come to her and she reported the incident of R#1 hitting her in the eye. 9. Review of the facility Admission Record revealed R#9 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed BIMS of 00 indicating severe cognitive impairment. The MDS Section G Functional Status revealed R#9 could walk unsteady with help, had lower extremity impairment on one side and did not use a device for mobility. During an interview on 1/15/2020 at 1:14 p.m. CNA HH revealed that he was walking R#9 toward the dining room, when R#1 came walking behind them with his arm in the air to hit R#9. He stated that he quickly moved R#9 out of the way. This incident occurred late September or early October. CNA HH could not recall the name of nurse to whom he reported the incident. During an interview on 1/15/2020 at 2:03 p.m. CNA GG revealed that R#9 was walking in the hallway and R#1 walked up on R#9 with his arm up to hit R#9. She stated that she grabbed R#9 arm and moved him away from R#1. And that R#1 told her that he was glad that she had gotten R#9, because he was getting ready to hit R#9 because he could not help it. This happened in late September. And that she reported it to the nurse but could not recall which nurse. She revealed that she has not had any training for residents with mental illnesses and that she does not know what to do because there is nothing in place to follow. 10. Review of the facility Admission Record revealed R#10 was admitted with [DIAGNOSES REDACTED]. The MDS Admission assessment dated [DATE] revealed BIMS score of 4 indicating severe cognitive impairment. The MDS Section G Functional Status revealed R#10 could walk unsteady but able to stabilize without help, had no upper or lower extremity impairment and did not use a device for mobility. Review of the facility Progress Notes dated 10/11/19 through 12/30/19 revealed on 10/18/19 a CNA reported that when she went to R#10 room to get him for a shower, R#10 had an open spot over his left eye. An on 10/22/19, R#10 wandered into R#1's room, and R#1 threw R#10 into the hall. R#10 landed on his face. He was assisted off the floor by the CNAs who noticed R#10 was bleeding. R#10 was taken to the ER. Review of emergency room Assessment Report dated 10/22/19 revealed R#10 was sent to the ER from the nursing facility. He had approximately 5 cm laceration above the right eye. Per EMS, patient was pushed across the room. The laceration located above the right eye was closed with Dermabond Advance. The CT scan of the head and cervical spine were negative for fractures. During an interview on 1/15/2020 at 2:03 p.m. CNA GG revealed that R#1 walks around jumping on people without a reason. CNA GG confimred that a male resident (identified as R#10) was hit and thrown out of R#1's room. CNA GG revealed that she had not had any training on providing care for residents with mental [DIAGNOSES REDACTED]. CNA GG continued to state that she stays away from R#1 and when she sees other resident going toward R#1, she will redirect the residents away from R#1. During an interview on 1/15/2020 at 3:02 p.m. CNA AA revealed that R#1 has a bad behavior problem. He would walk up on a person and hit them for no reason. She continued to state that R#10 wanders and R#1 grabbed him by the shoulder. By the time she got down the hall, R#10 was in the hall. She was told what had happened, and she could not remember if R#10 was hurt. 11. Record review revealed R#12 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed BIMS score of 12 indicating moderate cognitive impairment. The MDS Section G Functional Status revealed R#12 could walk unsteady but able to stabilize without help, had upper extremity impairment on one side and did not use a device for mobility. Review of the nursing facility Progress Notes dated 1/17/2020 through 1/21/2020 revealed on 1/18/2020 that R#1 walked up to him and slapped R#12. R#12 grabbed a wet floor cone and threw it at R#1. The two residents began to fight and fell to the floor. R#12 sustained a scratch to the left side of his face. The police were called and R#1 was sent to an acute care hospital for evaluation and was then transferred to an inpatient behavior health facility. Review of a Sherrif's Office Miscellaneous Incident Report dated 1/18/2020 documents that Law Enforcement responded to a call in reference to a fight at this facility and that staff advised that R#1 was at the nurse's desk and R#1 started swinging at R#12 and a fight broke out between the two residents. The staff seperated the residents. Law Enforcement made contact with R#12 who stated that R#1 swung on him for no reason and had caused a slight red scar on his head. The nurses at the nurses station advised Law Enforcement that R#1 had not been taking his medications for some days now and was known to be having physical altercations between staff and residents. Another Law Enforcement Officer arrived at the facility and and transported R#1 to an acute care hospital for a mental evaluation. 12. Review of the nursing facility Admission Record revealed R#16 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed a BIMS score of 15 indicating cognitition intact. The MDS Section G Functional Status revealed R#16 could walk unsteady but able to stabilize without help, had upper extremity impairment on one side and did not use a device for mobility. During an interview on 1/23/2020 at 2:03 p.m. R#16 (BIMS 15 indicating cognition intact) revealed that she was hit in her left eye by R#1. She stated it happened the day before he left. He walked up to her and just hit her in her left eye, and she that she was afraid of him. She continued to say that she had told LPN OO. There were not any injuries noted. Review of the psychiatric facility Admission History and Physical dated 12/24/19 revealed that R#1 apparently had become increasingly aggressive and agitated over the past several weeks. The inpatient psychiatric facility resumed R#1's [MEDICATION NAME] 50 milligrams (mg) take two tablets by mouth twice a day. The Discharge Summary dated 12/27/19 revealed that the plan for R#1 was to continue medications, encourage compliance and follow-up with local mental health center. R#1's discharge medications included for R#1 to continue to receive [MEDICATION NAME] 25 mg take two tablets by mouth daily. During an interview on 1/15/2020 at 1:14 p.m. Certified Nurse Aide (CNA) HH revealed that he witnessed another resident's Family of R T walking down the hall to leave, and R#1 charged at the resident's family member. CNA HH was asked to define what he meant by the word charged. He defined charged as an aggressive manner. CNA HH stated that R#1 is very noncompliant and is always in a violent rage. CNA HH revealed that the facility has not provided any type of training for residents with mental health issues. The facility has promised for seven years to give them training and some type of education, but this has not happened. Interview on 1/15/2020 at 3:44 p.m. with CNA II revealed that she has not been trained to handle residents with psychiatric [DIAGNOSES REDACTED].#1. During an interview on 1/16/2020 at 12:17 p.m. Licensed Practical Nurse (LPN) JJ revealed that R#1 is out of control and everybody is afraid of him. LPN JJ stated the evening shift is terrified of R#1. During an interview on 1/16/2020 at 12:29 p.m. the Psychiatric Nurse Practitioner (PNP) WW with the new psychiatric services revealed that she works for a psychiatrist. PNP WW stated that she started coming to the facility on [DATE] to see all residents on [MEDICAL CONDITION] drugs. PNP WW continued to state that R#1 does not need to be in this facility. He is a risk for harm to others. PNP WW stated that her first visit to the facility on [DATE] that she had been informed that R#1 had hit staff but that was not aware that he had hit other residents. PNP WW stated that at this point she only had access to the paper records, which contained labs and physician progress notes [REDACTED].#1. During an interview on 1/21/2020 at 11:36 a.m. the Physician/Medical Director (MD) revealed that in regard to being notified of R#1 assaulting other residents, that he was aware of one or two residents and two staff member who were assaulted by R#1, but that he may not have been told every name. Interview on 1/21/2020 at 1:13 p.m. with the former Director of Nursing (DON) revealed that she was against R#1 being admitted to the facility because he was on [MEDICATION NAME] ([MEDICATION NAME]) and the Physician did not have psychiatric experience. The former DON stated that R#1 was violent and noncompliant with his medications. The DON stated that the Administrator made the decision to admit/readmit R#1. The former DON stated that staff have never received any training on how to provide care and services for residents that have mental illnesses/psychiatric diagnoses. The former DON stated that she was aware of the incidents that occurred between R#1 and R#8, R#3, R#7, and R#6. During an interview on 1/22/2020 at 9:02 a.m. the Psychiatrist (with the Behavioral Health facility) revealed that the facility should have been trained on how to take care of residents with psychiatric [DIAGNOSES REDACTED].#1's prior psychiatric history; the number of hospitalization s; and his tendency toward violence. The Psychiatrist stated this should have been reviewed prior to the facility accepting R#1 into the nursing home facility. The Psychiatrist stated R#1 is a danger to others and that the best option for R#1 would be a state hospital. During an interview on 1/23/2020 at 1:26 p.m. Family of R T revealed he was in the facility visiting a resident. He revealed that he saw two male resident's fighting. He went over to try to separate them, because he works as security in a hospital. The nurse told him to stop. Family of R T stated R#1 was trying to hit the other male resident in the face. Family of R T said this happened on Thursday 1/18/2020 around 11:45 to 12:30 p.m. Further interview with Family of R T revealed that R#1 came up to him saying I will hurt you. He stated that he ignored R#1 and didn't say anything to the resident. Continued interview with Family of R T revealed that he had come to the facility to bring clothes to put in the closet for his family member and when he came out of her room, R#1 followed him from the nursing station to the dining room. Family of R T stated that this was the 3rd incident, other people in the facility did see these incidents. He stated that he did not report it because the resident did not touch him or the resident that he was visiting. Family of R T stated that he can't say if resident he was visiting was safe from R#1. During an interview on 2/3/2020 at 3:33 p.m. the Administrator stated that it was discussed with the team to accept R#1. The Administrator continued to state that each time R#1 was sent to a behavioral unit, he was readmitted to the facility because the receiving behavioral unit would not accept the resident for treatment without this agreement.

