Every finding on record at Pleasant Hills Community Living Center

Based on observation, record reviews, interviews and facility policy review, the facility failed to properly secure a wheelchair security device and prevent accidents for residents who depended on the facility van and staff for transfers to medical appointments for one (1) of three (3) sampled residents. Resident #1. Findings Included:Record review of the facility of the facility policy Accidents/Incidents (undated) revealed .Purpose: To assure that all persons who are involved in an incident or accident, or suspected to have had an incident or accident, are evaluated and receive treatment as indicated and are monitored for disposition of incident and accident .Record review of the incident report dated 1/08/26 for Resident #1 revealed the incident was described as . while in route to Dr. Appointment, resident fell backwards in wheelchair and hit the back of her head causing a small hematoma (area of trauma where blood vessels broke and blood pooled beneath the skin).Record review of the Facility Investigation dated 1/08/26 revealed Resident #1 .was on the transportation van on her way to an appointment when her (wheel)chair fell backwards and she hit the back of her head on the floor causing a hematoma to form. Certified Nursing Assistant (CNA) #1 and CNA #2 went to the back of the van and they both assisted (Proper name of Resident #1) getting up.CONCLUSION: (Proper name of Resident #1) was strapped in but (Proper name of CNA #1 transportation assistant, failed to ensure that the wheelchair straps were appropriately placed to firmly secure the chair resulting in the chair rolling backwards.Record review of the hospital After Visit Summary dated 1/08/26 for Resident #1 revealed the resident was seen at the local hospital emergency department for Fall.Injury of head and based on radiography X-Ray and computed tomography (CT) scans the resident had no new diagnoses or orders. Documentation indicated the resident was treated with an over-the-counter analgesic.Record review of the Quality Assurance and Performance Improvement (QAPI) committee meeting document with attached signature sheet dated 1/08/26 revealed the facility QAPI committee determined the root cause of the fall experienced by Resident #1 on 1/08/26 was Root Cause: The primary cause of the fall was that the resident's wheelchair was not properly secured with appropriate straps to maintain a stable and secure position during transportation. On 2/23/26 at 11:00 AM, during an interview CNA #1 revealed that on 1/08/26 during transportation for Resident #1, she used four (4) hooks to secure the frame of the wheelchair using the facility van's resident securement system. She stated the wheelchair was attached to the floor of the van. She stated that during transport of the resident to a physician's appointment at a local hospital at approximately 8:10 AM, she heard a noise in the van and looked in the rear of the van and saw Resident #1 on the van floor with her wheelchair turned over on its side, and the seatbelt was no longer secured over (or around) the resident. She stated that the resident had come out of the chair. She said that she and CNA #2 asked the resident how she was and the resident responded, I hit my head and reported head pain. She said she and CNA #2 picked the wheelchair up and assisted the resident back into the chair and then telephoned the Administrator and told her that the resident had fallen over in her wheelchair on the van during transport and hit her head. She stated that the Administrator instructed them to take her to the same hospital, but to the emergency department for assessment. She explained that the attachment on the driver's side had come loose.On 2/23/26 at 11:20 AM, during an interview CNA #2 revealed she and CNA #1 on 1/08/26 at approximately 8:00 AM assisted Resident #1 onto the facility van's and secured the resident's wheelchair using the resident securement system, but that she had not observed or used any checklist to ensure correct or proper securement. She said that as she drove Resident #1 to a physician's appointment at a local hospital, she heard a noise in the back of the van and observed Resident #1 on the floor of the van and her wheelchair turned over on its side. She stated after parking the van she and CNA #1 asked the resident if she was ok and the resident responded by saying her head hurt and that she had hit her head. CNA #2 confirmed that she and CNA #1 had turned the wheelchair upright and assisted the resident into the wheelchair and then called the facility Administrator who instructed them to continue to the hospital but to take the resident to the emergency department instead of the physician's office. She confirmed that she and CNA #1 had returned to the facility where the Maintenance Supervisor had inspected the resident securement system and determined that all components were intact and functioning correctly.On 2/23/26 at 12:00 PM, during an interview the Administrator revealed she had been notified shortly after 8:10 AM on 1/08/26 by CNA #1 that during transportation via facility van, Resident #1's wheelchair had fallen over, and the resident had hit her head. The Administrator confirmed that CNA #1 informed her that she and CNA #2 had asked the resident if she was ok and the resident reported she had hit her head and her head hurt. The Administrator stated that if the transportation staff had called her prior to moving the resident, she would have instructed them to stay put and call emergency services to come to them so qualified personnel could evaluate and assess Resident #1 prior to moving the resident. The Administrator confirmed that the facility QAPI committee met on 1/08/26 and reviewed the incident and determined that the root cause of the fall was that the resident's wheelchair was not properly secured by facility staff with appropriate straps to maintain a stable and secure position during transportation. She stated that all staff involved in transportation of residents in the facility van were in-serviced on the resident securement system and fall policy regarding appropriate assessment and evaluation of residents by appropriately licensed prior to moving the residents following a fall or accident.On 2/23/26 at 3:15 PM, during an interview the Maintenance Supervisor stated that upon returning the van to the facility following the transport of Resident #1 he had inspected the facility van resident securement system and found all the components of the system intact and functioning correctly. He stated that he was not involved with training staff regarding procedures for falls because nursing staff were responsible for that part of the training.Record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, heart failure and rheumatoid arthritis.Record review of the Significant Change Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date (ARD) of 12/12/25 revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Section GG indicated Resident #1 required a wheelchair for mobility.