Based on record review, staff and resident interviews, review of the facility policy titled, Abuse Prevention Policy & Procedure the facility failed to ensure that all alleged violations involving abuse and neglect were reported timely, for seven of 23 residents (R#1, R#5, R#4, R#3, R#2, R#7, R#12) that were reviewed for abuse. On 1/29/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and Social Services Director were informed of the Immediate Jeopardy on 1/29/2020 at 10:26 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/26/19. Immediate Jeopardy is outlined as follows: Resident (R) #1, a [AGE] year-old ambulatory male resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 had been prescribed [MEDICATION NAME] (an antipsychotic medication) since 2012. When R#1 was admitted to the facility this medication was discontinued because the Attending Physician/Medical Director did not complete the required online training required by the prescribing pharmacy in order to administer this medication. In addition, this medication required a laboratory test (ANC-Absolute [DIAGNOSES REDACTED] Count) be obtained and there was no evidence the required laboratory test was obtained. In addition, R#1 had a Preadmission Screening/Resident Review (PASSR) Level II dated 8/9/2019, that recommended medication management and on-going psychiatric care and treatment. There was no evidence the facility provided R#1 with any psychiatric services from the time of his admission on 8/15/19, until a new Behavior Health provider began providing psychiatric/behavioral health services on 1/9/2020. Record review revealed that R#1 started refusing his medications and on 9/26/2019, R#1 attacked R#5 and pushed him to the floor and kicked him. From 9/26/2019 until 1/18/2020, R#1 attacked 11 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16). Two of these eleven residents (R#3 and R#2) had to be sent to the emergency room for evaluation and treatment. R#3 had an acute/chronic displaced nasal fracture and R#2 received a laceration that required Dermabond to close. Record review revealed R#1 was sent out to a Behavioral Health Unit on 10/3/2019, 11/4/2019, 12/3/2019, 12/24/19, and although the facility was not able to meet his needs for medication management and ongoing psychiatric services the facility continued to readmit R#1 back to the facility. Although the facility was aware of R#1's aggressive behavior the facility failed to put measures in place to protect residents from R#1. In addition, the facility failed to provide psychiatric services for other residents in the facility with Level II PASSRs that had recommendations for psychiatric services from October of 2019 until January of 2020. On 1/18/2020, after R#1 was in a physical altercation with another resident R#1 was sent out of the facility to a Behavioral Health Facility. The facility did not have any plans to readmit R#1 after he was sent out of the facility on 1/18/2020. The immediate jeopardy is outlined as follows: 42 CFR 483.12 (a)(1) Abuse and Neglect, F600, Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; C.F.R. 483.15(a) Admissions policy, F620 Scope/Severity: K; 42 CFR 483.20(k)(1)-(3) PASARR Screening for MD & ID, F645 Scope/Severity: J; 42 CFR 483.21(b) Comprehensive Care Plans,42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision, F657 Scope/Severity: K; 42 CFR 185.25 Quality of Care, F684 Scope/Severity: J;42 CFR 483.25 Quality of Care, F684; 42 CFR 483.40 Behavioral Health, F740 Scope/Severity: K; 42 CFR 483.40(a) Sufficient/Competent Staff-Behavioral Health Needs,F741 Scope/Severity: K; 42 CFR 483 40(d) Provision of Medically Related Social Services; F745 Scope/Severity: J; 42 CFR 483.70 Administration, F835 Scope/Severity: K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; 42 CFR 483.25 Quality of Care, F684 Scope/Severity: J; and 42 CFR 483 40(d) Provision of Medically Related Social Services, F745 Scope/Severity: J. At the time of the exit on February 3, 2020, the Immediate Jeopardy remained ongoing. Findings include: Review of the facility policy Abuse Prevention Policy & Procedure (revised 2/26/19) revealed that the purpose of this written Resident Abuse, Neglect and Misappropriation Prevention Program (RANMP) is to outline the preventative steps taken by this facility to reduce the potential for the mistreatment, neglect and abuse of residents and the misappropriation of resident property, and to review those practices and omissions, which if allowed to go unchecked, could lead to abuse. The scope of this program should apply to the prevention of abuse committed by anyone, including but not limited to, staff, other residents, consultants, volunteers and staff of other agencies serving the individual, family members, legal guardians, friends, or other individuals. RESIDENT-TO-RESIDENT ABUSE POLICY It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from physical and verbal abuse from other residents. Resident-to-Resident Abuse Policy, Procedures: 7. The investigation protocol must be implemented, and a report given to the appropriate agencies as specified by law and regulations. Procedures: 2. If staff and medications, as ordered by the Physician, cannot control residents, it may be necessary to call the local police for assistance. 5. REPORTING/INVESTIGATION/RESPONSE POLICY Administrator shall take the following actions to address issues of resident care raised by suspected abuse. 3. The Administrator or designee shall call local police when assault, sexual abuse, homicide, forgery or wanton neglect is suspected and/or confirmed by investigation. Procedures: Reporting - All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, so that the resident's needs can be attended to immediately and investigation can be undertaken promptly. Facility Reports - are official self- report notifications to the State Survey Agency or CMS Regional Office of incidents required by federal and/or state law, regulation or policy. 1. Review of the nursing facility Progress Notes for R#1 dated 9/26/19 revealed that R#1 assaulted R#5. R#1 pushed R#5 down and a fight evolved. Further record review revealed that the facility did not have any evidence of documentation that this incident was reported to the State Survey Agency or to law enforcement 2. Review of the nursing facility Progress Notes or R#1 dated 9/29/19 revealed that R#1 punched R#4 in the eye for no apparent reason, other than he did not like the way she smelled. Further record review revealed that the facility did not report this incident to the State Survey Agency or to law enforcement 3. Review of the nursing facility Progress Notes dated 11/9/19, for R#1, revealed that R#1 punched R#3 on the right side of the face, right side of neck, right shoulder and right shoulder blade. Further record review revealed that the facility did not report this incident to the State Survey Agency or to Law Enforcement. 4. Review of the nursing facility Progress Notes for R#1 dated 12/3/19 revealed that R#1 hit R#2 in the face. Further record review revealed that the facility did not report this incident to the State Survey Agency. 5. Review of the nursing facility Progress Notes dated 12/27/19 (R#7 health record) revealed that R#1 fell on to R#7 and when R#7 pushed R#1 off then R#1 hit R#7 in the face. Further record review revealed that R#7 received a superficial laceration beneath his left eyebrow. Further record review revealed that the facility did not report this incident to the State Survey Agency or to law enforcement 6. Review of the law enforcement Miscellaneous Incident Report dated 1/18/2020 revealed that R#1 was involved in an incident documented as: affray-fighting and disorderly conduct. Documentation revealed that R#1 began swinging at R#12 and a fight broke out between both residents. A slight red scar was noted to be on R#12's head. Further record review revealed that the facility did not report this incident to the State Survey Agency. The Physician and the Administrator were notified at the time of the incident. However, this incident was not reported to the state authorities until 1/21/2020 at 3:55 p.m. by the Administrator of the facility. During an interview on 1/23/2020 at 8:45 a.m. the Law Enforcement (LE) CCC (with the police department of Whigham) revealed that in December of 2019 when a male resident (R#1) attacked a nurse, the facility was told that the law enforcement could not take the male resident to jail due to his severe mental illness and the facility was told they needed a signed 1013 (a form medical providers or police use to document an emergency transport to have a person evaluated because they may be a threat to themselves or others) from the Physician to send a resident out to be evaluated. LE CCC revealed that it is a liability for police to transport residents without a signed 1013. In addition, Law Enforcement CCC revealed that he has had a conversation with the Administrator and told her that by law she must notify the police for all instances of assault. During an interview on 1/24/2020 at 9:00 a.m. Clerk YY (with the County Sheriff Department) revealed that there were only two reports completed for the nursing facility. During an interview on 1/16/2020 at 9:38 a.m. Licensed Practical Nurse (LPN) JJ revealed that she had informed Law Enforcement that she wanted to press charges against R#1 and when she went to get a copy of the report, she was told by law enforcement that the Administrator had told them the report was not needed. During an interview with the Administrator on 2/3/2020 at 5:46 p.m., she stated that the system they had in place was not working with regard to timely reporting incidents to the state survey agency. The above allegations of abuse were reviewed with the Administrator who confirmed that they were not reported to the State Survey Agency or not reported timely. The Administrator stated that all the incidents that she reported were done correctly and she was unaware of some of the things that happened.

Based on record review, staff interviews, and review of the facility policy titled, Abuse Prevention Policy & Procedure the facility failed to investigate six of 23 allegations of abuse for (R#1, R#5, R#4, R#3, R#2, R#7). On 1/29/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and Social Services Director were informed of the Immediate Jeopardy on 1/29/2020 at 10:26 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/26/19. Immediate Jeopardy is outlined as follows: Resident (R) #1, a [AGE] year-old ambulatory male resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 had been prescribed [MEDICATION NAME] (an antipsychotic medication) since 2012. When R#1 was admitted to the facility this medication was discontinued because the Attending Physician/Medical Director did not complete the required online training required by the prescribing pharmacy in order to administer this medication. In addition, this medication required a laboratory test (ANC-Absolute [DIAGNOSES REDACTED] Count) be obtained and there was no evidence the required laboratory test was obtained. In addition, R#1 had a Preadmission Screening/Resident Review (PASSR) Level II dated 8/9/2019, that recommended medication management and on-going psychiatric care and treatment. There was no evidence the facility provided R#1 with any psychiatric services from the time of his admission on 8/15/19, until a new Behavior Health provider began providing psychiatric/behavioral health services on 1/9/2020. Record review revealed that R#1 started refusing his medications and on 9/26/2019, R#1 attacked R#5 and pushed him to the floor and kicked him. From 9/26/2019 until 1/18/2020, R#1 attacked 11 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16). Two of these eleven residents (R#3 and R#2) had to be sent to the emergency room for evaluation and treatment. R#3 had an acute/chronic displaced nasal fracture and R#2 received a laceration that required Dermabond to close. Record review revealed R#1 was sent out to a Behavioral Health Unit on 10/3/2019, 11/4/2019, 12/3/2019, 12/24/19, and although the facility was not able to meet his needs for medication management and ongoing psychiatric services the facility continued to readmit R#1 back to the facility. Although the facility was aware of R#1's aggressive behavior the facility failed to put measures in place to protect residents from R#1. In addition, the facility failed to provide psychiatric services for other residents in the facility with Level II PASSRs that had recommendations for psychiatric services from October of 2019 until January of 2020. On 1/18/2020, after R#1 was in a physical altercation with another resident R#1 was sent out of the facility to a Behavioral Health Facility. The facility did not have any plans to readmit R#1 after he was sent out of the facility on 1/18/2020. The immediate jeopardy is outlined as follows: 42 CFR 483.12 (a)(1) Abuse and Neglect, F600, Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; C.F.R. 483.15(a) Admissions policy, F620 Scope/Severity: K; 42 CFR 483.20(k)(1)-(3) PASARR Screening for MD & ID, F645 Scope/Severity: J; 42 CFR 483.21(b) Comprehensive Care Plans,42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision, F657 Scope/Severity: K; 42 CFR 185.25 Quality of Care, F684 Scope/Severity: J;42 CFR 483.25 Quality of Care, F684; 42 CFR 483.40 Behavioral Health, F740 Scope/Severity: K; 42 CFR 483.40(a) Sufficient/Competent Staff-Behavioral Health Needs,F741 Scope/Severity: K; 42 CFR 483 40(d) Provision of Medically Related Social Services; F745 Scope/Severity: J; 42 CFR 483.70 Administration, F835 Scope/Severity: K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; 42 CFR 483.25 Quality of Care, F684 Scope/Severity: J; and 42 CFR 483 40(d) Provision of Medically Related Social Services, F745 Scope/Severity: J. At the time of the exit on February 3, 2020, the Immediate Jeopardy remained ongoing. Findings include: A review of the policy, Abuse Prevention Policy & Procedure revised 2/26/19, under number 5. Reporting/Investigation/Response Policy, states, Any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary or voluntary, is to be thoroughly reported, investigated and documented in a uniform matter . The policy also reveals, All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law. Additionally, the facility will thoroughly investigate, under the direction of the Administrator, all injuries of unknown origins to determine if abuse or neglect was involved. 1. Review of the nursing facility Progress Notes for R#1 dated 9/26/19 revealed that R#1 assaulted R#5. R#1 pushed R#5 down and a fight evolved. There was not any evidence of documentation of staff interview or statements confirming the investigation of this event. 2. Review of the nursing facility Progress Notes for R#1 dated 9/29/19 revealed that R#1 punched R#4 in the eye for no apparent reason, other than he did not like the way she smelled. There was no evidence of documentation to support this incident was thoroughly investigated. 3. Review of the nursing facility Progress Notes dated 11/9/19, for R#1, revealed that R#1 punched R#3 on the right side of the face, right side of neck, right shoulder and right shoulder blade. There is not any evidence of documentation that the facility thoroughly investigated this incident including witness statements from the resident's involved, or statements from staff or other residents. 4. Review of the nursing facility Progress Notes for R#1 dated 12/3/19 revealed that R#1 hit R#2 in the face. There was not any evidence of documentation that the facility thoroughly investigated this incident. Record review revealed there were not any witness statements from the resident's involved, staff or other residents. 5. Review of the nursing facility Progress Notes dated 12/27/19 (R#7 health record) revealed that R#1 fell on to R#7 and when R#7 pushed R#1 off then R#1 hit R#7 in the face. Further record review revealed that R#7 received a superficial laceration beneath his left eyebrow. Record review revealed that there is no evidence of documentation to support that the facility conducted a thorough investigation of this incident, such as gathering staff or resident witness statements. During an interview with the Administrator on 1/23/2020 at 2:33 p.m., revealed that that she could not fill in the gaps related to the missing information on the incident reports. The Administrator stated that she investigated what she knew happened. During another interview with the Administrator on 2/3/2020 at 5:46 p.m., revealed that the Director of Nursing (DON) was responsible for investigating incidents in the facility. She stated they did not have a system in place to identify, track and trend these incidents to ensure follow-ups are completed.

Based on record review, staff interview and review of the facility's policies titled, Admission Policies and Admission Criteria the facility failed to implement their facility's admission policies for one resident (R#1) of 23 residents reviewed. The facility failed to ensure the resident's need for medication managment and psychiatric services could be met prior to admission to the facility. On 1/29/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and Social Services Director were informed of the Immediate Jeopardy on 1/29/2020 at 10:26 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/26/19. Immediate Jeopardy is outlined as follows: Resident (R) #1, a [AGE] year-old ambulatory male resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 had been prescribed [MEDICATION NAME] (an antipsychotic medication) since 2012. When R#1 was admitted to the facility this medication was discontinued because the Attending Physician/Medical Director did not complete the required online training required by the prescribing pharmacy in order to administer this medication. In addition, this medication required a laboratory test (ANC-Absolute [DIAGNOSES REDACTED] Count) be obtained and there was no evidence the required laboratory test was obtained. In addition, R#1 had a Preadmission Screening/Resident Review (PASSR) Level II dated 8/9/2019, that recommended medication management and on-going psychiatric care and treatment. There was no evidence the facility provided R#1 with any psychiatric services from the time of his admission on 8/15/19, until a new Behavior Health provider began providing psychiatric/behavioral health services on 1/9/2020. Record review revealed that R#1 started refusing his medications and on 9/26/2019, R#1 attacked R#5 and pushed him to the floor and kicked him. From 9/26/2019 until 1/18/2020, R#1 attacked 11 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16). Two of these eleven residents (R#3 and R#2) had to be sent to the emergency room for evaluation and treatment. R#3 had an acute/chronic displaced nasal fracture and R#2 received a laceration that required Dermabond to close. Record review revealed R#1 was sent out to a Behavioral Health Unit on 10/3/2019, 11/4/2019, 12/3/2019, 12/24/19, and although the facility was not able to meet his needs for medication management and ongoing psychiatric services the facility continued to readmit R#1 back to the facility. Although the facility was aware of R#1's aggressive behavior the facility failed to put measures in place to protect residents from R#1. In addition, the facility failed to provide psychiatric services for other residents in the facility with Level II PASSRs that had recommendations for psychiatric services from October of 2019 until January of 2020. On 1/18/2020, after R#1 was in a physical altercation with another resident R#1 was sent out of the facility to a Behavioral Health Facility. The facility did not have any plans to readmit R#1 after he was sent out of the facility on 1/18/2020. The immediate jeopardy is outlined as follows: 42 CFR 483.12 (a)(1) Abuse and Neglect, F600, Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; C.F.R. 483.15(a) Admissions policy, F620 Scope/Severity: K; 42 CFR 483.20(k)(1)-(3) PASARR Screening for MD & ID, F645 Scope/Severity: J; 42 CFR 483.21(b) Comprehensive Care Plans,42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision, F657 Scope/Severity: K; 42 CFR 185.25 Quality of Care, F684 Scope/Severity: J;42 CFR 483.25 Quality of Care, F684; 42 CFR 483.40 Behavioral Health, F740 Scope/Severity: K; 42 CFR 483.40(a) Sufficient/Competent Staff-Behavioral Health Needs,F741 Scope/Severity: K; 42 CFR 483 40(d) Provision of Medically Related Social Services; F745 Scope/Severity: J; 42 CFR 483.70 Administration, F835 Scope/Severity: K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; 42 CFR 483.25 Quality of Care, F684 Scope/Severity: J; and 42 CFR 483 40(d) Provision of Medically Related Social Services, F745 Scope/Severity: J. At the time of the exit on February 3, 2020, the Immediate Jeopardy remained ongoing. Findings Include: Review of the facility policy titled, Admission Policies (revised December 2006) Policy Interpretation and Implementation 3. The objectives of our admission policies are to: b. Admit residents who can be adequately cared for by the facility; 4. It shall be the responsibility of the Administrator, through the admissions depart, to assure that the established admission policies, as they may apply, are followed by the facility and resident. Review of the facility policy titled, Admission Criteria Policy Statement: Our facility will admit only those residents who medical and nursing care needs can be met. Policy Interpretation and Implementation 1. The objectives of our admission criteria policy to: b. admit residents who can be cared for adequately by the facility; 5. Prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least: b. Medication orders, including (as necessary) a medical condition or problem associated with each medication; 10. The acceptance of residents with certain conditions or need may require authorization or approval by the Medical Director, Director of Nursing Services and/or Administrator. Record review revealed that R#1 was initially admitted to the facility from an acute care facility on 8/15/19 for community acquired pneumonia; however, R#1 had a primary [DIAGNOSES REDACTED]. Further record review revealed that R#1 was admitted to the facility with a PASRR Level II that recommended services of medication management and on-going psychiatric care and treatment. Review of the Admission Minimum Data Set ((MDS) dated [DATE]. MDS Section E-Behavior documented for R#1 that the resident displayed behavioral symptoms occurred one to three days, verbal behavioral symptoms 4 to 6 days. Section G Functional Status revealed that R#1 ambulates independently in room and corridor, had no upper or lower extremity impairment and used a cane. Review of the MAR indicated [REDACTED]. Further review revealed that even though R#1 had been administered [MEDICATION NAME] since before 2012 the facility abruptly stopped this medication without titrating the drug to reduce the risk of complications with withdrawal. Review of this same MAR indicated [REDACTED]. A Physician Order dated 8/20/19 at 1300 (military time for 1:00 p.m.) revealed an order for [REDACTED].#1 was started on [MEDICATION NAME] 50 mg two times a day. Review of the nursing facility Progress Notes dated 8/15/19 through 10/3/19 revealed that on 9/23/19, R#1 had been observed twitching/fidgeting and talking to himself. He was also being verbally aggressive at times. The Physician was notified of these behaviors and ordered to increase R#1's [MEDICATION NAME] to 100 milligrams (mg) twice day and a new order for [MEDICATION NAME] 1 mg at bedtime was received. On 9/26/19, there was a commotion in the dining room, the nurse observed R#1 pushing R#5 down. The residents were separated, and no injuries were noted. On 9/29/19. R#1 hit R#4 without any reason. It was documented that R#1 hit R#4 because she walked to close to him and had body odor. Review of the nursing facility Progress Notes dated 10/3/19 revealed that R#1 was sent to a behavioral facility for aggressive behavior. R#1 was prescribed [MEDICATION NAME] during this inpatient behavioral facility stay. Although R#1 was to continue to receive ongoing psychiatric services, that the facility was not providing, R#1 was readmitted to the facility on [DATE]. Review of the nursing facility Progress Note dated 11/4/19 revealed that R#1 was transferred to a behavioral facility for aggressive behavior toward other residents. Further record review revealed that R#1 was prescribed [MEDICATION NAME] 25 milligrams (mg) two tablets daily during his inpatient stay at the behavioral facility and this medication was on the residents discharge medications when R#1 was discharged from the behavioral facility. Although R#1 was to be receiving ongoing psychiatric services, that the facility was not providing, R#1 was readmitted to the facility on [DATE]. Review of the nursing facility Progress Note dated 12/3/19 revealed that R#1 was transferred out of the facility on a 1013 (a form medical providers or police use to document an emergency transport to have a person evaluated because they may be a threat to themselves or others) after he assaulted R#2. Record review revealed that R#1 was prescribed [MEDICATION NAME] 25 milligrams (mg) two tablets daily during his inpatient stay at the behavioral facility and this medication was on the residents discharge medications when R#1 was discharged from the behavioral facility. During R#1's inpatient stay the facility discussed seeking placement with other facility's. Review of a 12/5/19 at 11:34 a.m. At Risk Meeting note documented the following: resident discussed r/t (related to) noncompliance, behavior issues, tendency for violent outburst and recent incident on 12/3/19. Resident was 1013d, currently at Inpatient Behavioral Health facility. To Return, per staff there, since he is uncooperative with treatment. RP (Responsible Party) and family already aware of ongoing issues. We are seeking placement with other facility's who can meet his needs. The facility discussed seeking placement with other facility's; however, R#1 returned to the facility on [DATE], and there was no evidence that the facility pursued transferring R#1 to another facility and there was not any evidence that a 30 day discharged was considered. R#1 was transferred out of the facility on 12/23/19 to an acute care facility after R#1 exhibited aggressive behavior toward staff. The acute care facility sent R#1 out to a psychiatric unit. Further record review revealed that R#1 was prescribed [MEDICATION NAME] 25 milligrams (mg) two tablets daily during his inpatient stay at the behavioral facility and this medication was on the residents discharge medications when R#1 was discharged from the behavioral facility. Although R#1 was to be receiving ongoing psychiatric services, that the facility was not providing, R#1 was readmitted to the facility on [DATE]. Review of the nursing facility Progress Note dated 1/18/2020 revealed R#1 was escorted out the facility by a local sheriff due to a physical altercation with another resident. The facility did not have any plans to readmit R#1 back to the facility after he was sent out on 1/18/2020. However, the facility had identified in September 2019 that R#1 had repeated aggressive and violent behaviors directed toward other residents, visitors and staff. Had the facility initiated the 30-day notice for discharge for R#1 then the repeated aggressive incidents toward other residents and staff could have avoided. During an interview on 1/21/2020 at 1:13 p.m. the former Director of Nursing (DON) SS revealed that she was against the admission of R#1 because R#1 was prescribed [MEDICATION NAME] and the staff in the facility had not received any training to provide care for residents with mental illnesses. During an interview on 1/22/2020 at 10:05 a.m. with the previous Telehealth Provider (TP) NN, reveaeld that the process her office took was that about one week prior to coming to the facility to provide psychiatric or tele- psychiatric services, she would send a list of the residents that were to be seen to the facility for confirmation, TP NN stated that this facility did not respond to their communication/e-mails and it was impossible to schedule the telehealth visits without the facility's confirmation. TP NN stated that it was considered a liability to provide services when the residents were not being seen regularly and that this facility would not communicate with them. TP NN stated the last medication management visits that were conducted by her company were provided on 9/11/19 for some residents and the last counseling services provided by her company that were conducted on-site was on 10/28/19. Further record review revealed that although Telehealth Provider was providing psychiatric services for the facility, R#1 was never seen by the Telehealth Provider. Interview on 1/24/20 at 2:13 p.m. LPN DD revealed that the decision to admit R#1 was made by the Administrator during the morning meeting while reviewing his records from the hospital. During an interview on 1/28/2020 at 12:50 p.m. the Physician/Medical Director revealed that he did not know why the facility kept accepting R#1 back into the facility. During an interview on 1/28/2020 at 3:33 p.m. the Administrator revealed that the receiving facility's would sometime say that they would not accept the residents unless the facility would take them back. Cross refer F600

Based on record review and staff interviews, the facility failed to revise the care plans for seven of 23 residents (R#3, R#5, R#6, R#7, R#8, R#13, R#16) that were reviewed for care plans. On 1/29/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and Social Services Director were informed of the Immediate Jeopardy on 1/29/2020 at 10:26 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/26/19. Immediate Jeopardy is outlined as follows: Resident (R) #1, a [AGE] year-old ambulatory male resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 had been prescribed [MEDICATION NAME] (an antipsychotic medication) since 2012. When R#1 was admitted to the facility this medication was discontinued because the Attending Physician/Medical Director did not complete the required online training required by the prescribing pharmacy in order to administer this medication. In addition, this medication required a laboratory test (ANC-Absolute [DIAGNOSES REDACTED] Count) be obtained and there was no evidence the required laboratory test was obtained. In addition, R#1 had a Preadmission Screening/Resident Review (PASSR) Level II dated 8/9/2019, that recommended medication management and on-going psychiatric care and treatment. There was no evidence the facility provided R#1 with any psychiatric services from the time of his admission on 8/15/19, until a new Behavior Health provider began providing psychiatric/behavioral health services on 1/9/2020. Record review revealed that R#1 started refusing his medications and on 9/26/2019, R#1 attacked R#5 and pushed him to the floor and kicked him. From 9/26/2019 until 1/18/2020, R#1 attacked 11 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16). Two of these eleven residents (R#3 and R#2) had to be sent to the emergency room for evaluation and treatment. R#3 had an acute/chronic displaced nasal fracture and R#2 received a laceration that required Dermabond to close. Record review revealed R#1 was sent out to a Behavioral Health Unit on 10/3/2019, 11/4/2019, 12/3/2019, 12/24/19, and although the facility was not able to meet his needs for medication management and ongoing psychiatric services the facility continued to readmit R#1 back to the facility. Although the facility was aware of R#1's aggressive behavior the facility failed to put measures in place to protect residents from R#1. In addition, the facility failed to provide psychiatric services for other residents in the facility with Level II PASSRs that had recommendations for psychiatric services from October of 2019 until January of 2020. On 1/18/2020, after R#1 was in a physical altercation with another resident R#1 was sent out of the facility to a Behavioral Health Facility. The facility did not have any plans to readmit R#1 after he was sent out of the facility on 1/18/2020. The immediate jeopardy is outlined as follows: 42 CFR 483.12 (a)(1) Abuse and Neglect, F600, Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; C.F.R. 483.15(a) Admissions policy, F620 Scope/Severity: K; 42 CFR 483.20(k)(1)-(3) PASARR Screening for MD & ID, F645 Scope/Severity: J; 42 CFR 483.21(b) Comprehensive Care Plans,42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision, F657 Scope/Severity: K; 42 CFR 185.25 Quality of Care, F684 Scope/Severity: J;42 CFR 483.25 Quality of Care, F684; 42 CFR 483.40 Behavioral Health, F740 Scope/Severity: K; 42 CFR 483.40(a) Sufficient/Competent Staff-Behavioral Health Needs,F741 Scope/Severity: K; 42 CFR 483 40(d) Provision of Medically Related Social Services; F745 Scope/Severity: J; 42 CFR 483.70 Administration, F835 Scope/Severity: K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; 42 CFR 483.25 Quality of Care, F684 Scope/Severity: J; and 42 CFR 483 40(d) Provision of Medically Related Social Services, F745 Scope/Severity: J. At the time of the exit on February 3, 2020, the Immediate Jeopardy remained ongoing. Findings include: 3. Record review revealed that R#3 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed a BIMS score of 13 indicating cognitition intact. The MDS Section G Functional Status revealed R#3 could walk unsteady but able to stabilize without help; had impairment upper and lower extremities on one side and did not use a device for mobility. Review of the care plan dated 10/9/19 (revised 11/13/19) revealed R#3 was physically assaulted by R#1 and sent to the ER for evaluation. Further review revealed there were no new interventions put in place for this incident after the quarterly assessment on 12/10/19. 5. Record review revealed R#5 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed BIMS score of 14 indicating R#5 was cognitively intact. Review of the care plans for R#5 dated revealed the resident's care plan was not revised to reflect that R#5 was hit by R#1 on 9/26/19. Further review revealed there were not any interventions put in place for this incident. 6. Record review revealed that R#6 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed BIMS score of nine indicating moderate cognitive impairment. Review of the Behavior care plan for R#6 dated 10/9/19 revealed R#6 (a former roommate of R#1) was verbally threatened by R#1 on 11/17/19. After this incident R#6 was afraid to enter the room and had to be moved to a different room due. Further review revealed that the care plan for R#6 was not updated to reflect this incident. 7. Record review revealed R#7 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed BIMS score of 13 indicating R#7 was cognitively intact. Review of the care plan dated 10/22/19 (revised 1/6/2020) revealed R#7 that on 12/27/19, R#1 fell on him and when he pushed R#1 off R#1 punched R#7 in the face. R#7 had a small bruise below his left eyebrow and treatment was provided. Further review revealed there were not any interventions put in place for this incident. 8. Record review revealed R#8 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed BIMS score of 9 indicating moderate cognitive impairment. Review of the care plan dated 6/6/19 revealed that R#8's care plan was not revised to reflect that she had been punched in the eye by R#1 on 1/1/2020. 9. Record review revealed R#13 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed BIMS score of 15 indicating the resident was cognitively intact. Review of the care plan dated 3/22/19 revealed that the care plan was not revised to reflect that R#13's eyeglasses were taken 1/13/2020 by R#1 who wore her eyeglasses in the facility. The eyes glasses were later found with a lens missing. R#13's hobbies and interest included reading. Further review revealed there were not any interventions put in place for this incident. 10. Record review revealed R#16 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed a BIMS score of 15 indicating cognititom intact. Review of the care plan dated 3/29/19 revealed that the care plan was not revised to reflect that R#16 had been punched in left eye by R#1 on 1/17/2020. During an interview on 2/3/2020 at 5:33 p.m. the Administrator was asked what is the facility's process was to ensure that you, as the Administrator, are made aware of resident behavior/incidents which are clearly significant enough to be included on the resident's care plan? The Administrator stated, The police should have taken him. However, the Administrator never addressed the question regarding what was the facility's process regarding the resident's behavior being included on the resident's care plan.