Based on observation, interviews, record review and facility policy review, the facility failed to provide adequate supervision and a secure environment to prevent the elopement of one (1) of ten (10) sampled residents, Resident #9. On 11/28/25, at approximately 10:40 AM a member of the facility staff observed Resident #9 with a Rollator exit the facility behind a visiting nurse. Resident # 9 was outside unsupervised for approximately 22 minutes. At 11:02 AM Resident # 9 was located 0.4 miles away from the facility down a busy four lane street in the parking lot of a local funeral home. The temperature at the time was 51 degrees; the resident was dressed in a sweatshirt and jeans.The facility's failure to provide adequate supervision to prevent the elopement of Resident #9 placed this resident, and other residents at risk for wandering and elopement, in a situation that was likely to cause serious injury, harm, impairment, or death. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 11/28/25 and existed at 42 CFR(s): 483.25(d)(1)(2) Free of Accidents Hazards/Supervision/Devices (F689) - Scope and Severity (S/S) of J. The SA notified the facility's Administrator of the IJ and SQC on 12/2/25, at 3:20 PM and provided the Administrator with the IJ template. Based on the facility's implementation of corrective actions on 11/29/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of 11/30/25, prior to the SA's first entrance on 12/1/25. Findings include:Record review of facility Elopement/Unsafe Wandering Plan dated 02/07/2012 revealed, Policy: It is the policy of this facility to protect the resident from harm while providing care in a manner that helps promote quality of life and safe environment procedures. Risk Evaluation: An evaluation of the resident's risk for unsafe wandering or elopement is to be conducted on admission, quarterly, after a significant change in condition, and after an incident of elopement. Identification: Residents at risk will have some type of identifier on their person. Plan of Care: If a resident is identified at risk for elopement or unsafe wandering, a preventative plan of care is to be implemented at the time the risk is identified. Unsafe wandering and/or elopement potential is to be entered into the ADL (activity of daily living) system and ADL plan of care. Supervision: Visual supervision may be necessary in some instances. The nursing staff will complete and document the visual checks as necessary. Facility Systems: Systems such as alarms, Wanderguard systems and special locks/keypads as allowed by state and local authorities will be utilized to the extent possible.Record review of the admission Record for Resident #9 revealed the facility admitted the resident on 11/11/25 and the resident had diagnoses including Depression, Unspecified, Repeated Falls, and Chronic Atrial Fibrillation.Record review of the admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 11/18/25 for Resident #9 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 09, which indicated moderate cognitive impairment. No mood or behavioral issues were noted, including wandering or exit seeking behaviors.Record review of the clinical note dated 11/26/2025 revealed the entry was labeled as New Recommendations and directed the reader to review the clinical notes for details. The note identified a new referral for psychiatric symptom management and a psychiatric medication review. The documented reason for referral was listed as new referral, psychiatric symptom management, and psychiatric medication review.During an interview on 12/03/24 at 11:30 AM Licensed Nursing Home Administrator (LNHA) described her understanding of the incident involving Resident 9. She stated she first became aware of the elopement when therapy staff sent a message reporting that the resident had been seen walking out of the facility. She said this occurred at 9:55 AM. She stated that staff should have verified the resident's location immediately and initiated the missing resident procedure without delay. She stated Registered Nurse (RN) # 1 last saw the resident at 10:37 AM, but staff did not maintain awareness of the resident's movement near the exit. She said the therapist observed the resident exiting behind a hospice Certified Nurse Aide who held the door open. She stated that this indicated a failure to follow the facility's Wandering and Missing Resident Procedures because staff did not block the exit or redirect the resident. She stated that between 10:37 AM and 10:40 AM no staff intervened to stop the resident, and no one initiated the Elopement and Wandering Prevention Plan as required. She said this allowed Resident #9 to leave the building unsupervised. The LNHA stated that Resident # 9 was found at 11:02 AM off the premises on a nearby street. She said the resident was near the roadway area and appeared anxious. She said the resident told staff that someone was trying to kill her. She confirmed that the resident was returned to the facility at 11:09 AM. During an interview 12/03/25 at 1:25 PM, Physical Therapist Assistant (PTA) # 1 revealed he returned to the building through the south entrance at approximately 10:40 AM. He stated that when he opened the door to enter, Resident # 9 was standing at the door waiting to exit with a female nurse in blue scrubs. He stated he stepped to the side and held the door for them to exit because he assumed the nurse was accompanying the resident. He stated he observed both individuals from the therapy room. He reported that the nurse got into her vehicle and left the premises, and Resident # 9 continued walking toward the south parking lot entrance and exit. He stated Resident # 9 stood for a few minutes in an area where other residents who have the authority to sign themselves out commonly gather. He stated he believed she had possibly signed herself out. He stated that when he observed Resident # 9 completely exit the premises and take a right onto street in front of the facility, he decided to send a group text to inform his coworkers. He stated that once he learned this was an active elopement, he assisted the social worker, and the Administrator, in locating the resident. He stated they found the resident in a parking lot at a nearby Funeral Home. He stated they collectively calmed the resident, who expressed that someone was coming to the facility to kill her and her husband. He stated the resident agreed to return to the facility and rode back with the social worker and administrator.During an interview with the Social Worker # 1 on 12/03/25, at approximately 11:09 AM, the staff member stated the staffing coordinator contacted her to ask whether the resident was in their room. She reported that she immediately went to check and found that the resident was not present in the room. She stated a Code W was initiated throughout the building. She reported that shortly afterward, administration contacted her and informed her that the resident had left the facility following a visitor. She stated that a body audit was performed once the resident returned. She reported that vital signs were obtained and were within normal limits with no abnormalities noted at that time. She stated the resident was last visibly seen by her at 10:37 AM. She stated she provided this information to accurately document the events as she observed them. During an interview on 12/04/25 at 3:00 PM, Registered Nurse (RN) #1 stated that at approximately 11:09 AM on the day of the incident, the staffing coordinator contacted her and asked whether the resident was present in her room. She stated the coordinator told her therapy personnel had asked if the Resident # 9 was supposed to be on the highway. She stated she immediately went to check and found the resident was not in her room. She stated a Code W was initiated throughout the building. She stated that a few minutes later, administration and Social Services notified her that the resident had been observed standing in a parking lot down the road. She stated that when the resident returned to the facility, she assessed the resident for injuries and found none. She stated vital signs were taken and were within normal limits. She stated therapy personnel informed staff that he believed the resident was leaving with the lady in blue scrubs, and because of that assumption, he entered the exit code to allow them to leave the building. She stated the lady in blue scrubs was identified as a hospice nurse. She stated the hospice nurse was contacted and reported that the tall man in therapy had let both of them out but clarified that the resident was not with her. She stated Social Services contacted the resident's responsible party, who arrived at the facility to meet with the resident. She stated administration interviewed the resident, and the resident reported that her husband told her someone was going to kill him, and she believed she needed to leave the facility to avoid being harmed. She stated the resident was assured by administration that safety was being provided for both her and her spouse, and the resident voiced understanding. She stated the on-call nurse practitioner was contacted and provided a new order for a psychiatric evaluation.On 12/03/25 at 10:00 AM observation revealed the first parking space on the right was approximately fifty-five feet from the front entrance. Observation revealedsix other vehicles traveling through the parking lot. The driveway which led from the facility's front area, along the front of the parking spaces led to a busy four lane street with a speed limit of thirty-five miles per hour and no cross walks; observation revealed one hundred twenty-five (125) vehicles traveling on the boulevard between 10:00 AM and 10:05 AM. Record review of the local weather history according to WWW.Wunderground, Copyright The Weather Channel, for the facility for 10:53 AM on 11/28/25 revealed the temperature was fifty-one (51) degrees Fahrenheit, with zero (0) precipitation, five (5) mile per hour winds.Corrective Action PlanOn 12/2/25 at 3:20 PM, the State Agency presented an Immediate Jeopardy [NAME] which notified the Administrator of the facility that the facility failed to ensure Resident #9, who has a Brief Interview for Mental Status (BIMS) score of 9 (cognitively impaired) was adequately supervised to prevent elopement. On 11/28/25 at approximately 10:30 AM, Resident #9 was witnessed leaving the facility behind another staff member and was located at a busy intersection approx. 0.4 miles from the facility. Staff did not prevent the resident from leaving, did not verify her location, and did not intervene as required by the facility's elopement and wandering procedures. This placed resident #9 and other residents at risk for elopement in a situation that was likely to cause serious injury, serious harm, impairment or death. On 11/28/2025, at 10:55 am, Physical Therapy Assistant (PTA), sent a message to the Interdisciplinary Team (IDT) group message thread asking if Resident #9 was supposed to be walking on the highway. At this time, the IDT initiated a search within the building and outside the parameters for Resident #9. The Administrator immediately went to check Resident #9's room; Resident #9 was not in there. The Administrator then proceeded to the front entrance to see if she could see Resident #9; she could not. Social Service Director (SSD) and the PTA came outside to look as well. At 11:00 am the PTA, SSD and the Administrator got in vehicles to go look for Resident #9. At 11:02 am we located Resident #9 in front of the funeral home, 0.4 miles from the facility. Resident #9 was found safe and uninjured. The temperature was in the upper 50s. Resident #9 was appropriately dressed in a sweatshirt and jeans. Corrective Action: On 11/28/25 at 10:00 AM, Resident #9 was last seen by Certified Nursing Assistant (CNA) #1. On 11/28/25 at 10:37 AM, Resident #9 was last seen by Registered Nurse (RN) #1. On 11/28/25 at 11:05 AM, SSD called Resident #9s Resident Representative (RR), RR did not answer. On 11/28/25 at 11:18 AM, Resident #9s RR returned the call to SSD where she was informed of the incident. On 11/28/25 at 11:18 AM, a census was printed for the North and South unit, and a head count was completed to ensure all residents in the facility were accounted for. On 11/28/25 at 11:38 AM, a body audit was completed on Resident #9 by RN with no injuries noted. On 11/28/25 at 12:19 PM, Administrator reported the incident to the State Agency. On 11/28/25 at 12:26 PM, Maintenance #1 completed an audit on all doors and windows to ensure proper functioning. On 11/28/25 at 12:28 PM, On-Call Nurse Practitioner (NP) #1 was notified by RN. A new order for an in-house psych eval was given. On 11/28/25 at 12:30 PM, Medical Director, Medical Doctor (MD) and NP #2 were notified by Administrator of the incident. On 11/28/25 at 1:00 PM, All staff in-services began on Elopement/Unsafe wandering plan and the Emergency Procedure - Missing Resident and Abuse and Neglect. All in-services were completed on 11/29/25 by Assistant Director of Nursing (ADON). On 11/28/25 at 1:30 PM, An Elopement Drill was conducted by Maintenance Director and completed on 11/29/25. On 11/28/25 at 2:00 PM, An emergency Quality Assurance Performance Improvement (QAPI) meeting was held by Administrator with IDT members to discuss the incident, actions to be taken and further interventions put in place. The QAPI committee reviewed the incident and actions taken. The policy was reviewed with no recommendations for change. All protocols were followed per policy; no changes were needed. The QAPI committee determined at this time to prevent further adverse events the interventions would include adding Resident #9 to the wander book and providing a wander guard. Person centered in-services will be completed with staff whenever any new residents are identified as an elopement risk and any newly identified residents who are at risk for elopement. An elopement drill on all shifts and one elopement drill per week on alternating shifts for four weeks. These interventions are as follows: Head count by census, Maintenance quality check on all doors and windows, an elopement drill for all staff on each shift, then weekly for 4 weeks on alternating shifts, Then monthly three (3) months (Elopement/Unsafe Wandering Missing Resident, February 2010, Elopement Prevention Plan - Process. Upon hire and annually, the procedure is to notify all personnel on duty of the resident's absence, call a code W for missing resident with resident's name, search the premises inside and out, alert RR, MD, police if needed, regional director and state agency). SSD will complete 100% audits on all wanderers, update wander book, update care plans, in-service on wander book location, conduct interview with resident for any psychosocial harm. On 11/28/25 at 2:00 PM, Medication Administration Record (MAR) was updated with hourly visual monitoring for Nursing by RN. Point of Care (POC) updated for hourly visual tasks to fire off for CNAs to mark complete by Minimum Data Set (MDS) Nurse. On 11/28/25 at 2:30 PM, SSD conducted an interview with the resident to assess psychosocial harm. No psychosocial harm was noted. On 11/28/25 at 3:00 PM, Wander Guard bracelet was placed on Resident #9's left wrist. On 11/28/25 at 3:30 PM, Care plans were updated by SSD. On 11/28/25 at 4:00 PM a 100% audit was done on all wanderers by SSD and Wander Book was 100% updated with photos and face sheets. On 11/28/25 at 4:30 pm a 100% audit was done by SSD on all Wander Guard bracelets to ensure appropriate functional ability. The root cause analysis determined by the administrator and Director of Nursing found that the PTA assumed that CNA #2 was one of the facility staff members and that Resident #9 was being supervised by CNA #2. It was determined through an interview with the PTA that he was unsure if Resident #9 was her own Resident Representative (RR) and had signed herself out. It was determined through an interview with CNA #2 that she was unaware that Resident #9 was a resident. Resident #9 had two bags packed and looked as if she was visiting a family member. On 12/2/25 at 4:53 PM, Incident was reported to the Attorney General's Office by Administrator. On 11/28/25 The Maintenance Director Performed elopement drills on all shifts, this will continue for four (4) weeks and monthly for three (3) months and brought before the QAPI committee each month for review and recommendations. Any issues will be addressed immediately by the Administrator and the DON. Facility alleges that all corrective actions were complete on 11/29/25 and Immediate Jeopardy removed on 11/30/25. On 12/04/25, SA validations were made onsite during the complaint investigation through interviews and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 11/30/25, prior to the SA entrance on 12/1/25.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure Resident #1's right to be free from abuse when the facility failed to prevent repeated resident-to-resident physical aggression between Resident #1 and Resident #2.This resulted in Resident #1 sustaining periorbital edema and redness to the left eye, causing Resident #1 pain that required analgesic (pain) medication for two (2) of (30) sampled residents. Resident #1 and Resident #2. Findings included: Record review of the facility policy Resident Abuse or Neglect Prevention Plan dated March 15, 2004, revealed, The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion .Guideline: Theses requirements specify the right of each resident to be free from abuse .and the facility's responsibilities to prevent not only abuse, but also those practices .that if left unchecked, lead to abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents Record review of the Facility Investigation dated 6/20/25 with an attached statement by Licensed Practical Nurse (LPN) #1 revealed On June 9, 2025, nurse reported to writer that resident 4918 punched resident 4864 in face at drink machine. Certified Nursing Assistant (CNA) witnessed incident take place. Administrator notified. On 6/18/25 at 7:35 PM, during a telephone interview LPN #1 revealed that she was made aware of an allegation of abuse of Resident #2 by Resident #1 on 6/09/25. She said CNA #5 reported to her that she witnessed Resident #1 punch Resident #2 in the face. She said she couldn't recall if an incident report was completed. She confirmed that the two residents professed to be in a relationship, but staff had discouraged the relationship due to on-going abusive behavior by both residents toward each other and the two residents sought each other out regardless of room assignments. She stated that hourly monitoring/supervision had not proven successful as incidents happened so suddenly. On 6/19/25 at 2:50 PM, during an interview the Social Services Director, (SSD) confirmed she was the official Grievance Officer of the facility and stated that she made the Administrator aware of all credible allegations and all allegations of abuse and neglect. She stated her role in any allegation of abuse would be to offer counseling and support and send in referral to in-facility contracted psychiatric services (including psychosocial therapist and psychiatric Nurse Practitioner) to any victim and perpetrator in the case of resident-on-resident incidents. She said the contracted psych services visits weekly. She confirmed she had been made aware of several allegations of resident-on-resident abuse between Resident #1 and Resident #2 and had referred both to in-facility contracted services and outpatient and inpatient services as a result. She stated that Resident #1 was transported by the facility to outpatient services and she was awaiting response for referral for Resident #2 for inpatient services following an incident witnessed earlier in the day in which Resident #2 slapped Resident in the face with her hand and hit his left eye with a cellular telephone. She confirmed that there was an incident on or around 3/04/25, another on or around 5/30/25, another on 6/09/25, and another on 6/19/25. The SSD confirmed that discharge planning was underway for Resident #1 with referrals pending to more independent living facilities, and the process included obtaining a birth certificate for identification purposes for approval by the other facilities. She said she was awaiting postal delivery of his birth certificate to move to the next step. She said Resident #1 had recently been diagnosed with cancer and the facility was involved in providing services related to the diagnoses that included transportation to appointments. On 6/19/25 at 4:10 PM, during an interview Registered Nurse (RN) #3 reported that on 6/09/25 she exited the facility through the Business Office Entryway and was getting into her vehicle at approximately 11:49 PM after clocking out and CNA #5 was seated in a chair outside of the door. She stated that CNA #5 stood up to open the door and immediately turned and told her Resident #1 hit Resident #2. RN #3 said she instructed CNA #5 to go in and immediately notify the nurse and RN #3 called LPN#4 from her cell phone and reported the incident to LPN #4. On 6/19/25 at 5:30 PM, an interview with CNA #5 revealed that on 6/09/25 she had worked 3-11 shift and at approximately 11:40 PM she was going inside the Business office entrance and observed through the door window Resident #1 strike Resident #2. She said she reported immediately to RN #3, who was off duty, removed Resident #2 to the South Unit. CNA #5 said that Resident #2 was on hourly visual checks to ensure her whereabouts and safety due to previous allegations of her abuse by Resident #1. On 6/20/25 at 2:30 PM, during an interview CNA#4 revealed he had worked 7-3 on 6/19/25 and after lunch he was leaving room [ROOM NUMBER]B and observed Resident #2 slapping Resident #1 multiple times. He stated that he immediately went to get between the two and separate them and Resident #2 stood from her wheelchair and struck Resident #1's left eye with her cellular telephone (right hand). CNA #4 reported that Resident #2 continued fighting to get to Resident #1 and it took three (3) staff to calm the residents. He stated he had observed Resident #2 acting in an aggressive manner towards others, both staff and residents, prior to 6/19/25. He said that he had been made aware of acts of aggression between the two (2) residents when Resident #2 was transferred from North Unit to South Unit. Record review of the Progress Notes for Resident #1 revealed that 3/4/2025 11:59 (AM) Behavior Note Note Text: res (resident) informed writer that he and (Resident #2) had and alteration over a bag a candy. the bag remained in the res possession and after not returning it, she was upset. she started hitting me and was warned to stop, res continued and (Resident #1) hit other res in face. both res were informed to stop causing issues with one another and agreed to do so. And 5/30/2025 20:35 (8:35 PM) Behavior Note Note Text: Resident 1 was accused of physical assault on Resident 2 in bedroom of Resident 1. Resident 2 was visibly shaken and in distress when brought to nurses station. Resident 1 was asked about the incident that supposedly took place he denied physically assaulting but yelling at her in a threatening manner. Resident stated he was going to have a talk with her. Resident was advised not contact resident 2, resident 1 appeared to be agitated and dismissive. Writer will continue to monitor resident 1 for remainder of the shift. Writer consoled resident 2 and reassured her safety for remainder of shift. Administrator notified immediately currently awaiting further instructions. There was no documentation of allegation against Resident #1 of the abuse of Resident #2 on 6/09/25. Progress Notes review revealed 6/19/2025 19:13 (7:13 PM) Incident Note Note Text: REPORTED BY ADMINISTRATOR THAT AT APPROXIMATELY 1330PM RESIDENT #4864 (Resident #2) HIT RESIDENT #1697 (Resident #1) WITH A CELL PHONE ON THE LEFT SIDE OF HEAD NEAR EYE AND ALSO HIT RESIDENT WITH HAND ON RIGHT SIDE OF HEAD NEAR EYE. NO DISCOLORATIONS, OPEN AREA OR ABRASIONS NOTED. REDNESS TO SCLERA NOTED TO OUTSIDE CORNER OF LEFT EYE. NO C/O HEADACHE OR BLURRY VISION. RESIDENT REPORTS AREA SORE .RESIDENT PLACED ON EVERY HOUR LOCATION MONITORING and 6/19/2025 18:01 (6:01 PM) Social Services Note Text: Resident reports that his face is hurting because his lady friend hit him with her cell phone. Incident reported to admin. On 6/20/25 at 11:45 AM, observation and interview revealed Resident #1's left eye had noticeable periorbital edema (swelling around eye) and redness of the sclera (white part of the eyeball). Resident #1 stated that on the afternoon of 6/19/25, Resident #2 slapped him on the right side of his face and hit him with a cellular telephone at the outer corner of his left eye. He stated it hurt at the time and into the evening and he had pain medication administered which controlled the pain. He said he did not know why she struck him, that they had been sitting near each other talking, he stated, she does that, she just all of the sudden starts hitting me. On 6/20/25 at 5:20 PM, during an interview with Resident #2 in her room revealed she was in a relationship with Resident #1 and confirmed she hit him and described hitting him as playing with him. She said that Resident #1 had not hit her. Her demeanor was giddy and friendly. The State Agency (SA) was unable to determine if Resident #2 had adequate memory to recall past events or only recent events. On 6/24/25 at 4:15 PM, during an interview with the Director of Nursing (DON) revealed the facility was aware of the on-going incidents of aggression and combativeness by and between Resident #1 and Resident #2. She said SSD was working with Resident #1 to find more independent living placement and Resident #2 was currently at an inpatient psychiatric care facility. She stated she had not considered one-on-one supervision of either resident to ensure residents' safety. She said Resident #2 had been transferred to different rooms twice, but the residents continued to seek each other out for interaction and the facility's position was that they had the right to visit with each other if they chose. On 6/24/25 at 6:25 PM, during an interview with the Administrator she stated she was aware of the on-going incidents of aggression and combativeness between Resident #1 and Resident #2. She confirmed the SSD was working with Resident #1 to find more independent living placement and Resident #2 was currently at an inpatient psychiatric care facility. She stated she had not considered one-on-one supervision of either resident to ensure residents' safety. She confirmed Resident #2 had been transferred to different rooms twice, and the residents continued to seek each other out for interaction and the facility's position was that they had the right to visit each other if they chose. She confirmed that the facility policy provided for provision of a safe environment, free from abuse. Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 11/04/24 with diagnoses that included Hemiplegia and hemiparesis following cerebral infarction (stroke) and Diabetes. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/08/25 for Resident #1 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Record review of the admission Record for Resident #2, revealed the facility admitted the resident on 1/19/24 with diagnoses that included Chronic kidney disease and Heart failure. Record review of the Annual MDS with an ARD of 6/19/25 for Resident #2 revealed she had a BIMS score of 14, which indicated no cognitive impairment. The MDS review revealed the resident displayed physical symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing) behavior and verbal behavior symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) 1 to 3 days during assessment period which put the resident at significant risk for physical illness or injury and Put others at significant risk of physical injury.

Based on observation, interview, record review and facility policy review, the facility failed to ensure the resident's right to respectful, dignified care when they failed to apply the indwelling urine catheter collection bag cover, leaving the bag and its contents visible from the hallway for one (1) of three (3) residents with indwelling catheters (Resident #3). Findings include: A record review of the facility's policy titled, Urinary Catheter Care, dated March 14, 2008, revealed, .A privacy bag should be placed over the drainage bag when the resident is to be out in public. This preserves the resident ' s dignity . A record review of the admission Record for Resident #3 revealed the facility admitted the resident on 12/28/2023 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction and Neuromuscular Dysfunction of Bladder. A record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 5/20/2025 for Resident #3 revealed the resident had no Brief Interview for Mental Status (BIMS) score due to her inability to participate. The MDS documented memory problems and severe cognitive impairment in daily decision-making. On 6/23/2025 at 1:30 PM, during an observation in Resident #3's room, she was seen resting in bed with a catheter urine collection bag (catheter bag) attached to the bed frame. The bag was visible from the open door, displaying approximately three hundred milliliters (300 ml) of clear, yellow liquid. A blue snap-on catheter bag cover was observed hanging unsnapped, failing to conceal the bag or its contents. On 6/23/2025 at 4:30 PM, during an observation and interview with the Director of Nursing (DON) in Resident #3's room, the DON confirmed the catheter cover had not been applied properly and acknowledged that it did not cover the bag or its contents. The DON left the room to locate a catheter bag cover that would provide adequate privacy to uphold Resident #3's dignity.