Based on record reviews and staff interviews the facility failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being; including the prevention and treatment of [REDACTED]. On 1/29/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and Social Services Director were informed of the Immediate Jeopardy on 1/29/2020 at 10:26 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/26/19. Immediate Jeopardy is outlined as follows: Resident (R) #1, a [AGE] year-old ambulatory male resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 had been prescribed [MEDICATION NAME] (an antipsychotic medication) since 2012. When R#1 was admitted to the facility this medication was discontinued because the Attending Physician/Medical Director did not complete the required online training required by the prescribing pharmacy in order to administer this medication. In addition, this medication required a laboratory test (ANC-Absolute [DIAGNOSES REDACTED] Count) be obtained and there was no evidence the required laboratory test was obtained. In addition, R#1 had a Preadmission Screening/Resident Review (PASSR) Level II dated 8/9/2019, that recommended medication management and on-going psychiatric care and treatment. There was no evidence the facility provided R#1 with any psychiatric services from the time of his admission on 8/15/19, until a new Behavior Health provider began providing psychiatric/behavioral health services on 1/9/2020. Record review revealed that R#1 started refusing his medications and on 9/26/2019, R#1 attacked R#5 and pushed him to the floor and kicked him. From 9/26/2019 until 1/18/2020, R#1 attacked 11 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16). Two of these eleven residents (R#3 and R#2) had to be sent to the emergency room for evaluation and treatment. R#3 had an acute/chronic displaced nasal fracture and R#2 received a laceration that required Dermabond to close. Record review revealed R#1 was sent out to a Behavioral Health Unit on 10/3/2019, 11/4/2019, 12/3/2019, 12/24/19, and although the facility was not able to meet his needs for medication management and ongoing psychiatric services the facility continued to readmit R#1 back to the facility. Although the facility was aware of R#1's aggressive behavior the facility failed to put measures in place to protect residents from R#1. In addition, the facility failed to provide psychiatric services for other residents in the facility with Level II PASSRs that had recommendations for psychiatric services from October of 2019 until January of 2020. On 1/18/2020, after R#1 was in a physical altercation with another resident R#1 was sent out of the facility to a Behavioral Health Facility. The facility did not have any plans to readmit R#1 after he was sent out of the facility on 1/18/2020. The immediate jeopardy is outlined as follows: 42 CFR 483.12 (a)(1) Abuse and Neglect, F600, Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; C.F.R. 483.15(a) Admissions policy, F620 Scope/Severity: K; 42 CFR 483.20(k)(1)-(3) PASARR Screening for MD & ID, F645 Scope/Severity: J; 42 CFR 483.21(b) Comprehensive Care Plans,42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision, F657 Scope/Severity: K; 42 CFR 185.25 Quality of Care, F684 Scope/Severity: J;42 CFR 483.25 Quality of Care, F684; 42 CFR 483.40 Behavioral Health, F740 Scope/Severity: K; 42 CFR 483.40(a) Sufficient/Competent Staff-Behavioral Health Needs,F741 Scope/Severity: K; 42 CFR 483 40(d) Provision of Medically Related Social Services; F745 Scope/Severity: J; 42 CFR 483.70 Administration, F835 Scope/Severity: K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; 42 CFR 483.25 Quality of Care, F684 Scope/Severity: J; and 42 CFR 483 40(d) Provision of Medically Related Social Services, F745 Scope/Severity: J. At the time of the exit on February 3, 2020, the Immediate Jeopardy remained ongoing. Findings include: Review of the facility's Form CMS-672, Resident Census and Conditions of Resident Form, dated 1/14/2020, the facility had 52 residents with behavioral healthcare needs. Record review revealed that R#1 was admitted on [DATE] to the nursing home facility, from an acute care hospital, with the following [DIAGNOSES REDACTED]. The DMA-6 for R#1 revealed that his primary [DIAGNOSES REDACTED]. This medication is used after all other medications have failed. The most recent Minimum Data Set (MDS) for R#1 was an Admission assessment dated [DATE] and under Section C - Cognitive Patterns his cognitive level was assessed to be 10 out of 15 indicating that R#1 was moderately cognitively impaired. Record review of a 12/10/19 Behavioral Health Discharge Summary documented the following: Hospital Course: The patient (R#1) was admitted to the Behavioral Facility due to [MEDICAL CONDITION] with psychotic exacerbation and aggression, and medication non-compoliance. He was grossly delusional, mildly paranoid and lacked insight to his condition, and per nursing home this was his baseline. Discharge Exam: At the time of discharge, he (R#1) was alert and oriented to person, place but not to time or situation. Mentation wise he was lucid with derailed thought processes. The nursing home was kept in close contact regarding his treatment progress and the discharge status, and the patient was discharged without any complications. The patient could benefit from court mandated treatment to enforce medications, and this process can be done on an outpatient basis through the local mental health carrier. Record review revealed that R#1 was involved in many aggressive altercations toward other residents and staff during his stay at the facility, with 12 residents in the facility including: (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#13, R#16). Further record review revealed there was not any evidence of documentation that the facility ensured that the necessary care and services were person centered and provided meaningful activities to encourage and promote R#1's mental and psychological well-being. During an interview on 1/22/2020 at 12:30 p.m. with Social Worker UU revealed that there was not a process in place for identifying and monitoring residents that needed psychiatric services and to ensure those residents received these services. Cross refer F600

Based on record review and staff interviews the facility failed to provide in-service training and education to ensure staff had the appropriate competencies and skills to provide nursing care for 52 of 52 residents in the facility with behavioral healthcare needs. On 1/29/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and Social Services Director were informed of the Immediate Jeopardy on 1/29/2020 at 10:26 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/26/19. Immediate Jeopardy is outlined as follows: Resident (R) #1, a [AGE] year-old ambulatory male resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 had been prescribed [MEDICATION NAME] (an antipsychotic medication) since 2012. When R#1 was admitted to the facility this medication was discontinued because the Attending Physician/Medical Director did not complete the required online training required by the prescribing pharmacy in order to administer this medication. In addition, this medication required a laboratory test (ANC-Absolute [DIAGNOSES REDACTED] Count) be obtained and there was no evidence the required laboratory test was obtained. In addition, R#1 had a Preadmission Screening/Resident Review (PASSR) Level II dated 8/9/2019, that recommended medication management and on-going psychiatric care and treatment. There was no evidence the facility provided R#1 with any psychiatric services from the time of his admission on 8/15/19, until a new Behavior Health provider began providing psychiatric/behavioral health services on 1/9/2020. Record review revealed that R#1 started refusing his medications and on 9/26/2019, R#1 attacked R#5 and pushed him to the floor and kicked him. From 9/26/2019 until 1/18/2020, R#1 attacked 11 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16). Two of these eleven residents (R#3 and R#2) had to be sent to the emergency room for evaluation and treatment. R#3 had an acute/chronic displaced nasal fracture and R#2 received a laceration that required Dermabond to close. Record review revealed R#1 was sent out to a Behavioral Health Unit on 10/3/2019, 11/4/2019, 12/3/2019, 12/24/19, and although the facility was not able to meet his needs for medication management and ongoing psychiatric services the facility continued to readmit R#1 back to the facility. Although the facility was aware of R#1's aggressive behavior the facility failed to put measures in place to protect residents from R#1. In addition, the facility failed to provide psychiatric services for other residents in the facility with Level II PASSRs that had recommendations for psychiatric services from October of 2019 until January of 2020. On 1/18/2020, after R#1 was in a physical altercation with another resident R#1 was sent out of the facility to a Behavioral Health Facility. The facility did not have any plans to readmit R#1 after he was sent out of the facility on 1/18/2020. The immediate jeopardy is outlined as follows: 42 CFR 483.12 (a)(1) Abuse and Neglect, F600, Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; C.F.R. 483.15(a) Admissions policy, F620 Scope/Severity: K; 42 CFR 483.20(k)(1)-(3) PASARR Screening for MD & ID, F645 Scope/Severity: J; 42 CFR 483.21(b) Comprehensive Care Plans,42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision, F657 Scope/Severity: K; 42 CFR 185.25 Quality of Care, F684 Scope/Severity: J;42 CFR 483.25 Quality of Care, F684; 42 CFR 483.40 Behavioral Health, F740 Scope/Severity: K; 42 CFR 483.40(a) Sufficient/Competent Staff-Behavioral Health Needs,F741 Scope/Severity: K; 42 CFR 483 40(d) Provision of Medically Related Social Services; F745 Scope/Severity: J; 42 CFR 483.70 Administration, F835 Scope/Severity: K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; 42 CFR 483.25 Quality of Care, F684 Scope/Severity: J; and 42 CFR 483 40(d) Provision of Medically Related Social Services, F745 Scope/Severity: J. At the time of the exit on February 3, 2020, the Immediate Jeopardy remained ongoing. Findings include: Record review revealed that R#1 was admitted on [DATE] to the nursing home facility, from an acute care hospital, with the following [DIAGNOSES REDACTED]. R#1 was admitted with a Preadmission Screening/Resident Review (PASSR) Level II dated 8/9/2019, that recommended medication management and on-going psychiatric care and treatment. The most recent Minimum Data Set (MDS) for R#1 was an Admission assessment dated [DATE] and under Section C - Cognitive Patterns his cognitive level was assessed to be 10 out of 15 indicating that R#1 was moderate impaired cognitiion. Record review revealed that from 9/26/2019 until 1/18/2020, R#1 attacked eleven residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16). Two of these eleven residents (R#3 and R#2) had to be sent to the emergency room for evaluation and treatment. R#3 had an acute/chronic displaced nasal fracture and R#2 received a laceration that required Dermabond to close. During an interview on 1/15/2020 at 1:14 p.m. CNA HH revealed that the facility had not provided any type of training for residents with mental illnesses. The facility has promised for seven years to give them training and some type of education, but this had not happened. During an interview on 1/15/2020 at 2:03 p.m. CNA GG revealed that she had not had any training on how to provide care for residents with mental illnesses and that she does not know what to do because there was nothing (no policy or process) in place to follow. During an interview on 1/22/2020 at 9:02 a.m. the Psychiatrist (for a Behavioral Health facility) revealed that the facility should have been trained on how to take care of residents with psychiatric [DIAGNOSES REDACTED]. The Psychiatrist stated that in regards to the [MEDICATION NAME] being abruptly stopped that this would cause exacerbation of R#1's [MEDICAL CONDITION]. Interview on 1/27/2020 at 7:53 a.m., with Psychiatric Nurse Practitioner (PNP) WW, with Behavioral Health Services, the newly contracted behavioral health provider, revealed that she has had a lot of experience with severe psychiatric residents, but she has never seen this many psychiatric residents in a Long Term Care facility in such a small place without a locked unit, without policies and procedures for the staff and without specialized education/training for the staff for the needs of this special population. Record review of the In-Service Sign In Sheets revealed that Licensed Nurses received the following in-service education: In-service dated 9/10/19 revealed that the subject was activities of daily living, documentation, behavior management, call lights, and customer services. Review of the sign-in sheets revealed it was signed by 16 employees. In-service dated 10/9/19 revealed that subject was abuse, and reporting abuse. Review of the sign-in sheets revealed it was signed by 28 employees. In-service dated 1/7/2020 revealed that the subject was transfers, certified nursing aides charting and monitoring, linen, personal care, admission/readmission process including influenza and pneumonia vaccine, incident reports, falls, skin tears, behavior documentation, change in condition, as needed medications (PRN) and flu up charting. Review of the sign-in sheets revealed it was signed by 10 employees. In-service dated 1/23/20/20, after surveyor inquiry regarding in-services for behaviors, revealed that the subject was caring for residents with behaviors. Review of the sign-in sheets revealed it was signed by 18 employees. The facility did not provide the education material that was used for any of the above in-services. Record review revealed that the facility had 76 Employees. During an interview on 1/27/2020 at 8:22 a.m., with Social Worker (SW) OOO with Behavioral Health Services, the newly contracted behavioral health provider), stated that the main concern that she has is that there are no policies and procedures for the staff to follow when dangerous residents need transporting and that the staff do not have any specialized training/education to handle these types of residents. SW OOO stated she believes this facility is a psychiatric facility and not really a nursing home because of the extensive mental illnesses and aggressive behaviors of the residents that this facility admits. During an interview on 1/28/2020 at 3:33 p.m. the Administrator revealed that the staff have been trained on behaviors and that she has planned for the Ombudsman to provide an in-service on abuse, resident rights and behaviors. During an interview on 1/30/2020 at 10:19 a.m., Medical Director Assistant LLL stated that she seldom gets faxes from the facility, labs or otherwise, nor do they get a lot of notifications from this facility. She also stated that countless staff at multiple times, have approached her to tell her how badly they need direction, education and training on services and medications for these types of residents. They would like that more than just looking up medications on their telephones.

Based on record review, staff interviews, review of the facility's Job Description titled, Nursing Home Administrator the facility failed to be administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable mental and physical well-being for residents by failing to ensure that oversight and monitoring of residents with aggressive behaviors was provided, failed to ensure the safety and protection for 11 of 23 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16) reviewed for abuse, failed to ensure that all alleged violations involving abuse and neglect were reported timely, for six of 23 residents (R#5. R#4, R#3, R#2, R#7, R#12) , failed to ensure that residents with Preadmission Screening and Resident Review (PASSR) Level II's with recommendations for ongoing psychiatric services received the ongoing psychiatric services they needed for three of three residents (R#1, R#5, R#12), failed to ensure that staff were properly trained to provide care for resident's with mental illnesses and aggressive behavior, failed to meet the medication needs for one of 23 (R#1) residents reviewed for medications. Additionally, Administration failed to have a Physician order [REDACTED].#4, R#20), the facility failed to notify the Physician for lab results for nine of 23 residents (R#4, R#10, R#15, R#16, R#2, R#3, R#7, R#17, R#20), and the facility failed to ensure labs that were ordered were obtained for three of 23 (R#15, R#2, R#8) residents reviewed for labs. On 1/29/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and Social Services Director were informed of the Immediate Jeopardy on 1/29/2020 at 10:26 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/26/19. Immediate Jeopardy is outlined as follows: Resident (R) #1, a [AGE] year-old ambulatory male resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 had been prescribed [MEDICATION NAME] (an antipsychotic medication) since 2012. When R#1 was admitted to the facility this medication was discontinued because the Attending Physician/Medical Director did not complete the required online training required by the prescribing pharmacy in order to administer this medication. In addition, this medication required a laboratory test (ANC-Absolute [DIAGNOSES REDACTED] Count) be obtained and there was no evidence the required laboratory test was obtained. In addition, R#1 had a Preadmission Screening/Resident Review (PASSR) Level II dated 8/9/2019, that recommended medication management and on-going psychiatric care and treatment. There was no evidence the facility provided R#1 with any psychiatric services from the time of his admission on 8/15/19, until a new Behavior Health provider began providing psychiatric/behavioral health services on 1/9/2020. Record review revealed that R#1 started refusing his medications and on 9/26/2019, R#1 attacked R#5 and pushed him to the floor and kicked him. From 9/26/2019 until 1/18/2020, R#1 attacked 11 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16). Two of these eleven residents (R#3 and R#2) had to be sent to the emergency room for evaluation and treatment. R#3 had an acute/chronic displaced nasal fracture and R#2 received a laceration that required Dermabond to close. Record review revealed R#1 was sent out to a Behavioral Health Unit on 10/3/2019, 11/4/2019, 12/3/2019, 12/24/19, and although the facility was not able to meet his needs for medication management and ongoing psychiatric services the facility continued to readmit R#1 back to the facility. Although the facility was aware of R#1's aggressive behavior the facility failed to put measures in place to protect residents from R#1. In addition, the facility failed to provide psychiatric services for other residents in the facility with Level II PASSRs that had recommendations for psychiatric services from October of 2019 until January of 2020. On 1/18/2020, after R#1 was in a physical altercation with another resident R#1 was sent out of the facility to a Behavioral Health Facility. The facility did not have any plans to readmit R#1 after he was sent out of the facility on 1/18/2020. The immediate jeopardy is outlined as follows: 42 CFR 483.12 (a)(1) Abuse and Neglect, F600, Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; C.F.R. 483.15(a) Admissions policy, F620 Scope/Severity: K; 42 CFR 483.20(k)(1)-(3) PASARR Screening for MD & ID, F645 Scope/Severity: J; 42 CFR 483.21(b) Comprehensive Care Plans,42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision, F657 Scope/Severity: K; 42 CFR 185.25 Quality of Care, F684 Scope/Severity: J;42 CFR 483.25 Quality of Care, F684; 42 CFR 483.40 Behavioral Health, F740 Scope/Severity: K; 42 CFR 483.40(a) Sufficient/Competent Staff-Behavioral Health Needs,F741 Scope/Severity: K; 42 CFR 483 40(d) Provision of Medically Related Social Services; F745 Scope/Severity: J; 42 CFR 483.70 Administration, F835 Scope/Severity: K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; 42 CFR 483.25 Quality of Care, F684 Scope/Severity: J; and 42 CFR 483 40(d) Provision of Medically Related Social Services, F745 Scope/Severity: J. At the time of the exit on February 3, 2020, the Immediate Jeopardy remained ongoing. Findings include: Review of the facility's Job Description titled, Nursing Home Administrator (revised 3/2012) revealed: General Purpose: To lead and direct the overall operations of the facility in accordance with focus-on maintaining excellence care for the residents while achieving the facility business objectives. Facility Management: Oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of facility; morals of the staff; and ensure resident needs are being addressed. Other Duties: Protect residents from neglect, mistreatment and abuse. Job Description Review signed by the Administrator on 1/30/2020. Review of the Admission Policies (revised December 2006) Policy Interpretation and Implementation 3. The objectives of our admission policies are to: b. Admit residents who can be adequately cared for by the facility; 1. Administration failed to ensure that residents were free from physical abuse from Resident (R) #1, and the facility failed to protect residents from continued abuse for 11 of 23 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16) reviewed for abuse Cross refer F600 2. Administration failed to ensure that all alleged violations involving abuse and neglect were reported timely, for seven of 23 residents (R#1, R#5, R#4, R#3, R#2, R#7, R#12) that were reviewed for abuse Cross refer F609 3. Administration failed to investigate six of 23 allegations of abuse for (R#1, R#5, R#4, R#3, R#2, R#7). Cross refer F610 4. Administration failed to ensure residents that were admitted to the facility with a Preadmission Screening/Resident Review (PASSR) Level II that had recommendations for specialized services for ongoing psychiatric care received the psychiatric services recommended for three of 23 residents (R#1, R#5, R#12) reviewed for PASSR Level II. Cross refer F645 5. Administration failed to revise the care plans for seven of 23 residents (R#3, R#5, R#6, R#7, R#8, R#13, R#16) that were reviewed for care plans. Cross refer F657 6. Administration failed to provide medications as needed for R#1; failed to follow-up with medication orders received from the psychiatrist; failed to notify the Physician that R#1 was refusing medications. Cross refer F684 7. Administration failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being; including the prevention and treatment of [REDACTED]. Cross refer F740 8. Administration failed to provide in-service training and education to ensure staff had the appropriate competencies and skills to provide nursing care for 52 of 52 residents in the facility with behavioral healthcare needs. Cross refer F741 9. Administration failed to provide medically-related social services for three of three residents reviewed (#1, #5, and #12) that had a Preadmission Screening/Resident Review (PASSR) Level II assessment that required psychiatric care and services. Cross refer F745 10. Administration failed to have a Physician order [REDACTED].#4, R#20), failed to notify the Physician for lab results for nine of 23 residents (R#4, R#10, R#15, R#16, R#2, R#3, R#7, R#17, R#20), and failed to ensure labs that were ordered were obtained for three of 23 (R#15, R#2, R#8) residents reviewed for labs. Cross refer F773 An interview on 2/3/2020 at 5:46 p.m. with the Administrator revealed that she guesses that she has the overall reponsibility for reporting allegations of abuse/actual assault incidents.

Based on record review, staff and resident interviews, and review of the facility policy titled, Admission Criteria the facility failed to ensure residents that were admitted to the facility with a Preadmission Screening/Resident Review (PASSR) Level II that had recommendations for specialized services for ongoing psychiatric care received the psychiatric services recommended for three of 23 residents (R#1, R#5, R#12) reviewed that had a PASSR Level II. On 1/29/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and Social Services Director were informed of the Immediate Jeopardy on 1/29/2020 at 10:26 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/26/19. Immediate Jeopardy is outlined as follows: Resident (R) #1, a [AGE] year-old ambulatory male resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 had been prescribed [MEDICATION NAME] (an antipsychotic medication) since 2012. When R#1 was admitted to the facility this medication was discontinued because the Attending Physician/Medical Director did not complete the required online training required by the prescribing pharmacy in order to administer this medication. In addition, this medication required a laboratory test (ANC-Absolute [DIAGNOSES REDACTED] Count) be obtained and there was no evidence the required laboratory test was obtained. In addition, R#1 had a Preadmission Screening/Resident Review (PASSR) Level II dated 8/9/2019, that recommended medication management and on-going psychiatric care and treatment. There was no evidence the facility provided R#1 with any psychiatric services from the time of his admission on 8/15/19, until a new Behavior Health provider began providing psychiatric/behavioral health services on 1/9/2020. Record review revealed that R#1 started refusing his medications and on 9/26/2019, R#1 attacked R#5 and pushed him to the floor and kicked him. From 9/26/2019 until 1/18/2020, R#1 attacked 11 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16). Two of these eleven residents (R#3 and R#2) had to be sent to the emergency room for evaluation and treatment. R#3 had an acute/chronic displaced nasal fracture and R#2 received a laceration that required Dermabond to close. Record review revealed R#1 was sent out to a Behavioral Health Unit on 10/3/2019, 11/4/2019, 12/3/2019, 12/24/19, and although the facility was not able to meet his needs for medication management and ongoing psychiatric services the facility continued to readmit R#1 back to the facility. Although the facility was aware of R#1's aggressive behavior the facility failed to put measures in place to protect residents from R#1. In addition, the facility failed to provide psychiatric services for other residents in the facility with Level II PASSRs that had recommendations for psychiatric services from October of 2019 until January of 2020. On 1/18/2020, after R#1 was in a physical altercation with another resident R#1 was sent out of the facility to a Behavioral Health Facility. The facility did not have any plans to readmit R#1 after he was sent out of the facility on 1/18/2020. The immediate jeopardy is outlined as follows: 42 CFR 483.12 (a)(1) Abuse and Neglect, F600, Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; C.F.R. 483.15(a) Admissions policy, F620 Scope/Severity: K; 42 CFR 483.20(k)(1)-(3) PASARR Screening for MD & ID, F645 Scope/Severity: J; 42 CFR 483.21(b) Comprehensive Care Plans,42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision, F657 Scope/Severity: K; 42 CFR 185.25 Quality of Care, F684 Scope/Severity: J;42 CFR 483.25 Quality of Care, F684; 42 CFR 483.40 Behavioral Health, F740 Scope/Severity: K; 42 CFR 483.40(a) Sufficient/Competent Staff-Behavioral Health Needs,F741 Scope/Severity: K; 42 CFR 483 40(d) Provision of Medically Related Social Services; F745 Scope/Severity: J; 42 CFR 483.70 Administration, F835 Scope/Severity: K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; 42 CFR 483.25 Quality of Care, F684 Scope/Severity: J; and 42 CFR 483 40(d) Provision of Medically Related Social Services, F745 Scope/Severity: J. At the time of the exit on February 3, 2020, the Immediate Jeopardy remained ongoing. Findings include: The facility had no specific policy to cover the process of identifying, reviewing and applying for a PASRR Level II. However, review of the facility policy, Admission Criteria, (Revised December 2016); number 8, Nursing and medical needs of the individual with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-Admission Screening and Resident Review program (PASRR) . 1. Review of the Admission Record revealed that R#1 was admitted on [DATE] to the nursing home facility, from an acute care hospital, with the following [DIAGNOSES REDACTED]. His discharge medication list from the acute care hospital included [MEDICATION NAME] (only antipsychotic medication approved by the FDA for treatment-resistant [MEDICAL CONDITION]. This medication is used after all other medications have failed). The most recent Minimum Data Set (MDS) for R#1 was an Admission assessment dated [DATE] and under Section C - Cognitive Patterns his Brief Interview of Mental Status (BIMS) score was assessed to be 10 out of 15 indicating that R#1 was moderately cognitively impaired. Further record review revealed that R#1 was admitted to the facility with a PASRR Level II dated 8/9/19 that documented the following: Is there evidence of Serious Mental Illness? Yes Behavioral Health Assessment/Service Plan Recommended: Yes Diagnostic/Ongoing Psychiatric Care Recommended? Yes Further record review of the PASSR Level II for R#1 documented the Services are recommended for psychiatric medication managment, Recommended specialized services for SMI (Serious Mental Illness) include: Behavioral Health Assessment/Service Plan Development to assess history, symptoms, needs and to develop an individulized plan of care. Diagnostic/Ongoing Psychiatric care for medication management and monitoring of efficacy and side effects, as well as ordering labs to determine levels. There was not any evidence of documentation that R#1 received ongoing psychiatric services as recommended on his PASSR II. Continued review revealed that the only psychiatric services R#1 received was when he was sent out of the facility and had to be admitted to a Behavioral Health facility on 10/3/19, 11/4/19, 12/3/19, and 12/24/19 until a new Behavior Health provider started providing services on 1/9/2020. 