Based on observations, interviews, record review, and facility policy review, the facility failed to provide reasonable accommodation of resident needs and preferences by discontinuing the use of disposable premoistened cleansing cloths for four (4) of thirty (30) sampled residents. (Residents #8, # 9, #14, and #20). Residents and staff were informed that the premoistened disposable cloths could be provided for incontinent residents with wounds, due to their softer texture being less irritating to fragile, damaged, or healing skin. However, the facility failed to make the premoistened disposable cloths available. Findings included: Record review of the facility policy Resident Rights revised and implemented on Nov. 28, 2016 revealed .The resident has a right to be treated with respect and dignity, including .(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents On 6/17/25 at 12:20 PM, during an interview and observation of the facility supply room revealed Registered Nurse (RN) #1 stated We don't use wet wipes (disposable premoistened cleansing wipes). Observation revealed there were no disposable premoistened cleansing wipes in the supply room. On 6/18/25 at 2:10 PM, during an observation and an interview Resident #8 revealed her family purchased disposable premoistened cleansing cloths for her care. She confirmed that she had a wound on her leg for which she was receiving treatment. Regarding the dry disposable cloths, Resident #8 stated those little towels don't work. On 6/18/25 at 4:30 PM, during an interview Resident #14 stated she did not like it that the facility had stopped providing disposable premoistened cleansing wipes. She stated that the facility had replaced the disposable premoistened cleansing wipes with disposable dry wipes which were not soft, were not durable and left lint on her. Resident #14 described the dry disposable cleansing cloths as useless. Resident #14 stated I use those clothes at dialysis to wipe my nose. They are like Kleenex, thin and tear apart too easy. She confirmed she was the Resident Council President and said discontinuation of disposable premoistened cleansing cloths had been discussed at the 6/10/25 meet and greet for the new Director of Nursing (DON). She stated that she had a wound and fragile skin and preferred the disposable premoistened cleansing cloths because their texture was softer than the washable cloths. She stated that the facility had not had an adequate supply of linens since discontinuation of the disposable premoistened cleansing cloths which she said resulted in postponement and interruption of resident care. On 6/20/25 at 12:00 PM, during an interview with the facility Ombudsman on North Unit revealed he stated that he had received complaints from multiple residents regarding lack of clean linen and lack of staff resulting in postponement of resident care. He said he had also had multiple complaints regarding the discontinued provision of disposable premoistened cleansing cloths. On 6/23/25 at 12:53 PM, during an interview with the family of Resident #20 revealed she visited weekly, and family provided needed supplies for the resident's care, including disposable premoistened cleansing cloths since the facility no longer supplied them. She confirmed that Resident #20 had a wound on his right leg. On 6/23/25 at 2:00 PM, during an interview Resident #9 revealed that he was aware that the facility was not required to supply disposable cleansing cloths but was told that if residents with wounds requested them, they would be provided. He said he had told multiple staff that he preferred the disposable wipes for incontinence care due to the rough texture of the washable washcloths and the fragility of his skin, but none had been provided for him. He said he had never seen any Certified Nursing Assistant (CNA) flush premoistened disposable cleansing cloths. He stated that they always threw them in a trash bag. On 6/23/25 at 4:15 PM, during an interview the DON stated she was aware that the residents had concerns regarding the facilities discontinuation of disposable premoistened cleansing cloths for resident care. She confirmed the disposable cloths' texture was less rough, therefore less irritating to fragile, damaged or healing skin. She confirmed the facility discontinued the use of disposable premoistened cleansing cloths for resident care. The residents and staff were informed that the cloths could be provided for incontinent residents with wounds due to the disposable cloths' texture being less rough, therefore less irritating to fragile, damaged or healing skin. On 6/24/25 at 3:30 PM during an interview the facility's Regional Director of Operations (RDO) confirmed that corporation-wide the supply and use of disposable premoistened cleansing cloths had been suspended. She stated that the facility was not required to provide disposable premoistened cleansing cloths. She stated that if any resident had wounds they would be accommodated with disposable premoistened cleansing cloths because the washable cloths could be a rougher texture. On 6/24/25 at 6:25 PM, during an interview, the Administrator confirmed that she was aware of resident complaints by residents and staff regarding the discontinuation of supply of the premoistened disposable cleansing cloths. She said that on 6/10/25 during a meet and greet meeting with residents and the DON several residents mentioned their displeasure and voiced concerns regarding use of only washable cloths. Resident #8 Record review of the admission Record for Resident #8 revealed that the facility admitted the resident on 5/14/25 and the resident had diagnoses of chronic obstructive pulmonary disease, Diabetes and morbid obesity, atrial fibrillation, GERD, heart failure. Record review of the 5 Day MDS with ARD 5/21/25 for Resident #8 revealed she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The MDS review revealed the facility assessed the resident dependent for shower/ bath activity. Record review of the Order Summary Report with active orders as of 6/20/25 for Resident #8 included Neopsorin Plus Pain Relief MS External Cream 3/5-10000-10 (Neomycin-Polymyxin w/Pramoxine) Apply to Buttock and groin topically one time a day. Resident #9 Record review of the admission Record for Resident #9 revealed the facility admitted the resident on 5/20/25 with an initial admission dated listed as 9/09/08 with diagnoses that included paraplegia and diabetes. Record review of the admission MDS with ARD 5/27/25 for Resident #9 revealed he had a BIMs score of 15 which indicated no cognitive impairment. The MDS review revealed the facility assessed the resident dependent for toilet hygiene and personal hygiene. Record review of the Order Summary Report with active orders as of 6/24/25 for Resident #9 included Clean coccyx with wound cleanser, pat dry, apply calcium alginate and cover with bordered gauze one time a day of wound care with start date 5/31/25 and Clean sacral with wound cleanser, pat dry, apply hydrogel and cover with bordered gauze one time a day for wound care with start date 6/12/25. Resident #14 Record review of the admission Record for Resident #14 revealed the facility admitted the resident on 10/05/23 and the resident had diagnoses of end stage renal disease, diabetes, morbid obesity, hypertension, and dependence on renal dialysis. Record review of the Quarterly MDS for Resident #14 with ARD 4/14/25 revealed the residents had BIMS score of 15, which indicated no cognitive impairment. MDS review revealed the resident required dependence on wheelchair for mobility, and total dependence for toileting hygiene, shower/bathing activities. Record review of the Order Summary Report with active orders as of 6/24/25 for Resident #14 included Apply Nystatin Powder to rash under both breast daily until resolved one time a day with start date 2/05/25 Clean sacral with wound cleanser, pat dry, apply collagen and cover with ordered gauze one time a day for wound care with start date 6/13/25 and Give pain med 30 mins-hour (thirty minutes to an hour) prior to wound care every day shift with start date 7/10/21 and Nystatin External Powder 100000 Unit/GM (units per gram) (Nystatin(Topical)) Apply to abdominal folds and groin topically every 12 hours as needed for chaffing with start date 3/08/25. and Zinc Oxide Ointment 20% Apply to right inner thigh topically every shift for skin condition apply zinc oxide to buttock and right inner thigh with start date 12/27/24. Resident #20 Record review of the admission Record for Resident #20 revealed the facility admitted the resident on 9/07/23 and the resident had diagnoses of diabetes insipidus and cerebral infarction (stroke). Record review of the Quarterly MDS for Resident #20 with ARD 5/13/25 revealed the resident had no BIMS and included documentation of inability to participate in BIMS, memory problem and severe impairment of cognitive skills for daily decision making. Record review of the Order Summary Report revealed an order dated 6/26/25 Clean right medial lower leg with wound cleanser, pat dry, apply collagen and cover with bordered gauze.

Based on observations, interviews, record review and facility policy review the facility failed to provide a safe and comfortable environment for residents dependent on wheelchairs for mobility (Resident #28 and Resident #8) and failed to provide adequate clean linens for (Resident #9 and Resident #20) for four (4) of (30) sampled residents. Findings included: Record review of the facility policy Resident Rights revised and implemented on Nov. 28, 2016, revealed The resident has a right to .A safe, clean, comfortable, and homelike environment .Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; clean bed and bath linens that are in good condition . Resident #28 On 6/17/25 at 1:00 PM, during an observation and interview with Resident #28 revealed both armrests on the wheelchair of Resident #28 were torn with cover material tattered with all the cushion missing from both armrests. The resident stated that the condition of the armrest aggravated him and described them as uncomfortable. On 6/17/25 at 1:10 PM, during an observation of Resident #28's wheelchair and interview with Registered Nurse (RN)#1 revealed RN #1 confirmed the condition of the armrest and stated, That's going to have to be replaced. Record review of the admission Record for Resident #28 revealed the facility admitted the resident on 1/17/25 and the resident had diagnoses of Paraplegia and Muscle weakness. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/25 for Resident #28 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #8 On 6/18/25 at 2:10 PM, during an observation and an interview with Resident #8 revealed the left arm rest was broken off of her personalized mechanical wheelchair and laying in the seat of the chair. Resident #8 stated it was broken during a transfer using the mechanical lift approximately two weeks prior and said Certified Nurses Aide (CNA) #1 was assisting in the transfer. She said it was an accident, but she did not know why it had not been repaired. She confirmed that the facility staff was aware that it was broken and that a therapist and a man from the wheelchair company had visited her room and inspected the chair. On 6/19/25 at 1:50 PM, during an interview with CNA #1, she confirmed that the left armrest of the personalized mechanical wheelchair of Resident #8 was broken during chair-to-bed transfer using full mechanical lift. She stated that she reported this to the resident's nurse. She said she was not sure if the resident had been transferred into the chair since. On 6/20/25 at 11:00 AM, during an interview the Occupational Therapist Assistant (OTA)# 1 confirmed that he had been made aware that Resident #8's wheelchair arm had been broken, he couldn't recall dates but said he had inspected it and notified the company that serviced the mechanical wheelchairs who had visited and said he could fix it. He said the wheelchair was relatively new and he was not sure if the resident's insurance would pay for the repair, so he had not requested the chair be repaired. He stated that he was not aware that Resident #28's wheelchair arms were in disrepair. Record review of the admission Record for Resident #8 revealed that the facility admitted the resident on 5/14/25 and the resident had diagnoses of Chronic obstructive pulmonary disease and Heart failure. Record review of the 5 Day MDS with an ARD of 5/21/25 for Resident #8 revealed she had a BIMS score of 15, which indicated no cognitive impairment. On 6/24/25 at 4:15 PM, an interview with the Director of Nursing (DON) revealed she was not sure how many days Resident #8 was scheduled to get up in her wheelchair or that the resident's chair had been broken, but said that it was repaired on or after 5/20/25 and the resident had been up in her chair on 5/24/25. She stated she was not aware of damages to the armrests of the wheelchair of Resident #28. On 6/24/25 at 6:25 PM, an interview with the Administrator revealed she was not sure how long the wheelchair arm had been broken. She stated she had not been aware of the damaged condition of the wheelchair armrests of Resident #28. She confirmed that the residents had the right to a safe, clean, comfortable environment. Lack of clean linens On 6/17/25 at 11:45 AM, during an interview with a direct care staff member revealed that when she arrived at work for the 7:00 AM through 3:00 PM (7-3) shift on 6/15/25 there was dirty linen piled up and no clean towels or facecloth's on the hall for resident care. She reported that the CNAs went to the clean laundry room, found a large plastic tote with clean unfolded linen and divided the contents up for resident care. She stated that a housekeeper came and started washing laundry mid-morning and the first load of clean linens were not dry until after lunch. She explained that CNAs made rounds to provide incontinent care and other direct care for residents every two (2) hours throughout the day. She confirmed that not all residents received personal hygiene, such as bed bath and other care was interrupted or postponed due to lack of linens. She said that the nurses on duty were aware of the lack of linens, and she thought the nurses attempted to telephone management. She stated that she was not sure who, if anyone at the facility on 6/15/25 had a key to the Housekeeping Supervisor's office. On 6/17/25 at 12:35 PM observation in the supply room and an interview with RN #1 revealed she stated the facility no longer supplied disposable premoistened cleansing cloths and used washable cloth facecloth's and towels for all resident care, supplemented by disposable dry washcloths and body cleanser and body wash. She confirmed the facility had a census of 81 residents and supply of 850 ten by thirteen (10X13) inch disposable (dry) washcloths and (47) - (8) ounce and (31) four (4) ounce bottles of body wash and two (2) gallon bottles of cleanser for hair and skin. On 6/17/25 at 2:55 PM, interview with Licensed Practical Nurse (LPN) #5 revealed she stated she worked 7-3 shift on 6/15/25 and there was not adequate clean linen available to make resident's beds or give bed baths to all the residents who required assistance with personal hygiene/bathing activities. She stated that when she started to make last rounds for the shift between 1:00 PM and 2:00 PM there were no clean linens available. She stated there were no disposable premoistened cleansing cloths and described the disposable dry cloths as flimsy and easily torn. She stated the staff made do and did what they could but confirmed that resident care was interrupted and or postponed due to lack of clean linens. She stated that when she reported the need for linen she was told by nurses and housekeeping staff, We don't have it. On 6/17/25 at 4:50 PM, during an interview with CNA#6 and CNA#7 revealed CNA #6 reported she had worked 6/15/25 and that lack of adequate linens was a problem which caused postponement and interruption of resident care, including bathing/showering activities. Both stated that the facility only having one sit-to-stand lift, and one full-body lift caused postponement and interruption of resident care, including bathing/showering and surface-to-surface transfers. They explained that so many residents on North Unit preferred to get washed up and get up into their wheelchairs, requiring a mechanical lift before 7:00 AM, and that so many of the residents were very large and/or totally dependent and required two person assistance for bed mobility, incontinence care, bathing activities and transfers there was no way to accommodate preferences. They both stated that dialysis patients had priority to make sure they were prepared and up for transfer to dialysis appointments. Both reported that it was physically impossible for either lift to be employed by the South Unit staff for resident transfers and North Unit transfers, which resulted in some residents' care being postponed or interrupted while staff waited for a lift to become available. On 6/19/25 at 4:10 PM, during an interview Registered Nurse (RN)# 3 reported that she was on duty on the 7:00 AM through 3:00 PM (7-3) shift and there were not adequate towels or facecloth's for residents' care available. She confirmed that the lack of adequate quantity of towels and facecloth's cause an interruption and postponement of resident care throughout the shift. She confirmed she texted the housekeeping supervisor at approximately 9:18 AM on 6/15/25 and notified her of a lack of linens for resident care. She confirmed that an on-duty housekeeper responded mid-morning and began washing dirty linens. On 6/20/25 at 11:05 AM, during an observation and an interview with the Housekeeping Supervisor revealed that she explained that the door diagonally across from the North Unit Nurses' Station designated with a Clean Linen sign on the door was not the clean linen storage. She explained that clean linen storage had been moved to the laundry room mid-way between North and South Units. She was not able to explain why all nursing staff had indicated the room with the Clean Linen sign as the clean linen storage room for two (2) days. She said the clean linen closets were being changed to storage rooms. She then took a piece of plain white paper and wrote Supply Room on it and taped it over the Clean Linen sign. She stated the facility always had plenty of clean linen. The Housekeeping Supervisor stated that the situation that occurred on 6/15/25 was a result of miscommunication between her and Laundry Aide #1, who had notified her on the evening of Saturday, 6/14/25 that she was calling in for Sunday, 6/15/25. She said she thought Laundry Aide #1 meant Monday, 6/16/25. She stated that she had received a text from RN #3 at 9:18 AM on 6/15/25 that said the facility needed clean linen. She stated that she notified a housekeeper that she needed her to go to the laundry immediately and that the housekeeper went to the laundry at 10:30 AM. She confirmed that she was aware that the residents needed clean linens, specifically washcloths and towels for incontinence care, bathing/shower activities, personal hygiene during AM care prior to 10:30 AM and throughout the morning and day. On 6/20/25 at 11:30 AM, during an observation and interview Resident #8 confirmed that she had been told by staff that care was postponed due to lack of clean linens. She stated that she had not been assisted to get up for at least two weeks and could not recall the last date she was assisted into her wheelchair. She stated that staff routinely told her she would have to wait for care, including showers and surface-to-surface transfers. She stated, If there are three people working and it takes two to get me up, I have to wait if two of them are with someone else. Resident #9 On 6/23/25 at 2:00 PM, during an interview Resident #9 confirmed that he had voiced complaints regarding postponement and lack of care on 6/15/25 because he did not receive a bed bath or what he considered sufficient incontinence care and was told by the CNA (could not recall name) that the reason was that there were no clean linens. He said that he could not get sufficient incontinence care because of lack of linens and no disposable wipes. He said he was aware that the facility was not required to supply disposable cleansing cloths but was told that if residents with wounds requested them, they would be provided. He said he had told multiple staff that he preferred the disposable wipes for incontinence care due to the rough texture of the washable washcloths and the fragility of his skin, but none had been provided for him. He said that he did not get care in a timely manner on 3:00 PM to 11:00 PM (3-11) shift or the 11:00 PM to 7:00 AM (11-7) shifts and had to wait for bed baths, showers and to get out of bed routinely and was told that he had to wait because there were only two (2) CNAs scheduled and he required at least two (2) staff for bed mobility (to turn/reposition while in bed) and for bed/chair-to-chair transfers with mechanical lift. He said that sometimes he was told that he had to wait because the lift was not available because it was being used on the South Unit. He stated that it seemed to him that the facility had stopped being for the residents and was being run for the convenience of the staff. He said he did not understand why the facility could not provide disposable cleansing cloths or enough lifts for the staff to provide adequate care for the residents. He described the dry disposable wipes as a joke, not good for nothing; too flimsy. Record review of the admission Record for Resident #9 revealed the facility admitted the resident on 5/20/25 with an initial admission dated listed as 9/09/08 with diagnoses that included paraplegia and diabetes. Record review of the admission MDS with an ARD 5/27/25 for Resident #9 revealed he had a BIMS score of 15 which indicated no cognitive impairment. The MDS review revealed the facility assessed the resident dependent for toilet hygiene and personal hygiene. Resident #20 On 6/23/25 at 9:08 PM, during an interview, Contact #1 for Resident #20 revealed the family had been supplying disposable premoistened cleansing cloths for the care of Resident #20 because his lack of mobility contributed to skin issues and the washable cloths (face cloths and towels) had a rougher texture. She stated that her only complaint was that the facility had stopped providing disposable premoistened cleansing cloths for the care of Resident #20. Record review of the admission Record for Resident #20 revealed the facility admitted the resident on 9/07/23 and the resident had diagnoses of Diabetes insipidus and Cerebral infarction (stroke). Record review of the Quarterly MDS for Resident #20 with ARD 5/13/25 revealed the resident had no BIMS and included documentation of inability to participate in BIMS, memory problem and severe impairment of cognitive skills for daily decision making.

Based on interview, record review, and facility policy review, the facility failed to report an allegation of resident-on-resident physical abuse to the State Agency (SA) within the required timeframe for one (1) of four (4) reviewed allegations of abuse. Resident #1. Specifically, an allegation made on 6/09/25 that Resident #1 physically abused Resident #2 and was witnessed and reported by Certified Nursing Assistant (CNA) #5. This was investigated internally by the facility but not reported to the SA as required by federal regulations. Findings Included: Record review of the facility policy titled, Reporting Alleged Abuse or Neglect to State Agencies dated November, 1, 2004, revealed, It is the policy of this facility that persons employed in facilities owned or managed by this facility with knowledge of or a reasonable cause to believe that any patient or resident has been the victim of abuse, neglect, or mistreatment must report or cause a report to be made to the appropriate state agencies as prescribed by the laws of that state . On 6/18/25 at 1:13 PM, during an interview with Resident #1 in his room he confirmed there was an altercation between himself and Resident #2 near the vending machines on the evening of 6/09/25. Resident #1 stated that Resident #2 was slapping at his face and he caught her arm mid-swing and threw it back, hitting her face. On 6/18/25 at 7:35 PM, during a telephone interview Licensed Practical Nurse (LPN) #1 revealed that she was made aware of an allegation of abuse of Resident #2 by Resident #1 on 6/09/25. She said Certified Nursing Assistant (CNA)#5 reported to her that she witnessed Resident #1 punch Resident #2 in the face. She said she couldn't recall if an incident report was completed. On 6/19/25 at 2:50 PM, an interview with the Social Services Director, (SSD) confirmed she was the official Grievance Officer of the facility and stated that she made the Administrator aware of all credible allegations and all allegations of abuse and neglect. She confirmed that on or around 6/10/25 she was made aware of an allegation that occurred on 6/09/25. This was an incident of physical abuse of Resident #2 by Resident #1 in which CNA #5 reported that Resident #1 punched Resident #2 in the face. She confirmed that she had received the report that Resident #1 had said he took Resident #2's hand and made her hit herself in the face. On 6/19/25 at 4:10 PM, during an interview Registered Nurse (RN) #3 reported that on 6/09/25 she exited the facility through the Business Office Entryway and was getting into her vehicle at approximately 11:49 PM after clocking out and CNA #5 was seated in a chair outside of the door. She stated that CNA #5 stood up to open the door and immediately turned and told her that Resident #1 had hit Resident #2. RN #3 said she instructed CNA #5 to go in and immediately notify the nurse. RN #3 called LPN #4 from her cell phone and reported the information to LPN #4. On 6/19/25 at 5:25 PM, the SA attempted to contact the Resident Representative (RR) for Resident #2 without success. There was not an option to leave a message. On 6/19/25 at 5:30 PM, during an interview CNA #5 revealed that on 6/09/25 she had worked 3-11 shift and at approximately 11:40 PM she was going inside the Business Office entrance and observed through the door window Resident #1 strike Resident #2. She said she reported immediately to RN #3, who was off duty, removed Resident #2 to the South Unit and reported to LPN #4. She said that Resident #2 had been crying and had said on the evening of 6/09/25 that Resident #1 hit her. Record review of the Progress Notes for Resident #1 revealed that there was no documentation of any allegations against Resident #1 of the abuse of Resident #2 on 6/09/25. A progress note was dated with an effective date of 6/20/25 at 5:51 PM that addressed the incident that occurred on 6/9/25. Record review of Facility Investigation with Date of incident documented as 6/09/25 revealed the facility conducted interviews and investigation beginning 6/09/25 into an incident described as Resident on Resident (abuse). On 6/20/25 at 5:20 PM, an interview with Resident #2 in her room revealed she stated she was in a relationship with Resident #1 and confirmed she hit him and described hitting him as playing with him. She said that Resident #1 had not hit her. Her demeanor was giddy and friendly. The SA was unable to determine if Resident #2 had adequate memory to recall past events or only recent events. On 6/24/25 at 4:15 PM, during an interview the Director of Nursing (DON) revealed the facility was aware of the on-going incidents of aggression and combativeness by and between Resident #1 and Resident #2. She said the SSD was working with Resident #1 to find more independent living placement and Resident #2 was currently at an inpatient psychiatric care facility. She stated she had not considered one-on-one supervision of either resident to ensure residents' safety. She said Resident #2 had been transferred to different rooms twice, but the residents continued to seek each other out for interaction and the facility's position was that they had the right to visit with each other if they chose. On 6/24/25 at 6:25 PM, during an interview the Administrator revealed that on 6/10/25 she was made aware of an allegation of physical abuse of Resident #2 by Resident #1 on 6/09/25. She stated that she had not reported the allegation because of the ongoing incidents between the two residents and because during interview Resident #2 denied being struck by Resident #1. She confirmed that staff had reported Resident #1 crying following an interaction with Resident #1 near the vending machines on the evening of 6/09/25. Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 11/04/24 and the resident had diagnoses of Hemiplegia and hemiparesis following cerebral infarction (stroke) and Diabetes. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/08/25 for Resident #1 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Record review of the admission Record for Resident #2 revealed the facility admitted the resident on 1/19/24 and the resident had diagnoses of Chronic kidney disease and Heart failure. Record review of the Annual MDS with an ARD of 6/19/25 for Resident #2 revealed she had a BIMS score of 14, which indicated no cognitive impairment. Record review of the Quarterly MDS for Resident #2 with an ARD 3/19/25 revealed the resident had a BIMS score of 9, which indicated moderate cognitive impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to provide personal hygiene, specifically fingernail and toenail care during Activities of Daily Living (ADL) care for two (2) of (29) residents reviewed: Resident #18 and Resident #28. Findings included: A review of the facility's policy, A.M. Care, with a revision date of August 25, 2014, revealed, RESPONSIBILITY: Licensed Nurse, Certified Nursing Assistant .PURPOSE .2. To provide cleanliness, comfort and neatness .4. To assess the resident's condition. 5. To assess the resident's needs .EQUIPMENT .Care of nails . Resident #18 On 6/17/2025 at 12:50 PM, during an observation in the North Unit Day Room/Dining Room, Resident #18 was seated in his wheelchair with ten (10) long fingernails with a black substance under each nail. All fingernails extended past the ends of his fingers three-sixteenths (3/16) of an inch (comparable to three stacked dimes) to one-third (1/3) of an inch (comparable to four stacked dimes). Resident #18 stated that he wished they would cut them. Resident #18 then removed his right shoe and indicated that he wished to have his toenails trimmed also. The second and third (middle) toe on his right foot both measured approximately one-third (1/3) of an inch past his toes. A record review of the admission Record for Resident #18 revealed the facility admitted the resident on 4/25/2023. The resident had diagnoses of Chronic Obstructive Pulmonary Disease and Alzheimer's Disease. A record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 6/17/2025 revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated severe cognitive impairment. Resident #28 On 6/17/2025 at 12:50 PM, during an observation in the same room, Resident #28 was seated in the back left corner. He raised his hand and stated that he needed his fingernails cut. Observation revealed Resident #28 had ten (10) long fingernails with a black substance under each nail. All fingernails extended past the ends of his fingers three-sixteenths (3/16) of an inch (comparable to three stacked dimes) to one-third (1/3) of an inch (comparable to four stacked dimes). A record review of the admission Record for Resident #28 revealed the facility admitted the resident on 1/17/2025 with diagnoses that included Paraplegia and Muscle Weakness. A record review of the Quarterly MDS with ARD 3/31/2025 for Resident #28 revealed the resident had a BIMS score of fifteen (15), which indicated no cognitive impairment. On 6/17/2025 at 1:00 PM, during an observation and an interview with Registered Nurse (RN) #1, she confirmed that both residents' fingernails and toenails were observed during weekly body audits and that any licensed nursing personnel could trim fingernails or toenails. She stated that a list was maintained for residents who needed toenail care, which was provided by the contracted podiatrist who visited the facility routinely. Observation revealed the facility had adequate supplies for fingernail and toenail care in the supply closet on the North Unit. On 6/24/2025 at 4:15 PM, during an interview the Director of Nursing (DON), confirmed that nail care was included in ADL care and that any licensed nursing staff could trim fingernails or toenails for residents.

Based on record review, interviews and facility policy review, the facility failed to evaluate and analyze hazards and risks and failed to assess a resident following a documented fall for one (1) of three (3) residents with documented falls: Resident #27. Findings included: A review of the facility's policy, Falls, with a revision date of September 28, 2012, revealed, .If a fall occurs: 1. Incident and Accident report is to be filled out at the time of the fall and reviewed in standup/morning meeting and addressed on the 24 hour report. 2. Documentation is initiated at the time of the fall and continues, at a minimum, of every shift for three (3) days or until the condition stabilizes. 3. Fall investigation and Supervisor Report is to be completed. 4. Resident history of falls is an ongoing document (do not start one each month). This is to be completed with each fall and kept in a notebook. 5. Care plan and ADL(activities of daily living) Care Plan need to be updated with each fall. 6. All these forms need to be compiled at the end of the three days of documentation and kept together and the fall recorded on the event log. a) I/A (incident and accident) report. b) Fall Investigation/Supervisor. C.) Report Any statements . Record review of Progress Notes *NEW* dated 5/12/2025 revealed Note Text: Nurse went to check on resident after being informed of fall in bathroom by aides while his nurse was absent. Resident was conscience and was in no danger at the time. Reported to staffing coordinator. On 6/18/2025 at 7:35 PM, during a telephone interview with Licensed Practical Nurse (LPN) #1, she stated that she did not remember a fall by Resident #27 on 5/12/2025. She explained that there were times when disagreements occurred among staff regarding who was responsible for documenting incidents involving residents. On 6/20/2025 at 1:00 PM, during an interview with the Staffing Coordinator, she stated she was responsible for facility staffing and occasionally filled in as a direct care nurse. She reported that she did not recall a fall by Resident #27 being reported to her on 5/12/2025. On 6/24/2025 at 4:15 PM, during an interview with the Director of Nursing (DON), she explained that in the event of a fall, the resident's nurse or licensed nursing staff should be notified to assess the resident prior to transferring them from the floor. If the nurse determined the resident was unharmed, staff should assist the resident off the floor. A body audit should be performed by a licensed nurse, and the resident's primary healthcare provider and Responsible Party (RP) should be notified. An incident report should be completed with ongoing documented assessment for the following seventy-two (72) hours, including vital signs each shift. The DON stated that completing the incident report was important to help determine the cause of the fall, prevent future falls, and identify any changes in the resident's condition. She noted that she was conducting in-service training to ensure all staff were aware of the protocol and stated she was unaware of any falls prior to her employment in June 2025. She was not able to provide documentation of an incident report or follow-up monitoring related to Resident #27's 5/12/2025 fall. On 6/24/2025 at 6:25 PM, during an interview with the Administrator and a review of the medical record for Resident #27, the Administrator was not able to locate or provide documentation of an incident report related to the fall that occurred on 5/12/2025, which had been documented in the Progress Notes. She confirmed that she expected licensed nursing staff to provide and document an adequate assessment for residents following a fall. A record review of the admission Record for Resident #27, revealed the facility admitted the resident on 5/10/2024. The resident had diagnoses of Paranoid Schizophrenia, Muscle Weakness, Altered Mental Status, and a need for assistance with personal care. A record review of the Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) 4/24/2025 revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact

Based on observation, record review, interviews and facility policy review, the facility failed to safely and securely store medications for one (1) of thirty (30) sampled residents: Resident #8. Findings included: A review of the facility's policy, Medication Storage in the Facility, with a revision date of December 27, 2006, revealed, Storage of Medications Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . 4. Bedside Storage of Medications: Bedside medications storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber . On 6/20/2025 at 11:30 AM, during an observation and interview with Resident #8, two (2) vials of Albuterol Sulfate Inhalation Solution 0.5-2.5 (3) MG/3ML(milligrams/milliliter), (Ipratropium-Albuterol) were observed on the resident's overbed table. One vial was opened and one vial was unopened. The resident stated that the nurses brought them to her and left them. She added that she thought there were more somewhere, but was unable to locate them. Observation revealed there was no individual medication storage cabinet inside the resident's room. On 6/20/2025 at 4:15 PM, during an interview the Director of Nursing (DON), stated that she was not aware that Resident #8 had medications stored unsecured in her room. On 6/24/2025 at 6:25 PM, during an interview with the Administrator, she confirmed that all medications were expected to be stored safely and securely in locked medication rooms or locked medication carts. A record review of the admission Record for Resident #8 revealed the facility admitted the resident on 5/14/2025. with diagnoses that included Chronic Obstructive Pulmonary Disease, Diabetes, and Heart Failure. A record review of the Five-Day Minimum Data Set (MDS) with Assessment Reference Date (ARD) 5/21/2025 revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated no cognitive impairment. A record review of the Order Summary Report with active orders as of 6/20/25 revealed a physician order dated 1/22/2025 Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML, 3 ml inhale orally every four (4) hours related to Acute Respiratory Failure with Hypoxia (J96.01). Please give the 0000 dose at 2300. Document breath sounds, duration, sputum, toleration in nebulizer assessment. There was no physician order for the storage of medications in the resident's room.

Based on observation, record review, interview, and facility policy review the facility failed to assess the resident population and identify resources needed to provide necessary day-to-day care and services for residents. The facility failed to evaluate the overall number of facility staff and mechanical lifts needed to ensure sufficient staff and equipment were available to meet residents' needs based on residents' assessments for (30) of (30) sampled residents with the potential to affect all residents. Findings included: A review of the facility's policy, Facility Assessment, with a review date of January 2023, revealed, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations .1. Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents . 3. The facility assessment includes a detailed review of the resources available to meet the needs of the resident population. This part of the assessment includes . 4.b. Equipment and supplies (medical and non-medical) . 4.e. All personnel .6. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment and supplies needed . A review of the facility's policy, Staffing, with a review date of October 2022, revealed, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment . A review of the facility assessment revealed the assessment did not include any information regarding the number of staff needed or the number of mechanical lifts required to meet the needs of residents. On 6/20/2025 at 1:00 PM, during an interview with the Staff Development Coordinator (SDC), she stated that she was responsible for facility staffing and occasionally filled in as a direct care nurse. She explained that she did not utilize the facility assessment for scheduling staff and was not sure what it was. She stated she scheduled staff using PPD (per patient day) and had not assessed the two units separately for resident acuity or daily care needs. She acknowledged that the North Unit was heavier, meaning it had more dependent residents and more residents with diagnoses of Morbid Obesity, which she confirmed required additional staff to assist with bed mobility, incontinence care, and bathing/showering activities. On 6/24/2025 at 5:00 PM, during an observation and interview with the Director of Nursing (DON) and Administrator, it was revealed that the facility had one (1) functional full-body lift and one (1) functional sit-to-stand lift. On 6/24/2025 at 6:25 PM, during an interview with the Administrator, she confirmed that if the direct care staff were using a lift on either unit, residents on the other unit would have to wait to get into or out of bed or to receive transfers. This could delay care such as showers or incontinence care. She confirmed that the number of lifts needed to provide timely resident care was not addressed in the facility assessment. She also confirmed that staffing levels necessary to meet resident care needs in a timely manner were not addressed in the facility assessment.