2. Record review revealed that R#5 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] for R#5 revealed a BIMS score of 14 indicating the resident was cognitively intact. Further record review revealed that R#5 was admitted to the facility with a Level II PASRR dated 5/10/13 with the recommendation for R#5 to receive specialized psychiatric care and treatment. There was no evidence of documentation that R#5 receive specialized psychiatric care and treatment once the previous Telehealth provider stopped providing psychiatric services on 10/28/19 until a new Behavior Health provider started providing services on 1/9/2020. 3. Record review revealed R#12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed BIMS score of 12 indicating moderate cognitive impairment. Record review revealed that R#12 was admitted to the facility with a Level II PASRR dated 8/28/18 with the recommendation for specialized services for his serious mental illness. Further record review revealed there was no evidence of documentation that R#12 received these specialized services for his mental illness once the previous Telehealth provider stopped providing psychiatric services on 10/28/19 until a new Behavior Health provider started providing services on 1/9/2020. Record review of the schedule for the previous Telehealth Provider regarding appointments that the facility had with the previous Telehealth Provider revealed the following documentation: Missed 1/9/19 appointment date due to connection issues and missed 1/22/19 - All visits moved to 2/12/19. Missed 3/14/19 appointment date - All visits moved to 4/16/19. 8/21/19 visits moved to 7/15/19 to have final visit with Jennifer 8/20/19 - New hire is due to see patient that was never activated - appointment moved to 8/27/19 but site (facility) did not confirm and was no show. Review of communication between the previous Telehealth Provider and the facility documented the following, in pertinent part: 8/22/19 at 9:21 a.m. - previous Telehealth Provider to facility - Attached is the schedule for next week. Please confirm. 8/27/19 at 11:49 a.m.- Facility to previous Telehealth Provider - Sorry have to reschedule. Did you receive confirmation from us for this appointment? 8/27/19 at 11:58 a.m. from previous Telehealth Provider to facility: I did not receive confirmation. This is an ogoing issue as I don't usually get a response from you when I send the schedule out so I don't know if you have even seen the email. 8/27/19 at 1:44 p.m. from previous Telehealth Provider to facility: I have moved your appointments to Friday 9/6/19 at 1:00 p.m. - Please confirm receipt of email and date of appointment. 8/29/19 at 9:28 am - from previous Telehealth Provider to facility: I'm still waiting for confirmation . will this date work for you? 9/3/19 at 12:11 p.m. from Facility to previous Telehealth Provider - Ok Friday at 1:00 p.m. is good 9/3/19 at 12:16 p.m. previous Telehealth Provider to Facility - I did not hear from you last week and another site was given that time slot. I can put you on the schedule for next Wednesday 9/11/19 at 1:00 p.m. but I need confirmation by tomorrow 9/4/19. 9/3/19 at 2:18 p.m. from Facility to previous Telehealth Provider - Ok Friday at 1:00 p.m. is good. 9/3/19 at 2:20 p.m. from Previous Telehealth Provider to Facility - The appointment is not Friday at 1:00 p.m. - It is for Wednesday 9/11/19 at 1:00 p.m. the Friday appointment was givent o another site since I did not hear back from you last week. During an interview on 1/22/2020 at 10:05 a.m. with the previous Telehealth Provider (TP) NN, she stated that the process her office takes was that about one week prior to coming to the facility to provide psychiatric or tele psychiatric services, she would send a list of the residents that were to be seen to the facility for confirmation, TP NN stated that this facility did not respond to their communication/e-mails and it was impossible to schedule the telehealth visits without the facility's confirmation. TP NN stated that it was considered a liability to provide services when the residents were not being seen regularly and that this facility would not communicate with them and that's why they stopped providing services. TP NN stated the last medication management visits that were conducted by her company were provided on 9/11/19 for some residents and the last counseling services provided by her company that were conducted on-site was on 10/28/19. During an interview on 1/22/2020 at 12:30 p.m. with Social Worker UU revealed that there was not a process in place for identifying and monitoring the new admissions for the correct PASRR Level, to ensure that the facility ensured residents received needed psychiatric services. During an interview with the Administrator on 2/3/2020 at 5:46 p.m., she stated that ensuring that the residents had the proper PASRR Level Screening was the responsibility of the Social Worker UU, with the Interdisciplinary Team's input. The Administrator stated that the system in place was not effective at this time and that this was ultimately her responsibility. Record review revealed that the last date of service by the previous Telehealth services was 10/28/19 until the facility signed a contract with a new Behavior Health provider that began providing psychiatric/behavioral health services on 1/9/2020. Review of the schedule for residents that were being seen by the previous Telehealth Provider, before these services were stopped, revealed that although the previous Telehealth Provider was available to provide behavioral health services for the facility there were only 16 residents on the list to be seen. Further record review revealed that R#1, R#5, and R#12 were not on the list of residents to be seen by the previous Telehealth Provider.

Based on record review, staff interviews, and review of the facility policy's titled, Administering Medications Policy, Pharmacy Services - Role of the Provider Pharmacy and Change in a Resident's Condition or Status the facility failed to provide medications as needed for R#1; failed to follow-up with medication orders received from the psychiatrist; failed to notify the Physician that R#1 was refusing medications, and failed to complete the required training to administer [MEDICATION NAME] for one of 23 (R#1) residents reviewed for medications. On 1/29/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and Social Services Director were informed of the Immediate Jeopardy on 1/29/2020 at 10:26 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/26/19. Immediate Jeopardy is outlined as follows: Resident (R) #1, a [AGE] year-old ambulatory male resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 had been prescribed [MEDICATION NAME] (an antipsychotic medication) since 2012. When R#1 was admitted to the facility this medication was discontinued because the Attending Physician/Medical Director did not complete the required online training required by the prescribing pharmacy in order to administer this medication. In addition, this medication required a laboratory test (ANC-Absolute [DIAGNOSES REDACTED] Count) be obtained and there was no evidence the required laboratory test was obtained. In addition, R#1 had a Preadmission Screening/Resident Review (PASSR) Level II dated 8/9/2019, that recommended medication management and on-going psychiatric care and treatment. There was no evidence the facility provided R#1 with any psychiatric services from the time of his admission on 8/15/19, until a new Behavior Health provider began providing psychiatric/behavioral health services on 1/9/2020. Record review revealed that R#1 started refusing his medications and on 9/26/2019, R#1 attacked R#5 and pushed him to the floor and kicked him. From 9/26/2019 until 1/18/2020, R#1 attacked 11 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16). Two of these eleven residents (R#3 and R#2) had to be sent to the emergency room for evaluation and treatment. R#3 had an acute/chronic displaced nasal fracture and R#2 received a laceration that required Dermabond to close. Record review revealed R#1 was sent out to a Behavioral Health Unit on 10/3/2019, 11/4/2019, 12/3/2019, 12/24/19, and although the facility was not able to meet his needs for medication management and ongoing psychiatric services the facility continued to readmit R#1 back to the facility. Although the facility was aware of R#1's aggressive behavior the facility failed to put measures in place to protect residents from R#1. In addition, the facility failed to provide psychiatric services for other residents in the facility with Level II PASSRs that had recommendations for psychiatric services from October of 2019 until January of 2020. On 1/18/2020, after R#1 was in a physical altercation with another resident R#1 was sent out of the facility to a Behavioral Health Facility. The facility did not have any plans to readmit R#1 after he was sent out of the facility on 1/18/2020. The immediate jeopardy is outlined as follows: 42 CFR 483.12 (a)(1) Abuse and Neglect, F600, Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; C.F.R. 483.15(a) Admissions policy, F620 Scope/Severity: K; 42 CFR 483.20(k)(1)-(3) PASARR Screening for MD & ID, F645 Scope/Severity: J; 42 CFR 483.21(b) Comprehensive Care Plans,42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision, F657 Scope/Severity: K; 42 CFR 185.25 Quality of Care, F684 Scope/Severity: J;42 CFR 483.25 Quality of Care, F684; 42 CFR 483.40 Behavioral Health, F740 Scope/Severity: K; 42 CFR 483.40(a) Sufficient/Competent Staff-Behavioral Health Needs,F741 Scope/Severity: K; 42 CFR 483 40(d) Provision of Medically Related Social Services; F745 Scope/Severity: J; 42 CFR 483.70 Administration, F835 Scope/Severity: K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; 42 CFR 483.25 Quality of Care, F684 Scope/Severity: J; and 42 CFR 483 40(d) Provision of Medically Related Social Services, F745 Scope/Severity: J. At the time of the exit on February 3, 2020, the Immediate Jeopardy remained ongoing. Findings include: Review of the facility's policy titled, Administering medications: [REDACTED]. Medication's must be administered in accordant with the orders, including the time frame. Review of the facility's policy titled, Pharmacy Services - Role of the Provider Pharmacy revealed Policy Interpretation and Implementation 3. k. Help the facility handle non-formulary or non-covered medications exception request. Review of the facility's policy titled, Change in a Resident's Condition or Status revealed Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or Physician on call when there has been a(an): f. refusal of treatment or medications two or more consecutive times. Record review revealed R#1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His most recent Minimum Data Set (MDS) was an Admission assessment dated [DATE] and under Section C - Cognitive Patterns his cognitive level was assessed to be 10 out of 15 indicating that R#1 was moderately cognitively impaired. Further record review revealed that R#1 was admitted to the facility with a PASRR Level II that recommended services of medication management and on-going psychiatric care and treatment. Review of the acute care facility Discharge Medication List dated 8/15/19 revealed that R#1 had Physician Orders for [MEDICATION NAME] 100 milligram (mg) by mouth twice a day ([MEDICATION NAME] is an antipsychotic medication that is used to treat [MEDICAL CONDITION] patients after all other medications have failed) and that his next dose of [MEDICATION NAME] was due on 8/15/19 at 9:00 p.m. Review of the nursing facility Order Summary Report dated 8/15/19 revealed that R#1 had an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Furthermore R#1 was not administered [MEDICATION NAME]. The nursing Progress Notes dated 8/16/19 documented that the nurse was awaiting [MEDICATION NAME] from the pharmacy. However, the [MEDICATION NAME] was never received. A Physician's Interim/Telephone Orders dated 8/20/19 at 11:00 a.m. revealed an order to discontinue the [MEDICATION NAME] 100 mg twice a day. Review of the MAR indicated [REDACTED]. Further review revealed that even though R#1 had been administered [MEDICATION NAME] since before 2012 the facility abruptly stopped this medication without titrating the drug to reduce the risk of complications with withdrawal. Review of this same MAR indicated [REDACTED]. A Physician Order dated 8/20/19 at 1300 1:00 p.m. revealed an order for [REDACTED].#1 was started on [MEDICATION NAME] 50 mg two times a day. Review of the MAR indicated [REDACTED]. The [MEDICATION NAME] was increased to 100 mg twice a day on 9/23/19. The nursing facility Progress Note: dated 9/23/19 revealed the increase was for incidents of R#1 being verbally aggressive at times. Review of the Medication Administration Record [REDACTED] On 10/3/19 R#1 was out of the facility to the emergency room (ER) and from the ER to a behavioral health facility. On 10/6/19 through 10/10/19 revealed R#1 was in a behavioral facility. He returned to the Long Term Care (LTC) facility on 10/11/19. Record review revealed that R#1 had Physician Orders to continue taking medications and had a new order for [MEDICATION NAME] ([MEDICATION NAME]) 10 milligram (mg) injection twice a day (9 a.m. & 9 p.m.) with additional instructions to hold the [MEDICATION NAME] if the resident was compliant with taking his oral medications. R#1 also had a Physician order for [REDACTED]. Continued review of the MAR indicated [REDACTED] On 10/11/19 night dose. On 10/19/19 morning dose. On 10/21/19 & 10/22/19 morning dose. On 10/24/19 through 10/27/19 the night dose. On 10/29/19 the night dose. On 10/30/19 both day and night dose. On 10/31/19 night dose. Further review of the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED] On 11/1/19 through 11/3/19 R#1 had refused morning and night dose medications On 11/5/19 he refused the morning dose On 11/6/19 he refused both morning and night dose On 11/7/19, he refused the night dose On 11/8/19 & 11/9/19 both morning and night dose. The dates for 11/10/19 through 11/14/19 and the morning of 11/15/19 revealed R#1 was out of the facility at a behavioral facility (R#1 was sent out of the facility on 11/10/19 to the ER then to a Behavioral Health facility. R#1 returned to the facility on [DATE] with orders for [MEDICATION NAME] tablet 25 mg give two tablets by mouth one time a day. Continue review of the MAR indicated [REDACTED]. Record review revealed that R#1's [MEDICATION NAME] was discontinued on 11/27/19; However, R#1 never received the [MEDICATION NAME]. Review off the MAR indicated [REDACTED] On 12/1/19 through 12/3/19 both morning and night dose. R#1 was transferred to a behavioral facility 12/4/19 through the morning of 12//10/19 On 12/11/19 both morning and night dose. On 12/12/19 the night dose. On 12/13/19 through the morning of 12/16/19 R#1 refused all medications. On 12/17/19, R#1 refused both morning and night medications. On 12/18/19 and 12/20/19, R#1 refused the night dose. On 12/21/19, R#1 refused both morning and evening dose. On 12/22/19 & 12/23/19, R#1 refused the morning medications dose. On 12/10/19 night dose; or his 12/19/19 night dose, there are no initials to indicate whether R#1 received or refused his medications. Further record review revealed a new Physician order for [REDACTED].