Based on observation, interviews, record review, and policy review, the facility failed to ensure medications were secured when a medication cart and treatment cart were left unlocked and unattended and failed to ensure medications were not left at a resident's bedside for two (2) of three (3) days of the survey. Findings included: A review of the facility's policy, Medication Labeling and Storage, revised February 2023, revealed, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys .Medication Storage .4. Compartments (including .carts .)containing medications and biologicals are locked when not in use, and .carts used to transport such items are not left unattended if open or otherwise potentially available to others . A review of the facility's Medication Administration - General Guidelines, dated 08/25/2014, revealed, .Procedure .2. Administration .d. Medications are administered at the time they are prepared . Medication Cart: On 12/10/2024 at 11:37 AM, during an observation of the North Unit, a medication cart was noted to be unlocked and unattended in the hallway at the nurse's station until 11:41 AM. During this time, ten (10) residents were observed walking past the cart, but none attempted to open it. On 12/10/2024 at 11:43 AM, during an interview and observation of the medication cart, Licensed Practical Nurse (LPN) #1 confirmed that the cart was unlocked and stated, It was an accident. I got distracted while giving medications. She noted that residents on the hall were ambulatory but stated she had not witnessed any rummaging behaviors, or anyone attempting to go through the medication cart. She acknowledged that a lot could happen if residents were to get into the medication cart, including taking other residents' medications. There were numerous medications for different residents observed on the cart, including liquid valproic acid for seizures and over-the-counter medications such as Tylenol, vitamins, and aspirin. On 12/10/2024 at 2:14 PM, during an interview with the Director of Nursing (DON), she revealed her expectation was that nurses should lock their carts when stepping away. She stated that not locking the cart could result in residents ingesting medications not intended for them. Treatment Cart: On 12/11/2024 at 1:49 PM, during an observation and interview, the treatment cart in the hallway located near room [ROOM NUMBER] was noted to be unlocked while the wound care nurse was in the resident's room performing wound care. LPN #2 walked through the hall and locked the cart. She verified the cart had been left unlocked and confirmed there were things on the cart that could be poisonous to residents if ingested. On 12/11/2024 at 1:53 PM, during an observation, Registered Nurse (RN) #1 (Wound Care Nurse) retrieved supplies from the cart, including two (2) Kerlix wraps, but did not lock the cart before returning to the resident's room. At 1:55 PM, RN #1 exited the room, locked the cart, turned it toward the wall, and returned to complete wound care. On 12/11/2024 at 2:00 PM, during an interview with RN #1, she verified the cart had been left unlocked and unattended. The cart contained scissors, antimicrobial solutions, Dakin's solution (diluted bleach), and multiple ointments. The wound care nurse confirmed residents should not have access to these items. Medications at bedside: On 12/11/2024 at 8:08 AM, during an observation, Resident #71 was finishing breakfast. A clear medication dispensing cup with multiple tablets and capsules was observed sitting on the bedside table. The resident stated that the facility staff sometimes left his medications on the bedside table for him to take. On 12/11/2024 at 8:10 AM, during an interview, LPN #5 confirmed that she left medications the residents morning medications unattended at the bedside. She stated she was not supposed to leave medications at the bedside and acknowledged she would not know if the resident had taken the medication or not. On 12/11/2024 at 8:13 AM, during an observation and interview with Resident #71 and LPN #5, the medication dispensing cup was observed to be empty. Resident #71 stated he had already taken the medications. On 12/11/2024 at 8:22 AM, during an interview, the DON confirmed that it was not proper procedure for medications to be left unattended at the bedside. She explained that the nurse would not know if the resident took the medication and emphasized that medications should never be left at the bedside. A record review of the Admission Record revealed the facility admitted Resident #71 on 10/12/2023 with diagnoses including Cerebral Infarction. A record review of Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/17/2024 revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated he was cognitively intact. A record view of the electronic Medication Administration Record (MAR) for December 2024, revealed Resident #71's morning medications administered on 12/11/2024 consisted of: Allopurinol 100 milligrams (mg), Amlodipine 10 mg, Ascorbic Acid 500 mg, Aspirin 81 mg, Flomax 0.4 mg, Hydrochlorothiazide 25 mg, Multivitamin, Plavix 75 mg, Amantadine 100 mg, Baclofen 10 mg, Coreg 6.25 mg, Docusate Sodium 100 mg, Metformin 500 mg, Methenamine Hippurate 1 gram (gm), and Gabapentin 400 mg. 41680

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure residents' rights were followed related to respect and dignity when a Certified Nurse Aide (CNA) attempted to check a resident for incontinence in the hallway and against his wishes (Resident #7) and failed to have a privacy cover on a urinary drainage bag (Resident #79) for two (2) of 19 sampled residents. Findings included: A review of the facility's Resident Rights policy, dated 07/24/2023, revealed, Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation .1 .These rights include the right resident's right to .b. be treated with respect, kindness, and dignity . Resident #7 On 12/09/2024 at 10:10 AM, during an interview, Resident #7 reported that while he was listening to a church service on 10/27/2024 around 10:00 AM, CNA #1 approached him in the hallway and attempted to check for incontinence. The resident stated that the CNA began pushing his wheelchair down the hall, prompting him to lock the wheels to stop her. He claimed that she then attempted to look inside his pants, leading him to hold his pants and tell her, Leave me alone. He further stated that CNA #1 left, stating she would get another staff member as a witness, and he returned to the church service. There were no other interactions with the CNA. On 12/11/2024 at 10:10 AM, during an interview, CNA #1 acknowledged the incident and stated she recognized after the fact that her actions, including attempting to check the resident's brief against his wishes, were inappropriate. She stated it was close to the end of her shift, and she was trying to make sure all her residents were taken care of before shift change. She further stated it was not her intention to upset the resident, she was just trying to take care of him. On 12/12/2024 at 8:10 AM, during an interview, Licensed Practical Nurse (LPN) #3 confirmed that on 10/27/24, Resident #7 was outside the dining room window listening to the church service. She stated that CNA #1 attempted to assist the resident but that he declined care, stating he preferred to wait until 2:30 PM. On 12/12/2024 at 10:25 AM, during an interview, the Licensed Nursing Home Administrator (LNHA) corroborated that CNA #1 attempted to assist Resident #7 on 10/27/24, who had requested to delay care until later. A record review of the Admission Record revealed the facility originally admitted Resident #7 on 6/18/2024 and he had a current diagnosis of Paraplegia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/2024 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. A record review of a Behavior Note, dated 10/27/24 at 2:32 PM, revealed the CNA was attempting to check the resident for incontinence and the resident told her to Go on now. A record review of a Grievance/Concern Decision Report, dated 11/4/24, revealed Resident #7 filed a grievance against the CNA and alleged the CNA was attempting to check him for incontinence in the hallway and he told her to go on and he would return to his room for care at 2:30 PM. Corrective action included that CNA will no longer be assigned to the resident and the District Ombudsman was contacted. Resident #79 On 12/10/2024 at 11:40 AM, during an observation and interview with Resident #79, he was in his wheelchair in the hallway, a urinary catheter drainage bag was visible hanging from the side of the wheelchair and was not covered, leaving the urine visible. He went into his room and stated he was unsure how long he had a catheter or the reason for it. He stated, They usually keep it in a bag when I am out of my room, and noted that it should be in a privacy bag. On 12/10/2024 at 11:45 AM, during an interview, LPN #4 stated the catheter drainage bag should always be in a privacy bag. She explained that the purpose of privacy is to ensure the urine is not openly visible. On 12/11/2024 at 11:40 AM, during an interview, the Director of Nursing (DON) confirmed that urine drainage bags should be kept in a privacy bag so that other residents and visitors are not able to see the resident's urine. A record review of the Admission Record revealed the facility admitted Resident #79 8/1/24 and he had a current diagnosis of Neuromuscular Dysfunction of the Bladder. A record review of the Order Summary Report, revealed Resident #79 had an order, dated 12/3/24, for an suprapubic catheter. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/07/2024 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. 41680

Based on observation, interviews, and facility policy review, the facility failed to label and date enteral feeding bags for three (3) of four (4) observations for a resident with enteral feedings. Resident # 24 Findings include: Review of the facility's policy Enteral Feeding Via Continuous Pump, dated 8/25/2014, revealed, The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally .Steps in the Procedure .Initiate Feeding .5. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order . During an observation on 7/8/24 at 11:42 AM, Resident #24 had a feeding tube bag hanging from a pole in her room. The bag was not labeled to indicate the name of the formula or the date and time of when the bag was hung. During an observation, on 7/9/24 at 8:44 AM, Resident #24's tube feeding bag was not labeled and dated to indicate the time the bag was hung, or the name of the substance in the bag. During an observation, on 7/10/24 at 9:46 AM, Resident # 24's tube feeding bag was not labeled to indicate the type of formula and there was no date to indicate the time the bag was hung. During an interview and observation, on 7/10/24 11:23 AM, with Licensed Practical Nurse (LPN) #1, she confirmed the feeding bag was not labeled with the type of feeding or the date it was hung. She stated she checked the residents' rooms every morning to verify the rate on the feeding pumps were accurate because the previous shift was responsible for changing and labeling the tube feeding bag, the tubing, and the feedings. She explained she did not notice the feeding tube bag was not labeled. During an interview on 7/10/24 at 2:43 PM, with the Director of Nursing (DON), she explained it was the night nurses' responsibility to label the feeding tube bags with the type of feeding, date, time and initial the time the feeding was hung or administered. A record review of the Medication Administration Record for 7/1/24 through 7/31/24 revealed Resident #24 had a Physician's Order, with a start date of 3/12/24, for .Isosource 1.5- 40 ml/hr (milliliters per hour) x (times) 22 hrs . A record review of the Clinical record revealed the facility admitted Resident #24 on 9/20/23. A record review of the of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident # 24 received nutrition via a feeding tube.

Based on staff interview, record review, and facility policy review, the facility failed to revise a comprehensive care plan intervention when an order changed related to accuchecks for one (1) of 20 sampled residents. (Resident #62) Findings include: Review of the facility's policy, Care Plans, Comprehensive Person-Centered, reviewed 10/2022, revealed, .A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Policy Interpretation and Implementation .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Record review of the comprehensive care plan with an intervention target date of 08/18/2024 revealed Focus I have a DX (Diagnosis) of Diabetes Mellitus .Intervention .HumaLOG KwikPen Subcutaneous Solution . sliding scale . This was a Physician's Order that had been discontinued. There was no intervention for the current physician's order related to accuchecks weekly. Record review of the Order Summary Report, with active orders as of 7/11/24, revealed Resident #62 had a current physician's order, dated 6/16/24, Accuchecks weekly one time a day every Sun (Sunday) .BSG (Blood Sugar Glucose) . Record review of the discontinued physician's orders revealed Resident #62 had a Physician Order for HumaLog KwikPen with sliding scale (ss) coverage that was discontinued on 6/12/24. On 7/11/24 at 8:49 AM, in an interview with Licensed Practical Nurse (LPN) # 2/Minimum Data Set (MDS) nurse, she stated the care plan nurse was responsible for revising care plans and the care plan nurse was currently on vacation. She explained the care plan nurse ran a report daily of all new orders written for the previous 24 hours and updated/revised the care plan according to those orders. She confirmed the care plan had not been revised when the physician's order changed from accuchecks with ss coverage to accuchecks weekly without ss coverage. On 7/11/24 at 9:51 AM, in an interview with the Director of Nursing (DON), she stated she expected the care plans to be revised when physician orders change because conflicting interventions could cause confusion when caring for the residents. Record review of the Admission Record revealed the facility admitted Resident #62 on 4/27/23 with current diagnoses including Type 2 Diabetes Mellitus.

Based on interviews, record review, and facility policy review, the facility failed to conduct a safety smoking assessment for a resident to safeguard against the potential hazards for burns and/or fires. This concern was identified for one (1) of three (3) residents reviewed for accidents and hazards. Resident #1 Findings include: Review of the facility's policy, Smoking, undated, revealed, .It is the policy of this facility to provide a safe environment for residents who smoke .Additional precautions may apply to some residents due to safety awareness concerns or medical conditions .Procedure for Resident safety during smoking 1) Residents with known history of smoking .will be evaluated on admission, quarterly, and as needed for safety awareness and any physical limitations related to smoking safety . On 7/9/24 at 9:55 AM, in an interview with Resident # 1, she explained she smoked at the designated times and had always smoked since she was admitted to the facility several years ago. Record review of the medical record revealed a Smoking and Tobacco Evaluation, dated 7/6/2021. Resident #1 did not have a current smoking safety evaluation completed. A record review of the Admission Record revealed the facility initially admitted Resident #1 on 9/10/2013 and she had current diagnoses including End Stage Renal Disease. A record review of the Comprehensive Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/29/23 revealed Resident #1 currently used tobacco. On 7/11/24 9:21 AM, in an interview with the Licensed Practical Nurse (LPN) #2/MDS nurse, she confirmed Resident #1 had not been assessed for smoking since 2021. She stated Resident #1 had been a resident at the facility for a long time and had always smoked. She explained that smoking assessments are completed for residents quarterly and not assessing residents for safe smoking could put them at risk for burns. LPN #2 explained it was the responsibility of the nursing supervisors to complete the assessment form per the facility's policy. On 7/11/24 at 10:21 AM, in an interview with the Director of Nurses (DON), she confirmed that not having a smoking assessment puts residents at risk for burns. The DON stated the staff should use information from the smoking assessment to ensure a safe smoking environment for Resident #1. She revealed the smoking evaluation form should be completed by the nursing supervisors and Resident #1's must have gotten missed. A record review of the Quarterly MDS with an ARD of 5/7/24 revealed Resident #1 had a Brief Interview for Mental Status score of 15, which indicated she was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure indwelling catheter tubing was secured to prevent complications for one (1) of one (1) resident reviewed with an indwelling catheter. Resident # 3 Findings include: A review of the facility's policy Catheter Care, Urinary dated 8/25/14, revealed, .The purpose of this procedure is to prevent catheter-associated urinary tract infections . 17. Secure catheter utilizing a leg band . On 7/11/24 at 8:30 AM, during an interview and observation of catheter care with Certified Nurse Aide (CNA) #1 and Licensed Practical Nurse (LPN) #1 revealed Resident #3 had an indwelling catheter but there was no leg strap to secure the tubing. CNA #1 and LPN #1 confirmed the resident did not have a leg strap in place. LPN #1 stated she would get one for the resident and explained a leg strap was used to secure the catheter tubing to prevent the tubing from pulling or becoming dislodged. Record review of the Order Summary Report with active orders as of 7/12/24 revealed Resident # 3 had a Physician's Order, dated 1/19/24, to Check urinary catheter leg strap every shift and replace as needed . On 7/11/24 at 10:30 AM, during an interview with the Administrator and the Director of Nursing (DON), the DON explained that all residents with an indwelling catheter should have a leg strap to secure the tubing. The Administrator reported that she expected the staff to provide quality care to the residents. A record review of the Admission Record revealed the admitted Resident # 3 on 12/28/23 with current diagnoses including Neuromuscular Dysfunction of Bladder. A record review of Section H of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/18/24, revealed Resident # 3 was coded for an indwelling catheter.