#1 refused the [MEDICATION NAME][MEDICATION NAME]. However, further review revealed that the [MEDICATION NAME][MEDICATION NAME] was never received in the facility because it was denied authorization by R#1's insurance on 12/23/19. R#1 was transferred out of the facility to a behavioral health facility on 12/23/19 after he attacked a nurse. He returned to the facility on [DATE]. Record review revealed that R#1 had a Physician's Order for [MEDICATION NAME] 25 mg tablet take two tablets by mouth twice a day. Further review revealed that it was documented that R#1 continued to refuse all of his medications for the month of December and that the resident did not receive the ordered [MEDICATION NAME]. Review of the MAR indicated [REDACTED]. During an interview on 1/21/2020 at 1:13 p.m. the former Director of Nursing (DON) SS revealed that R#1 was admitted to the facility on [MEDICATION NAME] and the Medical Director did not have psychiatric experience. The facility was unable to administer the [MEDICATION NAME] because no one was trained to meet the requirements to administer the [MEDICATION NAME]. Further interview revealed that because the facility could not give the [MEDICATION NAME], the resident's medication was changed to [MEDICATION NAME]. Former DON SS stated that the order for the [MEDICATION NAME][MEDICATION NAME], was not covered by the resident's insurance. During an interview in the facility on 1/21/2020 at 2:24 p.m. Physician/Medical Director again revealed that he was aware that R#1 was on [MEDICATION NAME] upon admission but was not aware that he could not prescribe [MEDICATION NAME] and that the facility should screen potential residents better to avoid these types of problems. However, record review revealed that R#19 was admitted to the facility on [DATE] with a Physician order for [REDACTED].#1 being admitted to the facility indicating that the facility was aware of the requirements for [MEDICATION NAME]. During an interview on 1/21/2020 at 2:03 p.m. the Pharmacy Technician TT revealed that the pharmacy could not release the [MEDICATION NAME] without having the ANC (absolute [DIAGNOSES REDACTED] count) and that the pharmacy never received this blood test for R#1 from the facility. Pharmacy Technician TT stated that the facility was told on 8/15/19 (verbal via phone) to have R#1's blood drawn and upload the results to the website to ensure the resident had an adequate [DIAGNOSES REDACTED] count (ANC) in order to receive the [MEDICATION NAME]. During an interview on 1/22/2020 at 9:02 a.m. Psychiatrist BBB (Psychiatrist with a Behavioral Health facility that R#1 had been admitted to) revealed that in regard to R#1's [MEDICATION NAME] abruptly being stopped; this would cause an exacerbation of his [MEDICAL CONDITION]. Psychiatrist BBB Continued to explain that [MEDICATION NAME] is a last resort medication for difficult to treat [MEDICAL CONDITION] patients and is prescribed after all other medications have failed. Psychiatrist BBB stated that a resident who is prescribed [MEDICATION NAME] has to have a Psychiatrist to monitor the resident that has the knowledge and the privilege (meaning has completed the online training) to prescribe the medication. In addition, the resident must have a weekly blood test for a White Blood Count (WBC) to monitor the residents absolute [DIAGNOSES REDACTED] count (ANC's). During an interview on 1/22/2020 at 10:44 a.m. Pharmacist PP (one of the Pharmacists that dispenses medications to the facility) revealed that [MEDICATION NAME] requires blood work and has a monitoring program. The Physician must be certified to prescribe [MEDICATION NAME]. There is a website where the Physician must register the patient who is being prescribed [MEDICATION NAME]. The website shows the resident's blood work for white blood cells (WBC) with absolute [DIAGNOSES REDACTED] count and if the resident's last blood test result was from a hospital, the site will tell the prescriber how many days are left to dispense the medication. The pharmacy cannot dispense [MEDICATION NAME] without an ANC (absolute [DIAGNOSES REDACTED] count). During an interview on 1/22/2020 at 11:11 a.m. Pharmacist Consultant QQ (The Pharmacist Consultant revealed that he had made rounds in August prior to R#1 being admitted to the facility and that when he came in September 2019, he did not question the [MEDICATION NAME] because it had already been discontinued. Pharmacist Consultant QQ stated that the pharmacy would have provided a pre-admission analyst for R#1's medications. However, not all of the facility's send in a pre-admission medication list for pending new admission. Record review revealed that the facility did not complete a pre-admission analyst of R#1's medications prior to the resident being admitted to the facility. During an interview on 1/27/2020 at 12:43 p.m. Pharmacist XX (a Pharmacist with a retail pharmacy) revealed R#1 had starting using their pharmacy on 6/13/2012 and that R#1 had been prescribed [MEDICATION NAME] since before he started using their pharmacy. During a second interview on 1/28/2020 at 12:50 p.m. with the Physician/Medical Director revealed that in regard to the training requirements for the [MEDICATION NAME], he stated that he was not comfortable with the facility giving this medication and he did not feel comfortable prescribing this medication. During an interview on 1/28/2020 at 3:33 p.m. the Administrator stated she was not aware of R#1 having an order for [REDACTED].

Based on record review, staff interview, and review of the facility's Job Description for the Social Worker the facility failed to provide medically-related social services for three of three residents reviewed (#1, #5, and #12) that had a Preadmission Screening/Resident Review (PASSR) Level II assessessment that required psychiatric care and services. On 1/29/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and Social Services Director were informed of the Immediate Jeopardy on 1/29/2020 at 10:26 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/26/19. Immediate Jeopardy is outlined as follows: Resident (R) #1, a [AGE] year-old ambulatory male resident, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 had been prescribed [MEDICATION NAME] (an antipsychotic medication) since 2012. When R#1 was admitted to the facility this medication was discontinued because the Attending Physician/Medical Director did not complete the required online training required by the prescribing pharmacy in order to administer this medication. In addition, this medication required a laboratory test (ANC-Absolute [DIAGNOSES REDACTED] Count) be obtained and there was no evidence the required laboratory test was obtained. In addition, R#1 had a Preadmission Screening/Resident Review (PASSR) Level II dated 8/9/2019, that recommended medication management and on-going psychiatric care and treatment. There was no evidence the facility provided R#1 with any psychiatric services from the time of his admission on 8/15/19, until a new Behavior Health provider began providing psychiatric/behavioral health services on 1/9/2020. Record review revealed that R#1 started refusing his medications and on 9/26/2019, R#1 attacked R#5 and pushed him to the floor and kicked him. From 9/26/2019 until 1/18/2020, R#1 attacked 11 residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#12, R#16). Two of these eleven residents (R#3 and R#2) had to be sent to the emergency room for evaluation and treatment. R#3 had an acute/chronic displaced nasal fracture and R#2 received a laceration that required Dermabond to close. Record review revealed R#1 was sent out to a Behavioral Health Unit on 10/3/2019, 11/4/2019, 12/3/2019, 12/24/19, and although the facility was not able to meet his needs for medication management and ongoing psychiatric services the facility continued to readmit R#1 back to the facility. Although the facility was aware of R#1's aggressive behavior the facility failed to put measures in place to protect residents from R#1. In addition, the facility failed to provide psychiatric services for other residents in the facility with Level II PASSRs that had recommendations for psychiatric services from October of 2019 until January of 2020. On 1/18/2020, after R#1 was in a physical altercation with another resident R#1 was sent out of the facility to a Behavioral Health Facility. The facility did not have any plans to readmit R#1 after he was sent out of the facility on 1/18/2020. The immediate jeopardy is outlined as follows: 42 CFR 483.12 (a)(1) Abuse and Neglect, F600, Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; C.F.R. 483.15(a) Admissions policy, F620 Scope/Severity: K; 42 CFR 483.20(k)(1)-(3) PASARR Screening for MD & ID, F645 Scope/Severity: J; 42 CFR 483.21(b) Comprehensive Care Plans,42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision, F657 Scope/Severity: K; 42 CFR 185.25 Quality of Care, F684 Scope/Severity: J;42 CFR 483.25 Quality of Care, F684; 42 CFR 483.40 Behavioral Health, F740 Scope/Severity: K; 42 CFR 483.40(a) Sufficient/Competent Staff-Behavioral Health Needs,F741 Scope/Severity: K; 42 CFR 483 40(d) Provision of Medically Related Social Services; F745 Scope/Severity: J; 42 CFR 483.70 Administration, F835 Scope/Severity: K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: K; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F609 Scope/Severity: K; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: K; 42 CFR 483.25 Quality of Care, F684 Scope/Severity: J; and 42 CFR 483 40(d) Provision of Medically Related Social Services, F745 Scope/Severity: J. At the time of the exit on February 3, 2020, the Immediate Jeopardy remained ongoing. Findings include: The facility had no specific policy to cover the process of identifying, reviewing and applying for a PASRR Level II. However, review of the facility policy, Admission Criteria, (Revised December 2016); number 8, Nursing and medical needs of the individual with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-Admission Screening and Resident Review program (PASRR) . 1. Review of the Admission Record revealed that R#1 was admitted on [DATE] to the nursing home facility, from an acute care hospital, with the following [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) for R#1 was an Admission assessment dated [DATE] and under Section C - Cognitive Patterns his Brief Interview of Mental Status (BIMS) score was assessed to be 10 out of 15 indicating that R#1 was moderately cognitively impaired. Further record review revealed that R#1 was admitted to the facility with a PASRR Level II that recommended services of medication management and on-going psychiatric care and treatment. 2. Record review revealed that R#5 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] for R#5 revealed a BIMS score of 14 indicating the resident was cognitively intact. Further record review revealed that R#5 was admitted to the facility with a Level II PASRR dated 5/10/13 with the recommendation for R#5 to receive specialized psychiatric care and treatment. 3. Record review revealed R#12 was admitted with [DIAGNOSES REDACTED]. The MDS Quarterly assessment dated [DATE] revealed BIMS score of 12 indicating moderate cognitive impairment. Record review revealed that R#12 was admitted to the facility with a Level II PASRR dated 8/28/18 with the recommendation for specialized services for his serious mental illness. Review of the facility's Job Description for the Social Worker position was provided by the facility and documented: Department: Social Services, Reports to: Administrator, Under General Purpose Identify and provide for each resident's social, emotional and psychological needs, and the continuing development of the resident's full potential during his/her stay at the facility. Under, Essential Job Functions, bullet point 16 states, Work closely with the facility Mental Health provider to ensure that all resident psychosocial needs are identified, referrals are made, and services provided. Interview on 1/15/2020 at 1:14 p.m. Certified Nurse Aide (CNA) HH revealed that the facility had not provided any type of training for residents with mental health issues. The facility had promised for seven years to give them training and some type of education, but this had not happened. Interview on 1/15/2020 at 2:03 p.m. CNA GG revealed that she had not had any training on providing care for residents with mental [DIAGNOSES REDACTED]. Interview on 1/15/2020 at 3:44 p.m. with CNA II revealed that she has not been trained to handle residents with psychiatric [DIAGNOSES REDACTED].#1. Interview on 1/16/2020 at 3:41 p.m. LPN LL revealed that she had not had any training on how to care for residents with psychiatric diagnoses/mental illnesses and that she did not know what to do. During an interview on 1/22/2020 at 12:30 p.m., with Social Worker UU stated that she did not have a system in place to review PASRR screening levels for newly admitted residents or a system to identify any existing residents with changes in condition or new [DIAGNOSES REDACTED]. During an interview on 1/29/2020 at 10:43 a.m., with the Social Worker UU stated that she had a list of residents that she believed could possibly have benefited from some sort of extended psychiatric care and services. During an interview on 1/22/2020 at 10:05 a.m. the previous Telehealth Provider (TP) NN, she stated that the process her office takes was that about one week prior to coming to the facility to provide psychiatric or tele psychiatric services, she would send a list of the residents that were to be seen to the facility for confirmation, TP NN stated that this facility did not respond to their communication/e-mails and it was impossible to schedule the telehealth visits without the facility's confirmation. TP NN stated that it was considered a liability to provide services when the residents were not being seen as ordered and because of this the last medication management visit that was conducted by her company were provided on 9/11/19 for some residents and the last counseling services provided by her company that were conducted on-site was 10/28/19. During an interview on 2/3/2020 at 5:46 p.m., the Administrator stated it was the responsibility of Social Worker UU to ensure residents had the proper PASRR screening, to identify residents who needed a PASRR Level 2 review and to ensure residents with behaviors were identified. The Administrator further stated that it was also the responsibility of Social Worker UU to ensure residents who were approved for specialized physiatric care and services received them as recommended.

Based on medical record review, emergency room record review, dietary recipe review, observation of pureed food preparation, and staff interview, it was determined that the facility failed to provide food prepared in a form to meet the needs of residents who required pureed food form for one (1) resident (#1), who had been assessed to need and ordered by the physician to receive pureed food, on a total survey sample of nineteen (19) residents. Resident #1 subsequently choked and required transfer and admission to the hospital. A listing provided by the facility indicated that in addition to Resident #1, six (6) additional residents (Resident #s 7, 8, 9, 10, 11, and 12) also required food in a pureed form. Based on the above, it was determined that the facility's failure to provide food in the correct form had caused serious harm to Resident #1, and had a likelihood of serious harm to these six (6) other residents who had orders for food to be prepared in a pureed food form. It was therefore determined that the facility's noncompliance with one or more requirements had resulted in an immediate and serious threat to resident health and safety which was identified to have existed on September 22, 2011 and continued through October 27, 2011, at which time a plan was implemented by the facility to remove the immediate jeopardy situation as of October 28, 2011. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on October 26, 2011 at 4: 30 p.m. Findings include: Record review for Resident #1 revealed a Speech Therapy SLP Evaluation and Plan of Treatment which documented that services had been provided from 04/26/2011 to 07/22/2011. This evaluation revealed that the recommendations included a diet of puree consistency, thickened liquids and close supervision. This evaluation also documented risk factors for this resident which included aspiration, due to the resident's physical impairments and associated functional deficits. Review of the resident's September 2011 Physician order [REDACTED]. The Nurse's Notes dated 09/22/2011 at 1:30 p.m. documented that the nurse was called to the dining room and that Resident #1 was noted having difficulty breathing and was choking on a mechanically soft chicken she had eaten for lunch. This Note documented that the resident was noted with stridor breathing and that the [MEDICATION NAME] Maneuver was performed with several thrusts, resulting in the resident breathing better. Cheek sweeps revealed that the resident was pocketing chicken in the cheeks. This Note documented that the resident was assisted to the room, and the return of respiratory distress was noted, with audible stridor. Her skin color, lips and hands were turning blue. The [MEDICATION NAME] Maneuver was again performed several times without success. Nothing was noted in the mouth at that time, and the resident was noted to be breathing but with difficulty. This Note documented that the resident was receiving oxygen per mask at 3 liters, and her oxygen saturation level was eighty-four (84) percent. Emergency Medical Services (EMS) 911 was called. A Nurse's Notes entry of 09/22/2011 at 1:45 p.m. documented that EMS was at the resident's bedside and that the resident continued with a partial airway obstruction. An additional Nurse's Notes entry of 09/22/2011 at 1:50 p.m. documented that the resident was transported to the hospital. A review of the Emergency Department Triage notes for Resident #1 dated 9/22/2011 documented that the resident arrived at the emergency room at 2:15 p.m. Documentation in these Triage notes indicated that the resident had been eating chicken and then started choking, that the EMS personnel had retrieved approximately three (3) inches of chicken, and that the resident was alert upon arrival at the hospital. During an interview with Nurse "AA" conducted on 10/26/2011 at 10:45 a.m., this nurse stated that on the day Resident #1 choked, the resident was in the dining room and had been feeding herself chopped chicken. The resident then choked on the chopped chicken, the [MEDICATION NAME] Maneuver was performed, and the resident went from full obstruction to partial obstruction. EMS was then called, and EMS personnel were able to remove the obstruction. During an interview with the Dietary Manager conducted on 10/26/2011 at 11:14 a.m., the Dietary Manager acknowledged that Resident #1 had a diet order dating from 05/18/2011 which had specified for the resident to receive a no-added-salt diet with pureed meat. Based on the above, the facility had failed to provide Resident #1 with the pureed meat that was ordered. The resident became choked and the facility was unable to completely clear the resident's airway, thus EMS were called and the resident was transported to the hospital. It was determined that the immediate jeopardy was removed as of October 28, 2011, by which time the facility had completed the following actions: Beginning on 10/27/2011 the following actions were being taken to ensure Resident #1, as well as any other resident, was not affected by non-compliant dietary issues. 1. On 10/27/2011, all aspects of care related to the diet for Resident #1 as well as all other residents were reviewed. Areas with potential for error involving the staff were identified and the changes implemented as follows. 2. On 10/27/2011, all diet orders were reviewed and verified by the MDS Coordinator and Dietary Manager. 3. On 10/27/2011, a process was begun by which upon receipt of a dietary order, the nurse will write the order in the chart and communicate the order to dietary utilizing the Dietary Communication Form. Either the Dietary Manager or the food server will initial receipt of the order. Forty-nine (49) of fifty-six (56) of the nursing staff were inserviced on this procedure on 10/27/2011. The 7 members of the nursing staff that had not been inserviced were not allowed to return to work until completion of the inservice. 4. On 10/27/2011, a process was begun indicating that once the trays carts are completed and prior to delivery of the meal to the resident, the Charge Nurse will check the trays to ensure that the diet marked on the tray ticket reconciles with the consistency of the meal on the tray. Forty-nine (49) of fifty-six (56) of the nursing staff were inserviced on diet consistency on 10/27/2011. The 7 members of the nursing staff that had not been inserviced were not be allowed to return to work until completion of the inservice. 5. On 10/27/2011, a process was begun by which the Assist Director of Nursing (ADON) will audit trays and monitor nursing staff performance in the Dining Room to verify implementation of this procedure 5 times a week for 2 weeks, 3 times a week for 2 weeks, and weekly for 2 months. 6. On 10/27/2011, the Dietary Manager conducted an inservice with 7 of 9 dietary staff on reading the tray tickets, diets, food consistency, reconciliation of ticket-to-tray and proper procedure for receiving new dietary orders. The 2 dietary staff that had not been inserviced were not allowed to return to work until completion of the inservice. 7. On 10/27/2011, 7 of 9 dietary staff completed competency evaluations verifying that they could recognize the proper consistency of specialty diets and correctly read the tray ticket. The 2 dietary staff that had not completed the competency evaluation were not allowed to return to work until the evaluation had been conducted. All dietary staff will also complete the evaluation annually. 8. On 10/27/2011, the facility began audits of trays which will be completed by the Dietary Manager 5 times a week for 2 weeks, 3 times a week for 2 weeks, and weekly for 2 months. 9. On 10/27/2011, the facility initiated a process by which the Dietary manager will check food for consistency prior to the making of trays randomly 2 times a week for 3 months to ensure that the blender is giving a correct product. 10. On 10/27/2011, the facility initiated a process by which results of all audits referenced above will be presented to the Quality Assurance (QA) committee on 11/16/2011 for review by the Administrator and DON and follow up as needed. The Registered Dietician has been notified of the situation, to review the corrective actions and make any changes in the future if needed. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on 10/28/2011. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had implemented a process on 10/27/2011 by which, upon receipt of a dietary order, the nurse would write the order and communicate the order to dietary utilizing the Dietary Communication Form, and inservice was provided to 49 nursing staff. However, 7 nursing staff had not been inserviced as of that date, and were not allowed to return to work until completion of the inservice. Also, on 10/27/2011, a process was begun by which the Charge Nurse would check diet trays prior to delivery to residents to ensure the diet on the tray ticket reconciled with the consistency of the meal on the tray, and the facility provided inservice to 49 of the nursing staff. However, 7 members of the nursing staff had not been inserviced as of that date, and were not allowed to return to work until completion of the inservice. On 10/27/2011, the Dietary Manager conducted an inservice with 7 of 9 dietary staff on reading the tray tickets, diets, food consistency, reconciliation of ticket-to-tray and proper procedure for receiving new dietary orders, and conducted competency evaluations, but 2 dietary staff that had not been inserviced and evaluated as of that date, and were not allowed to return to work until completion of the inservice. Also, the facility initiated a process by which results of diet and tray audits will be presented to the Quality Assurance (QA) committee, but the committee does not meet until 11/16/2011. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "E" level.

Based on medical record review and staff interview, it was determined that the facility failed to revise the Care Plan of one (1) resident (#1) to address the resident's identified and assessed risk of aspiration and recent history of choking and aspiration, on a total survey sample of nineteen (19) residents. Based on the above, it was determined that the facility's failure to revise the Care Plan of Resident #1 to reflect the resident's risk of aspiration, and history of aspiration, had a likelihood of serious harm to this resident. It was therefore determined that the facility's noncompliance with one or more requirements had resulted in an immediate and serious threat to resident health and safety which was identified to have existed on September 22, 2011 and continued through October 27, 2011, at which time a plan was implemented by the facility to remove the immediate jeopardy situation as of October 28, 2011. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on October 26, 2011 at 4: 30 p.m. Findings include: Please cross refer to F365 for more information regarding Resident #1. Record review for Resident #1 revealed a Speech Therapy SLP Evaluation and Plan of Treatment which identified risk factors for this resident which included aspiration, and referenced the resident's need of food of a pureed consistency. Also, the resident's September 2011 Physician order [REDACTED]. A Nurse's Notes dated 09/22/2011 at 1:30 p.m. documented that Resident #1 was noted to be having difficulty breathing and was choking on a mechanically soft chicken, requiring the [MEDICATION NAME] Maneuver, the notification of Emergency Medical Services, and hospital transfer. During an interview with Nurse "AA" conducted on 10/26/2011 at 10:45 a.m., this nurse revealed that on 09/22/2011, Resident #1 had ingested chopped chicken and had choked. Review of the resident's current Care Plan revealed a 10/18/2011 entry identifying that the resident was to receive a pureed diet. However, this Care Plan did not address the resident's risk factor of aspiration, although that risk had been identified by Speech Therapy and the resident had choked and aspirated on 09/22/2011. It was determined that the immediate jeopardy was removed as of October 28, 2011, by which time the facility had completed the following actions: Beginning on 10/27/2011 the following actions were being taken to ensure Resident #1, as well as any other resident, was not affected by non-compliant dietary issues. 1. On 10/27/2011, all aspects of care related to the diet for Resident #1 as well as all other residents were reviewed. Areas with potential for error involving the staff were identified and the changes implemented as follows. 2. On 10/27/2011, all diet orders were reviewed and verified by the MDS Coordinator and Dietary Manager. 3. On 10/27/2011, a process was begun by which upon receipt of a dietary order, the nurse will write the order in the chart and communicate the order to dietary utilizing the Dietary Communication Form. Either the Dietary Manager or the food server will initial receipt of the order. Forty-nine (49) of fifty-six (56) of the nursing staff were inserviced on this procedure on 10/27/2011. The 7 members of the nursing staff that had not been inserviced were not allowed to return to work until completion of the inservice. 4. On 10/27/2011, a process was begun indicating that once the trays carts are completed and prior to delivery of the meal to the resident, the Charge Nurse will check the trays to ensure that the diet marked on the tray ticket reconciles with the consistency of the meal on the tray. Forty-nine (49) of fifty-six (56) of the nursing staff were inserviced on diet consistency on 10/27/2011. The 7 members of the nursing staff that had not been inserviced were not be allowed to return to work until completion of the inservice. 5. On 10/27/2011, a process was begun by which the Assist Director of Nursing (ADON) will audit trays and monitor nursing staff performance in the Dining Room to verify implementation of this procedure 5 times a week for 2 weeks, 3 times a week for 2 weeks, and weekly for 2 months. 6. On 10/27/2011, the Dietary Manager conducted an inservice with 7 of 9 dietary staff on reading the tray tickets, diets, food consistency, reconciliation of ticket-to-tray and proper procedure for receiving new dietary orders. The 2 dietary staff that had not been inserviced were not allowed to return to work until completion of the inservice. 7. On 10/27/2011, 7 of 9 dietary staff completed competency evaluations verifying that they could recognize the proper consistency of specialty diets and correctly read the tray ticket. The 2 dietary staff that had not completed the competency evaluation were not allowed to return to work until the evaluation had been conducted. All dietary staff will also complete the evaluation annually. 8. On 10/27/2011, the facility began audits of trays which will be completed by the Dietary Manager 5 times a week for 2 weeks, 3 times a week for 2 weeks, and weekly for 2 months. 9. On 10/27/2011, the facility initiated a process by which the Dietary manager will check food for consistency prior to the making of trays randomly 2 times a week for 3 months to ensure that the blender is giving a correct product. 10. On 10/27/2011, the facility initiated a process by which results of all audits referenced above will be presented to the Quality Assurance (QA) committee on 11/16/2011 for review by the Administrator and DON and follow up as needed. The Registered Dietician has been notified of the situation, to review the corrective actions and make any changes in the future if needed. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on 10/28/2011. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had implemented a process on 10/27/2011 by which, upon receipt of a dietary order, the nurse would write the order and communicate the order to dietary utilizing the Dietary Communication Form, and inservice was provided to 49 nursing staff. However, 7 nursing staff had not been inserviced as of that date, and were not allowed to return to work until completion of the inservice. Also, on 10/27/2011, a process was begun by which the Charge Nurse would check diet trays prior to delivery to residents to ensure the diet on the tray ticket reconciled with the consistency of the meal on the tray, and the facility provided inservice to 49 of the nursing staff. However, 7 members of the nursing staff had not been inserviced as of that date, and were not allowed to return to work until completion of the inservice. On 10/27/2011, the Dietary Manager conducted an inservice with 7 of 9 dietary staff on reading the tray tickets, diets, food consistency, reconciliation of ticket-to-tray and proper procedure for receiving new dietary orders, and conducted competency evaluations, but 2 dietary staff that had not been inserviced and evaluated as of that date, and were not allowed to return to work until completion of the inservice. Also, the facility initiated a process by which results of diet and tray audits will be presented to the Quality Assurance (QA) committee, but the committee does not meet until 11/16/2011. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "D" level.