Based on facility policy review, record review and interviews the facility failed to ensure that residents were treated and spoken to in a dignified and respectful manner for two (2) of four (4) sampled residents. Resident #1 and Resident #2. Findings include: Review of facility policy titled, Behavior of Employees, revised 12/13/17, revealed, Policy It is the policy of the Company that certain rules and regulations regarding employee behavior are necessary . Appropriate employee conduct includes: a. Treating all residents, visitors, and coworkers in a courteous manner; b. Refraining from behavior or conduct that is offensive . Record review of facility document titled, Resident Rights, revised and implemented on 11/28/16, revealed, (a) Residents Rights. The resident has a right to a dignified existence . (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life . On 4/04/24 at 9:03 AM, during a telephone interview with the facility Ombudsman, she confirmed that she visited the facility at least monthly and visited with residents. The Ombudsman revealed that she had received complaints from residents related to the way Licensed Practical Nurse (LPN) #1 had treated at spoken to them. The Ombudsman stated that residents had reported to her that LPN #1 routinely spoke to them in a loud, rude, and aggressive manner. On 4/04/24 at 11:00 AM, an interview with a Resident, who requested to remain anonymous, revealed LPN #1 was rude and had spoken to her disrespectfully. The resident stated that she had also witnessed LPN #1 speak disrespectfully to other residents. The resident explained that she had witnessed LPN #1 yell at residents to go to bed, go back to your room. The resident stated LPN #1 told the residents what she was going to do and not going to do. She said that she had also witnessed LPN #1 fuss at residents and tell them that she was not going to come back to answer their call light again, so they better tell her everything they wanted or leave the call light alone. On 4/04/24 at 11:55 AM, during an interview Resident #2 reported that LPN #1, that was rude and disrespectful to her and that she had witnessed LPN #1 being disrespectful to other residents. Resident #2 stated, LPN #1 is always hollering at residents. Resident #2 reported that she had witnessed LPN #1 yelling at residents to go to bed. She stated LPN #1 would tell residents to Get in your room. Go to sleep. The resident described LPN #1 as loud and aggressive. On 4/04/24 at 12:10 AM, an interview with a family member of Resident #2, she reported that she visited the facility frequently during different shifts and had witnessed LPN #1 yelling at residents. The family member stated that she felt it was more than speaking loudly to be heard because LPN #1 was yelling orders at the residents. She provided examples of things she had heard LPN #1 yelling at residents, like telling them to get in their rooms and go to bed. she added, some of these residents didn't even seem to be able to understand. On 4/04/24 at 1:50 PM, in an interview with Resident # 1, the previous Resident Council President, she revealed that the behavior of LPN #1 had been discussed in the Resident Council meetings. The resident stated the Activity Director had taken notes for the meetings, but she was not sure if concerns related to LPN #1 were recorded or not. The resident complained that LPN #1 was rude and disrespectful to residents, especially if she was assigned to their care and they requested anything. Resident #1 commented that it was reported that during a recent incident, when a resident requested something for their cold/allergy symptoms, LPN #1 told the resident No, you can't have that and walked out. On 4/04/24 at 5:00 PM, an interview with the Social Services Director (SSD) revealed that any staff member could document a grievance and that the grievances were turned in to her, and she directed them to the appropriate department head to be addressed. The SSD confirmed that she had received a grievance today from the Staffing Coordinator about a report she had received regarding the loud, rude, and aggressive behavior of LPN #1. On 4/05/24 at 1:58 PM, during an interview with the Staffing Coordinator, she confirmed Certified Nursing Assistant (CNA) #1 reported to her that LPN #1 needed to learn how to talk to people. CNA #1 had stated that LPN #1 was loud and that there had been complaints from residents that they did not like LPN #1's tone or volume and felt she was not speaking to them in a respectful manner. On 4/05/24 at 2:10 PM, an interview with the Assistant Director of Nurse (ADON), revealed the facility provided routine in-service training related to Resident Rights and treating residents with respect. She stated that the facility also provided routine in-service training related to Resident Abuse and Neglect Prevention and Reporting. The ADON commented that she had not witnessed or heard any allegations involving LPN #1 which rose to the level of verbal abuse, but had received a report of an allegation that LPN #1 had spoken to a resident in a rude, disrespectful manner and the allegation was currently being investigated and could result in the termination of the employment of LPN #1 from the facility because LPN #1 had already received multiple coaching and verbal warnings regarding therapeutic communication. Record review of the Record of Corrective Coaching and Witness Statement dated 3/13/24 and signed by the Director of Nurses (DON) revealed that on 3/13/24, LPN #1 received a verbal warning regarding behaviors and attitude and received an additional in-service on conduct of behavior for employee and therapeutic communication. Record review of the Admission Record for Resident #1 revealed the facility admitted the resident on 9/10/13, with diagnoses that included End stage renal disease and Type 2 diabetes. Record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/12/24, for Resident #1, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Record review of the Admission Record for Resident #2 revealed the facility admitted the resident on 8/16/22, with diagnoses that included Chronic respiratory failure and Neuralgia. Record review of the 5-Day MDS, with ARD 3/08/24, for Resident #2, revealed the resident had a BIMS score of 12, which indicated no cognitive impairment.

Based on interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision to prevent Resident #1, who was a vulnerable resident, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1 Resident #1 kicked open an entrance door and exited the facility. He was last observed by facility staff to be in his room in bed at 1:15 AM on 3/9/2024. The facility staff were unaware of Resident #1's absence until 3:15 AM when a staff member entered his room and noted he was not in bed. Resident #1 was located in a neighboring town by the police department at 9:09 AM, approximately 12 miles from the facility. Resident #1 had been off the facility grounds and unsupervised for approximately six (6) to eight (8) hours. The facility's failure to provide supervision and ensure the entrance door was secure, put Resident #1 and all other vulnerable residents at risk for the likelihood of serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 3/9/24. The State Agency (SA) notified the Administrator of the IJ on 3/15/24 at 12:40 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 3/9/24, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 3/10/24, prior to the SA's entrance on 3/14/24. Findings include: Record review of the facility policy, Emergency Procedure - Missing Resident, undated, revealed, .Resident elopement resulting in a missing resident is considered a facility emergency . Record review of the facility investigation, dated 3/09/24, revealed Certified Nurse Aide (CNA) #1 identified Resident #1 was not in his room at approximately 3:15 AM on 3/09/24. CNA #1 reported to Licensed Practical Nurse (LPN) #1 and after searching the building and perimeter it was determined that the resident had left the facility without notifying staff. Missing resident procedures were initiated. Resident #1 was located at approximately 8:50 AM by Police Officer #2 from a neighboring town, which was 12 miles from the facility. On 3/14/24 at 1:55 PM, an interview with the Director of Nurses (DON) revealed she was notified by LPN #1 that Resident #1 was missing at 4:10 AM on 3/09/24. She reported the resident was located approximately 11 miles from the facility by Police Officer #2 at or around 8:50 AM and taken to the Police Department (PD) in a nearby town. She stated that she and other staff went to the PD at approximately 9:20 AM on 3/09/24, where she immediately assessed the resident, who had no obvious injury. She reported the resident was wearing a clean burgundy T-shirt, blue jeans and black tennis shoes when located and was carrying three plastic shopping bags which contained some clothing. She described the weather as cool, mild, and dry. The DON stated Resident #1 reported that he had left the facility by kicking open the side door and he was trying to get to a city which was approximately 90 miles from the facility to be with family. On 3/14/24 at 10:54 PM, in a telephone interview with CNA #1, she recalled she and CNA#2 observed Resident #1 in his room at approximately 1:15 AM on 3/09/24 and when she made rounds at approximately 3:15 AM on 3/09/24, she did not see him in the bed. She reported that after quickly checking the surrounding rooms and areas, she advised LPN #1 that she was unable to locate Resident #1. Record review of the Police Department's Offense/Incident Report, dated 3/9/24, revealed Resident #1 was located by Police Officer #2 at 8:55 PM eleven (11) miles from the facility sitting outside on the curb near Hwy (highway) and transported to the officer's police department. The report included a statement by Police Officer #2 that he observed the resident sitting on the curb with a sign in his hand. The statement revealed the officer ran a local check on the information provided by the resident and discovered that he was listed as a missing person from a neighboring city. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated he was cognitively intact. Section E revealed he was not at risk for wandering or elopement. Record review of the .Quarterly Evaluation Bundle, dated 12/14/23, revealed Resident #1 was not a wanderer or elopement risk. Record review of the Weather Underground website (www.weatherunderground.com) temperatures between 3:15 AM and 8:55 AM on 3/09/24 were 59 to 60 degrees Fahrenheit with zero (0) precipitation and winds between 5 and 10 miles per hour. The facility submitted the following list of corrective measures: 1. 3/9/2024 at 3:15 AM the Certified Nursing Assistant (CNA) observed the residents' room and noted he was not present. She immediately notified the Licensed Practical Nurse (LPN) on duty. All staff on the unit began a search for the resident throughout the north unit and then moved to the south unit; at this time, all staff were directed by the LPN to conduct a search of all areas of the building and the perimeter. 2. 3/9/2024 at 4:14 AM, the LPN notified the Administrator in Training (AIT) that the staff searched the building and perimeter and could not locate the resident. The AIT notified the Administrator and Director of Nursing (DON) immediately after speaking with the nurse. The Administrator gave instructions to contact the Maintenance Supervisor and the Police Department. The LPN attempted to contact the resident's next of kin and the number was disconnected. 3. 3/9/2024 at 4:35 AM the Maintenance Supervisor arrived at the facility. He checked all exit doors for proper functioning and noted all doors were secure. He began a search of the perimeter including outside buildings and checked all windows noting all windows were secure. 4. 3/9/2024 at 5:00 AM a complete headcount was conducted by the nursing staff and all other residents were located. 5. 3/9/2024 at 5:00 AM a search team was assembled by the DON-and Maintenance-Supervisor-to search surrounding buildings, including churches, convenience stores, local bus stations and all open businesses. The LPN began making calls to all surrounding police stations. The Administrator contacted all local hospitals. 6. 3/9/2024 at 5:30 AM the Officer assigned to the case arrived at the facility and completed a missing person's report. 7. 3/9/2024 at 8:00 AM the Administrator notified the resident's physician to update the missing resident's status. 8. 3/9/2024 at 9:09 AM the Police Department confirmed with the Administrator that the resident was safe and secure at the Police Station. 9. 3/9/2024 at 9:18 AM the Director of Nursing and Social Service Director went to the Police Station, assessed the resident, found no issues or psychosocial harm then transferred the resident to the emergency room because he refused transport by ambulance. The resident was calm and expressed confidence in his purpose for leaving the facility. He stated he kicked the door, left the facility, walked to the corner of the road, caught a ride with two white ladies that helped him make a sign so he could get to (name of city) to see his family. 10. 3/9/2024 at 10:12 AM the DON arrived at the hospital, gave history of incident and medical information to the Physician along with current medications and morning medications that he had not received at this time. The DON remained with the resident while the nurse obtained vital signs including a blood glucose level and body audit. No issues were noted with skin assessments, all vital signs were within normal limits and the resident stated he felt fine, but his legs were sore. The Physician ordered labs and stated they would complete medical clearance for admittance. 11. 3/9/2024 at 12 PM a Quality Assurance Performance Improvement (QAPI) committee meeting was held regarding the incident involving Resident # 1. In attendance were the Administrator, the DON, the AIT, the Care Plan Nurse, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP), the Business Office Manager, the Maintenance Supervisor, the Wound Care Nurse, Medical-Director, the Regional Nurse Consultant, the Regional Director of Operations, and the Social Services Director (SSD). -QAPI minutes included: 3/9/2024 the QAPI committee reviewed the incident, actions taken, and the policy was reviewed with no recommendations for change. 3/9/2024 all facility staff were 100% in-serviced regarding elopement/missing resident policies and procedures prior to returning to work by the AIT and the DON. 3/9/2024 On hundred percent (100%) of all residents were assessed for elopement risk by the Wound Care Nurse and DON. 3/9/2024 Care Plan Nurse performed a 100% audit of all resident's care plans for those identified as an elopement risk. 3/9/2024 DON completed a 100% audit of all residents that were identified as an elopement risk to include visual monitoring, wander guard bracelets and testing. 3/9/2024 100% audit of the elopement book was performed by the Social Services Director and to ensure that all pictures were current. 3/9/2024 Maintenance Supervisor performed elopement drills on all shifts, this will continue for four (4) weeks and monthly thereafter and brought before the QAPI committee each month for review and recommendations. Any issues will be addressed immediately by the Administrator and DON. 3/9/2024 Maintenance Supervisor changed all door codes in the facility. 3/9/2024 AIT ordered keypad covers for all door keypads in the building. 3/9/2024 Maintenance Supervisor placed door alarms on all doors in the facility. The alarms will be monitored daily, and any issues will be addressed immediately by the Administrator and brought before the QAPI committee monthly for review and recommendations. 3/9/2024 Maintenance Supervisor contacted the alarm company to schedule testing of all doors in the building. 3/9/2024 State Department of Health (SA) was notified of the incident. 3/9/2024 the Attorney General's office (AGO) was notified of the incident. A follow up QAPI meeting was held on 3/11/2024 to discuss the incident; all actions taken were reviewed and determined to be 100% complete on 3/9/2024. The attending staff were the Administrator, the DON, the AIT, the Care Plan Nurse, the Assistant Director of Nursing (ADON)/infection Preventionist (IP), the Business Office Manager, the Maintenance Supervisor, the Wound Care Nurse, the Medical Director, the Regional Nurse Consultant, the Regional Director of Operations, and the Social Services Director. Pleasant Hills Community Living Center alleged that all interventions necessary to remove the immediacy of the incident were accomplished on 3/09/24. On 3/14/24, the SA validated the corrective actions taken by the facility: The SA validated through record review and interview that the staff identified that the resident was not in his room at approximately 3:15 AM and after searching the building and perimeter it was determined that the resident had left the facility without notifying staff. Missing resident procedures were initiated and the resident was located at approximately 8:50 AM in a neighboring community approximately twelve (12) miles from the facility by the local police department. The SA validated through interview that all notifications were made to facility management and the local police regarding Resident #1's elopement. The SA validated through record review and interview that the facility conducted a headcount of all residents, the Maintenance Supervisor came to the facility and checked all exit doors for proper functioning and ensured all windows were secure. The SA validated through interview that at approximately 5:00 AM a search team was assembled by the DON and Maintenance Supervisor to conduct a search of surrounding buildings to include churches, convenience stores, local bus stations and all open businesses and LPN #1 began making calls to all surrounding police stations; the and all local hospitals, until the time the resident was located. The SA validated through interview and record review Police Officer #1 completed a missing person's report. The SA validated through interview that the Administrator notified the resident's physician of an update on the status of the missing resident. The SA validated through record review and interview that at 9:09 AM the local Police Department confirmed that the resident was safe and secure at the Police Station of a neighboring city, 12 miles away from the facility. The SA validated through interview and record review that at 9:18 AM on 3/09/24, the DON and Social Services Director went to the Police Station and transported Resident #1 to the emergency room for evaluation as ordered by the Physician, because the resident had refused to go by ambulance; also that the DON and SSD assessed the resident and found no signs of physical or psychosocial harm. They both reported that the resident was calm and expressed confidence in his purpose for leaving the facility, and that he stated he kicked the door, left the facility, walked to the corner of the road, and caught a ride with two ladies who helped him make a sign so he could get to a city ninety (90) miles away to see his family. The SA validated through interview that at 10:12 AM, the DON arrived at the hospital with the resident, gave history of incident and medical information to the Physician along with current medications and morning medications that had not been received. The DON remained with the Resident while the nurse obtained vital signs including a blood glucose level and body audit with no issues noted and all vital signs were within normal limits and the Resident stated he felt fine, except his legs were sore. The Physician ordered labs and stated the hospital would complete medical clearance and admit the resident for a psychological evaluation. The SA validated through record review that all staff on duty were interviewed by the DON, AIT and/or Administrator and CNA #1 was the last person to see Resident #1 lying in bed at approximately 1:15 AM while making rounds. The SA validated on 3/15/24 at 9:40 AM through interview and record review and observation of the Business Office Entrance door that the door was locked and secure and LPN #1 indicated she heard the door as staff was going in and out for lunch but never heard a loud noise such as the resident kicking the door. Interview revealed the Maintenance Director checked the door, no damage was noted to the door, and it was functioning properly. The SA validated through interview that the Regional Director of Operations and Regional Nurse Consultant conducted a review of the medical record for Resident #1 The SA validated through interview when the resident was located, he was wearing appropriate clothing/footwear, and the outside temperature was 56 degrees. The SA validated through record review and interview that the facility held a QAPI meeting at 12:00 PM on 3/9/24, and those in attendance included the Administrator, AIT, DON, Care Plan Nurse, ADON/Infection Preventionist (IP), Business Office Manager, Maintenance Supervisor, Social Service Director, Wound Care Nurse, Regional Director of Operations, Regional Nurse Consultant and Medical Director. The committee reviewed the Elopement Incident, actions taken, and policy reviewed with no recommendations by the committee to change the policy. The SA validated through record review and interview the facility staff were in-serviced by the AIT and DON regarding elopement/missing resident policies and procedures prior to returning to work. The SA validated through interview with the DON and record review that all residents were reassessed for elopement risk by the DON. The SA validated through interview and record review that the Care Plan Nurse audited all resident care plans for those identified as elopement risk. The SA validated through interview and record review the DON audited records of all residents identified as elopement risk for visual monitoring, wander guard bracelets and testing. The SA validated through observation, record review, and interview there were Elopement Books at each nurse's station and the SSD audited the elopement books and ensured all residents identified had current pictures. The SA validated through record review and interview that elopement drills were conducted on all shifts on 3/09/24 and 3/11/24, with drills scheduled weekly for 4 weeks and monthly thereafter. The SA validated through interview that door codes were changed for all doors. The SA validated through interview the alarm company was consulted for additional options for door alarms. The SA validated through record review and interview that keypad covers were ordered for all exit doors. The SA validated through record review and interview that the Administrator notified the SA of the incident. The SA validated through record review and interview that the Administrator notified the Attorney General's Office of the incident. The SA validated through interview that the SSD located the Resident's family and notified them of the resident's elopement and hospitalization . The SA validated through record review that the facility held a QAPI Committee meeting on 3/11/2024 and discussed the outcome of the incident and that the QAPI Committee determined that before the incident, Resident #1 was not identified as a risk for elopement, was properly dressed, packed some belongings and was trying to get to see their family. The SA validated the Social Service Director spoke to the family and was working closely with Resident #1 to initiate discharge planning at the request of Resident #1.

Based on interviews and record review, the facility failed to treat residents with dignity and respect by failing to consistently ensure call lights were answered in a timely manner for three (3) of 31 sampled residents (Residents #1, 32, and 45) and one (1) unsampled resident (Resident #80). Findings include: Resident #32 On 02/11/24 at 12:30 PM, in an interview with Resident #32, he stated it takes staff over two (2) hours to answer call lights, leaving the resident wet and sometimes soiled waiting for assistance. Review of the Minimum Data Set (MDS, with Assessment Reference Date (ARD) of 01/16/24, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #1 On 02/11/24 at 01:01 PM, an interview with Resident #1 revealed there was a problem with call lights being answered timely. The resident stated she had to lay in urine and bowel movement for over an hour and had complained to the Ombudsman about their concerns. A record review of the MDS, with ARD 11/20/23, revealed Resident #1 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #45 On 02/13/24 at 12:54 PM, in an interview, Resident #45 complained about the staff not answering the call lights timely. A record review of Resident #45's MDS with ARD of 01/08/24, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #80 A record review of the facility's October grievance log revealed an unsampled resident's wife (Resident #80) had filed a grievance in reference to call lights not being answered timely. An interview with the Ombudsman on 2/12/24 at 10:00 AM, revealed she had gotten recent complaints regarding staff not answering lights in a timely manner. The Ombudsmen stated she was at the facility last Tuesday, because of the complaints and had spoken with the Assistant Administrator (AA), Social Service Director (SSD) and Activity Director (AD) along with resident council members. On 02/14/24 at 06:38 PM, in an interview with the Director of Nurses (DON), she confirmed she was made aware of the complaints about call lights not being answered timely by the activity's coordinator. The DON stated in response to the complaints the staff were in serviced on importance of answering call bell in a timely manner and staff on all shifts were in serviced. On 2/14/24 PM at 6:40 PM, in an interview with the AD, she confirmed a grievance was made in October in relation to call lights not being answered timely. She stated she reported the grievance to the Director of Nursing and notified the Administrator. She stated DON provided an in-service with staff as part of their plan to solve the problem. On 2/14/24 at 7:13 PM, in an interview with the SSD, she confirmed during resident council in the month of October there was a complaint about the call light not being answered. She stated the DON was notified and staff were in-serviced. She stated she had not had any more complaints on that topic from the residents since that time. On 02/14/24 at 07:16 PM, an interview with the Administrator confirmed residents complained in resident council about the staff not answering the call lights. The Administrator stated she had completed an in-service with the staff explaining the importance of answering the call lights and customer service. The Administrator also confirmed after that in-service, she completed one on-one in-services with staff because there was still a problem with answering call lights in a timely manner. She stated the last in-service on the topic of answering call lights in a timely manner was in December of 2023.

Based on observation, interviews, record review and facility policy review the facility failed to implement the comprehensive care plan for two (2) of nineteen care plans reviewed. Residents #38 and #55 Findings include: A record review of the facility's policy, Using the Care Plan, dated 12/5/16, revealed, It is the policy of the facility that the care plan be used in .the resident's daily care routines Resident #38 Record review of comprehensive Care Plan for Resident #38 initiated 3/21/19 revealed Focus I am at risk for falls r/t (related to) decreased mobility, side effects from medications, impaired cognition, and impaired safety awareness .I will not sustain any undetected injuries through the review date 10/19/23 . Interventions .Bed will be kept in lowest position while in bed .This intervention was initiated on 7/27/23. During an interview on 9/25/23 at 2:00 PM, with Licensed Practical Nurse (LPN) #1 she confirmed she observed Resident #38 on the floor on 9/8/23 at 7:35 PM. The nurse revealed Resident #38 was moved into different room, because she had COVID-19. LPN #1 also explained that Certified Nurse Aide (CNA) #2 reported to her that Resident #38's bed would not go down in low position after the resident had fallen. The nurse stated she put information about the problem with the resident's bed in the maintenance book. During an interview on 9/26/23 at 10:00 AM, with maintenance staff, he confirmed there had been a work order on his maintenance book on 9/9/23, revealing a problem with Resident #38's bed not being able to be lowered to the lowest position. The maintenance man stated he replaced that bed with a new electric bed and mattress, as the bed was an old crank bed and needed to be discarded. During an interview on 9/29/23 at 2:30 PM, with CNA #2, she said she was the CNA on 9/8/23, the night Resident #38 fell . CNA #2 said the nurse had called her for assistance to get Resident #38 off the floor. CNA #2 revealed the resident's bed was in high position and would not go down. The CNA said she told LPN #1 and they put the information in the maintenance book. CNA #2 also stated that the dayshift CNA reported to her that Resident # 38's bed wouldn't lower to the lowest position. A record review of the Admission Record for Resident #38 revealed the facility admitted the resident on 2/13/19 with diagnoses that included Cognitive Communication Deficit and Abnormalities of Gait and Mobility. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/7/23 revealed in Section C that Resident # 38 had been unable to participate in a Brief Interview for Mental Status (BIMS), which indicated she was cognitively impaired. Review of Section G also revealed Resident #38 needs extensive assistance with bed mobility. Resident #55 On 09/25/23 at 11:01 AM, an observation revealed Resident #55 sitting in her wheelchair in her room with the door closed. The resident was dry shaving her face with a blue razor, using her left hand. Resident #55 did not have any soap or shaving cream on her face. Record review of the comprehensive Care Plan for Resident #55, with a revision date of 9/26/23, revealed I have an ADL (activities of daily living) deficit .I prefer to shave my face with a razor with staff supervision .Interventions .Staff will observe me while shaving to ensure safety. Staff will provide me with razors and shaving cream . Review of the care plan Focus: I am at risk for bleeding r/t (related to) receiving Clopidogrel Bisulfate (a blood thinner) .Interventions .Observe for s/sx (signs/symptoms) of bleeding .Use care when providing assistance with ADL's to prevent injury that may cause bleeding . On 09/25/23 at 03:16 PM, in an interview with Registered Nurse (RN) #1 confirmed the resident should not have had a razor shaving herself without supervision. RN #1 confirmed the resident could have cut herself with the razor, which could have caused bleeding problems, as the resident is on a blood thinner. On 09/25/23 at 03:22 PM, in an interview with CNA #1, she stated she did not know that Resident #55 had the razor. CNA #1 revealed none of the residents are allowed to shave themselves unsupervised. On 09/29/23 at 09:25 AM, in an interview with Licensed Practical Nurse LPN #3/Care Plan Nurse revealed she is responsible for writing the resident care plans. She stated it is a personalized care plan to be used by all staff rendering care. LPN #3 confirmed that Resident #38 had a care plan with interventions that addressed falls and should have been followed. She stated that allowing Resident #55 to shave herself without CNAs in the room, was not following the care plan. She explained that this was a safety issue as Resident #55 could have cut herself shaving without assistance. She stated she expects all staff to follow the care plan. A record review of the Admission Record for Resident #55 revealed the facility admitted the resident on 6/11/2020, with diagnoses that included Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, and Seizures. A record review of Quarterly Minimum Data Set (MDS) for Resident #55, with Assessment Reference Date (ARD) of 6/29/23, revealed a Brief Interview for Mental Status (BIMS) score of two (2), which indicated Resident #55 had severe cognitive impairment. Section G for Personal Hygiene revealed the resident required extensive assistance with personal hygiene.

Based on interviews, record review, and facility policy review, the facility failed to report within two (2) hours to the State Agency (SA) an injury of unknown source that resulted in a resident experiencing an intracerebral hemorrhage (major head injury) for one (1) of nineteen (19) sampled residents. Resident # 38 Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, with a reviewed date of 10/2022, revealed, All reports of resident's abuse (including injuries of unknown origin) .are reported to local, state, and federal agencies (as required by current regulations) .Reporting Allegation to the Administrator and Authorities: . 3. Immediately is defined as: a. within two hours .result in serious bodily injury .Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident, and b. The injury is suspicious because of: (1) the extent of the injury . Record review of the facility policy Accidents and Incidents, undated, revealed .Accident/Incident Reporting and Investigating Guidelines .Level of Events-Quick Reference .Level 3 Results in and injury and .Results in transfer to another level of care .Examples: Fall with injury .requiring transfer . is reportable to state agencies Unusual Incidents: Reportable to State Agencies .Definition: An unusual incident is an unexpected occurrence or accident resulting in .serious physical injury to a resident . On 9/25/23 in an interview at 10:00 AM, with the Nurse Practitioner (NP), she confirmed Resident #38 had a major injury to the head after being found on the floor on 9/8/23. The NP revealed she doesn't know how the resident got on the floor, as she had never seen the resident make any attempts to get out of bed without assistance. The NP stated she had reviewed the resident's hospital discharge instructions, and the resident has a follow up visit with the neurosurgeon with an magnetic resonance imaging (MRI), to see if the resident has further damage to her head. During an interview on 9/25/23 at 2:00 PM, with Licensed Practical Nurse (LPN) #1, she confirmed that she observed the resident on the floor on 9/8/23 at 07:35 PM. LPN #1 stated Resident #14, the roommate of Resident #38 at the time, came out into the hall and stated, Resident #38 was on the floor. The nurse said she did not investigate what caused the resident to be on the floor, because Resident #38 was confused and unable to tell her what happened. The nurse confirmed she also did not ask Resident #14 if she knew how Resident #38 ended up on the floor. During an interview on 9/28/23 at 10:00 AM, with the Director of Nursing (DON), she confirmed Resident #38 was observed on the floor in her room on 9/8/23. The DON also confirmed she did not know how the resident got on the floor. The DON also mentioned that she had never seen Resident #38 make any attempts to get out of bed. The DON stated Resident #38 was sent to the hospital for evaluation. During an interview on 9/29/23 at 2:30 PM, with Certified Nursing Aide (CNA) #2, she revealed she was the CNA assigned to Resident #38 on 9/8/23, the night the resident was found on the floor. CNA #4 stated she was called by the nurse to come and help get Resident #38 off the floor. During an interview on 9/29/23 at 2:38 PM, with the Administrator, he confirmed he was aware of the incident involving Resident #38 that occurred on 9/8/23. The Administrator said it was discussed the next morning in their stand-up meeting. The Administrator explained he did not feel the incident needed to be reported to the State Agency (SA), because of the way her body was positioned on the floor in her room. He stated Resident #38 was sent to the emergency room at a local hospital for evaluation. A record review of the Admission Record for Resident #38 revealed the facility admitted the resident on 2/13/19 with diagnoses that included Cognitive Communication Deficit and Abnormalities of Gait and Mobility. A record review of Resident #38's Discharge Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/8/23, revealed the resident was sent to an Acute Hospital. Section G revealed that Resident #38 needed extensive assistance for bed mobility.

Based on observation, interviews, record review, and facility policy review, the facility failed to adequately supervise and implement interventions for dependent residents to prevent one (1) resident from ending up on the floor with a major head injury and one (1) resident from dry shaving herself in her room with the door closed for two (2) of four (4) residents reviewed for accidents. Residents #38 and #55 Findings include: Review of the facility's policy titled, Accidents and Incidents, revealed It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and those residents receive supervision and assistance devices to prevent accidents whenever possible. This is accomplished through the identification and evaluation of environmental hazards and individual risk factors, implementing interventions to reduce hazards and risks that are identified, and monitoring for the effectiveness of the interventions .Environmental risk may be identified through .routine inspection of the physical plant .These interventions may include repair, replacement . Resident # 38 A record review of the Progress Note, dated 9/13/23, revealed the Nurse Practitioner (NP) documented the hospital return of Resident #38 from a local Acute Care Hospital from 9/8/23 through 9/12/23, following hospitalization and treatment for an Intracerebral Hemorrhage. During an interview on 9/25/23 at 10:00 AM with the NP, she confirmed the resident had a major injury to the head after a fall at the facility. The NP revealed she didn't know how the resident got on the floor, as she has never seen the resident make any attempts to get out of the bed without assistance. A record review of Resident # 38's, Fall Assessments dated 9/8/23 revealed no history of falls within the last six (6) months. Record review of the facility's, Incident Report dated 9/8/23 at 7:35 PM by Licensed Practical Nurse (LPN) #1, revealed Resident #14 came out of her room, stating her roommate, Resident #38 was on the floor. The nurse also documented the resident was unable to give a description of the incident, however, a body audit revealed that the resident had a hematoma to the back of her head. Further review LPN #1's documentation of the incident revealed that possible predisposing factors was the furniture, recent illness, and a room change. There was also documentation that no witnesses were found. During an interview on 9/25/23 at 2:00 PM, with LPN #1, she confirmed she observed Resident #38 on the floor on 9/8/23 at 7:35 PM. LPN #1 said Resident #14 came out into the hall and said Resident #38 was on the floor. LPN #1 confirmed she did not ask Resident #14, the residents' roommate, how the resident ended up on the floor. The nurse explained Resident #14 was upset about having a roommate and having to stay in the room because they both had COVID-19. LPN #1 explained that Resident #38 was moved into the room with Resident # 14 because she had COVID-19. LPN #1 also explained that CNA #2 reported to her that Resident #38's bed would not go down in low position after the resident had fallen. The nurse stated she put information about the problem with the resident's bed in the maintenance book. In an interview on 9/26/23 at 10:00 AM, with maintenance staff, he confirmed there had been a work order on his maintenance book on 9/9/23, revealing a problem with Resident #38's bed not being able to be lowered to the lowest position. The maintenance man stated he replaced that bed with a new electric bed and mattress, as the bed was an old crank bed and needed to be discarded. On 9/28/23 at 10:00 AM, in an interview, with the Director of Nurses (DON), she confirmed Resident #38 was observed on the floor in her room on 9/8/23. The DON also confirmed she did not know how the resident ended up on the floor, as she had never seen the resident make any attempt to get out of her bed. The DON revealed they had moved the resident to another room and had sent the resident to the hospital for an evaluation. During an interview on 9/28/23 at 10:15 AM, with Resident #14, she refused to discuss Resident #38's fall. Resident #14 said all she knows is the resident was on the floor and she was not discussing that situation anymore. During an interview on 9/29/23 at 2:30 PM with CNA #2, she said she was the CNA on 9/8/23, the night Resident #38 fell . CNA #2 said the nurse had called her for assistance to get Resident #38 off the floor. CNA #2 revealed the resident's bed was in high position and would not go down. CNA#2 said she told LPN #1 and they put the information in the maintenance book. CNA #2 also stated that the dayshift CNA reported to her that Resident 38's bed wouldn't go down. CNA #2 revealed she had never seen Resident #38 attempt to get out the bed without assistance. CNA #2 also revealed that Resident #14 was upset and continued to stand by Resident #38's bed. CNA#2 said Resident #14 kept pressing Resident #38's call light. CNA #2 said she asked Resident #14 to leave Resident #38's call light alone and use her own call light if she needed assistance. During an interview on 9/29/23 at 2:38 PM, with the Administrator, he confirmed he was aware of Resident #38's fall that occurred on 9/8/23. The Administrator said it was discussed in stand-up the next morning. A record review of the Admission Record for Resident #38 revealed the facility admitted Resident #38 on 2/13/19 with diagnoses that included Cognitive Communication Deficit and Abnormalities of Gait and Mobility. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/7/23 revealed Resident # 38 had been unable to participate in a Brief Interview for Mental Status (BIMS) review, which indicated she was cognitively impaired. Review of section G also revealed Resident #38 needs extensive assistance with bed mobility. Record review of the Admission Record revealed the facility admitted Resident #14 on 8/20/17 with diagnoses that included Generalized Anxiety Disorder and Schizophrenia. Record review of the Quarterly MDS, with an ARD of 7/5/23, revealed Resident #14 had a BIMS score of 15, which indicated she was cognitively intact. Section G indicated Resident #14 was independent with transfers and bed mobility. Resident #55 On 9/25/23 at 11:01 AM, an observation of Resident #55, revealed the resident sitting in her wheelchair in her room with the door closed. Resident #55 was dry shaving her face with a blue razor using her left hand, without soap or shaving cream on her face. While being observed, Resident #55 attempted to put A&D ointment on her face to shave. Resident #55's speech was unclear; however, the resident could make simple needs known by pointing with her fingers and shaking her head yes and no answers. Resident #55 shook her head yes when asked if she shaved herself without staff present. The resident also shook her head yes when asked if the staff gave her the razor. No blood was noted on the resident's face and the hair over the resident's lip had been removed. Thick hair was noted under the resident's chin and neck. The Assistant Director of Nursing (ADON) entered the resident's room and asked the resident for the razor and finished shaving the resident. During an interview on 09/25/23 at 03:16 PM, with the ADON, she confirmed Resident #55 should not have a razor shaving herself without supervision. The ADON also confirmed Resident #55 could have cut herself with the razor, which could have been a problem, as the resident is on a blood thinner. During an interview on 09/25/23 at 03:22 PM, with CNA #1, she said she was told by the ADON that Resident #55 had a razor shaving herself in the room without supervision. CNA #1 said she didn't know the resident had the razor and explained the residents don't shave themselves at this facility. During an interview on 09/28/23 at 3:57 PM, with the DON, she said the resident should not have been using a razor unsupervised. The DON confirmed the resident could have cut herself and could have bled out with no staff in the room. Record review of the Admission Record revealed the facility admitted Resident #55 on 6/11/20, with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominate Side, Seizures, and Cerebral Infarction. Record review of the Quarterly MDS, with an ARD of 6/29/23, revealed Resident # 55 had a BIMS score of 02, which indicated she was severely cognitively impaired. Review of section G revealed Resident #55 needs extensive assistance with personal hygiene.

Based on interviews, record review, and facility policy review the facility, the facility failed to thoroughly investigate an injury of unknown source that resulted in an intracerebral hemorrhage (major head injury) for one (1) of nineteen sampled residents. Resident # 38 Findings include: Review of the facility's policy titles, Abuse, Neglect, Exploitation or Misappropriation -Reporting and investigating policy, reviewed on 10/2022, revealed, All reports of resident's abuse (including injuries of unknown origin), .thoroughly investigated by facility management. Findings of all investigations are documented .Investigating Resident Injuries . All Resident injuries are investigated . 1. The director of nursing services or a designee assesses all resident injuries and documents findings in the medical record . 7. If nursing and medical assessment determines an injury of unknown source the investigation will follow the protocols set forth in our facility's established abuse investigation guidelines . 8. Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident, and b. The injury is suspicious because of: (1) the extent of the injury . Record review of the facility policy Accidents and Incidents, undated, revealed .Accident/Incident Reporting and Investigating Guidelines .Investigations: Investigations should begin when the incident is identified. The nurse in charge should identify .who may have knowledge of the occurrence individuals should be interviewed and asked to provide a statement .Interviews of witnesses or caregiver for the past 24 hours .An attempt to determine the root cause .is made . Record review of the facility's, Incident Report dated 9/8/23 at 7:35 PM, by Licensed Practical Nurse (LPN) #1, revealed Resident #38 was observed on the floor in her room. The nurse was unable to determine how Resident #38 ended up on the floor. Resident #38 was noted with a hematoma to the back of her head. The resident was sent to the local emergency room in an Acute Care Hospital, for evaluation. Review of the Acute Care Hospital discharge instructions dated 9/12/23, revealed Resident #38 was diagnosed with an Intracerebral Hemorrhage with instructions for follow-up with neurosurgeon for an MRI ( magnetic resonance imaging) scheduled for 10/23/23. In an interview on 9/28/23 at 10:00 AM, with the Director of Nurses (DON), she confirmed Resident #38 was observed on the floor in her room on 9/8/23. The DON also confirmed she did not know how the resident ended up on the floor, as she had never seen the resident attempt to get out of the bed. The DON confirmed she had not done a thorough investigation. She reported that she did not have any statements from the staff or other residents regarding Resident #38's fall. The DON revealed that the only thing that was done (regarding the incident) was an incident report was filled out and the resident was sent to the emergency room at (proper name of local hospital) for evaluation and it was discussed in the stand-up meeting the next morning. On 9/29/23 at 2:38 PM, during an interview , the Administrator confirmed he was aware of the incident involving Resident #38, that occurred on 9/8/23. The Administrator said it was discussed in stand-up the next morning. The Administrator explained he did not feel the incident needed to be investigated because of the way Resident #38's body was positioned on the floor in her room. The Administrator said he determined the resident fell out of the bed, by the way her body was positioned. A record review of the Admission Record for Resident #38 revealed the facility admitted the resident on 2/13/19 with diagnoses that included Cognitive Communication Deficit and Abnormalities of Gait and Mobility. A record review of Resident #38's Discharge Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/8/23, revealed the resident was sent to an Acute Hospital. Section G revealed the resident needed extensive assistance for bed mobility.

Based on observation, interviews, record review, and facility policy review the facility failed to put in place appropriate interventions to prevent an incident of an unwitnessed fall on 08/02/2022 that resulted in a closed non-displaced fracture of the head of left radius for Resident #6, one (1) of three (3) residents reviewed for falls. A fall risk assessment was completed after admission to the facility on [DATE], which indicated Resident #6 was at high risk for falls. Resident #6 had an unwitnessed fall on 08/02/2022. Resident # 6 was found to be laying on the floor beneath the bedside table. She was sent to the local hospital for further evaluation. X-rays completed at the hospital revealed a closed nondisplaced fracture of head of left radius. Resident #6 sustained two (2) additional falls on 08/24/2022 and 09/01/2022. The facility's failure to provide assistance and put interventions in place for a resident who was at high risk of falls placed this resident and other residents at risk, in a situation that was likely to cause serious harm, serious injury, serious impairment or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), that began on 08/02/2022 when Resident #6 had an unwitnessed fall resulting in a major injury. On 10/27/2022 at 2:28 PM, the State Survey Agency (SSA) notified the facility's interim Administrator and Nurse Consultant of the IJ and SQC. The facility submitted an acceptable Removal Plan on 10/27/2022, in which the facility alleged all corrective action were completed on 10/27/2022. The IJ was removed on 10/28/2022. The SSA validated the Removal Plan and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR(s) 483.25 (d) (1) (2)- Free of Accidents/Supervision/Devices, F689 was lowered from a J to a scope and severity of a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy titled Accidents and Incidents, dated December 19, 2017, revealed, Policy It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and those residents receive supervision and assistance devices to prevent accidents whenever possible. This is accomplished through the identification and evaluation of environmental hazards and individual risk factors, implementing interventions to reduce hazards and risks that are identified, and monitoring for the effectiveness of the interventions. Process Evaluating/Identifying Risk Individual Risk, Residents are to be routinely evaluated for individual risk factors in areas to include but are not limited to: falls .These evaluations are completed at specific times such as admission, quarterly, annually, and with change in condition .Determining and Implementing Interventions to Reduce Risk, Individual Risk, Once the risk has been identified and evaluated, the interdisciplinary team develops individualized interventions to reduce the risk . Record review of Resident #6's Fall Report dated 08/02/2022 at 11:40 AM revealed . Incident Location: Resident's Room. Person Preparing Report: LPN #4 . Nursing Description: Resident was laying on her left side under the bedside table. Her left arm/hand was under her . Resident Description: Resident stated she was trying to get her device and stood up using the bedside table. That's how she ended on the floor. Immediate Action Taken: Director of Nursing (DON) and nurses assessed the resident . Resident states she hit her head and her hand is hurting . Notified MD of the incident and the order was given to send her out . Injury Type: Abrasion 30) left hand(back) .Other info non-slid socks on. Bedside table without capability to lock to prevent from rolling. Recent admission 07-29-2022 . A record review of Progress Notes for Resident #6 revealed the only note on 08/02/2022 at 11:11 PM . Resident returned to facility per stretcher via Proper Name x2 staff at bedside, able to communicate verbally no c/o pain . L arm splinted and wrapped with ace bandage . DON, Administrator contacted and RP aware . Progress Notes dated 08/03/2022 at 02:14 AM revealed . Diagnosis: Closed nondisplaced fracture of head of left radius due to fall, neuro-checks in process. Record review of Resident#6's Admission Record revealed the facility admitted resident on 07/29/2022 with the diagnoses of [CONDITION(S)], Hypertension, [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. A secondary diagnosis of Displaced Fracture of head of left radius, sequela was added on 08/03/2022. Record review of Resident#6's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/05/2022 revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately cognitively impaired. Section G revealed Resident #6 required one person assistance with transfers, eating, personal hygiene, and toilet use. Section H revealed Resident#6 had occasional incontinence of urine and always incontinent of bowel. Section J, Item J1800 revealed the resident had a fall since admission. Item J1900 revealed the resident had one (1) fall with major injury since admission. A record review of Resident #6's Admission Fall Risk Evaluation dated 07/30/2022 revealed . Category: Moderate Risk, Score: 14.0 INSTRUCTIONS: . If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan . A record review of Resident #6's Fall Risk Evaluation dated 08/02/2022 at 11:40 AM revealed . Score: 7 . Category: Moderate Risk . 1. Reason for Assessment request 1) Recent Falls . 6. Vision Pattern 2. Severely impaired . 11. Gait Analysis 2. Exhibits loss of balance while standing . A record review of Emergency Department Attending Physician Note dated 08/02/2022 at 3:35 PM revealed .Hx (History) of Dementia and [CONDITION(S)]. No obvious trauma . Patient only complaining of left forearm pain . Occult radial head fracture on x-ray . Splint applied . Referral to orthopedic surgery . Diagnosis: 1. Closed nondisplaced fracture of head of left radius, initial encounter 2. Fall, initial encounter . A record review of Radiology Results (08/02/2022) from local hospital revealed X-ray Forearm Left 2 views . Findings: There appears to be a nondisplaced radial head fracture with corresponding elbow joint effusion . A record review of Resident #6's Progress/Admit Note dated 08/03/2022 revealed . Present Illness/Change in Clinical Status: . New left radius fracture . A record review of Resident #6's Fall Report dated 08/24/2022 at 19:50 (7:50 PM) revealed . Incident location: Resident's room, Person Preparing Report: LPN #3, Incident Description: Nursing Description: While making rounds. Certified Nurse Aide (CNA) #4 noticed resident sitting on the floor next to her bed facing the door. Resident Description: Resident stated, I was trying to go to the restroom, and I slipped down. Immediate Action Taken, Description: After the writer checked for bruises, swelling, and deformities, there were none noted. Resident was wearing a brief and skid socks. With help of two assistants, the resident was assisted to bed. Resident was also instructed .to use her call light for assistance. Resident agreed. RP (Responsible Party) and DON notified of no-injury fall . Record review of Resident #6's Fall Risk Evaluation with effective date 08/24/2022 revealed . Score of 11 . Category: Moderate Risk . Record review of Resident #6's Fall Report dated 09/01/2022 at 20:33 (8:33 PM) revealed . Incident location: Resident's Room, Person Preparing Report: LPN #3, Incident Description: Nursing Description: Resident was found on the floor beside her bed. Resident Description: Resident stated that she was trying to go to the restroom and slid down to the floor. Immediate Action Taken: Description: Resident was checked for bruises and skin tears. No redness or swelling was noted. With the help from staff, the resident was assisted back to bed. The resident was wearing skid socks. The call light was placed, and the resident was instructed to use the call light for assistance. Because this was a no injury fall, the DON and family were notified . The facility could not provide a Fall Risk Evaluation after Resident #6 had fallen on 09/01/2022. On 10/25/22 at 08:00 AM, observed Resident #6 lying in the bed. She reported she does not remember falling. No fall mat observed at bedside. Bed observed at regular level and not low to the ground. On 10/25/22 at 08:20 AM, during interview with LPN #4, she explained Resident #6 is blind but cooperative with staff. She reported Resident#6 has had a few falls but does not remember any injuries or resident having a cast or broken bones. She doesn't remember resident having any falls while she was on duty. On 10/25/22 at 10:45 AM, during interview with Registered Nurse (RN) #4, South Supervisor, she explained Resident #6 did have a fall back in August and had a fracture to the arm but stated at first it was reported as a fracture but the follow up x-rays showed no fractures. Explained when Resident #6 fell she was trying to go to the bathroom without assistance. On 10/26/22 at 10:00 AM, observed Resident #6 sitting in the day room, she verbalized she has had [CONDITION(S)] for years but since being at the facility, the [CONDITION(S)] has become worse. Resident #6 verbalized she has had several falls at the facility. She reported she has waited for long periods of time after pushing call light and fell when trying to go to the bathroom by myself. On 10/27/22 at 8:20 AM, during a phone interview with Resident #6's Resident Representative (RR), daughter, she stated her mother has been in the facility since the end of July. She revealed her mother does get confused at times but is mostly coherent about herself and her surroundings. She reported her mom still does know when she must go to the bathroom but may have accidents and can use the call light for assistance. She explained sometimes when she has been visiting with her mother it does take longer for call lights to be answered. She reported her mother is very independent and some of the falls could be her mother's fault because she will use call light but after so long will try to get up on her own. She explained the facility did call her when her mother had falls and was sent to the hospital. She explained she did not go to the hospital when her mom fell but she did talk to the doctor. The facility notified her, her mother was either getting out of the bed or wheelchair, was alone and going to the bathroom. Her mom told the facility initially she hit her head but while at the hospital she told them she did not and at the time she was coherent and not disoriented so they believed her. A cast was placed on left arm due to a fracture for a couple of weeks. She went with her mother to the ortho follow-up at the Orthopedics' office and the cast was removed due to the fracture was healing. She explained her mother's [CONDITION(S)] has been a slow process. Fifteen years ago, one eye went blind and then the progression was to full [CONDITION(S)] about three (3) to five (5) years ago. She explained her mother still knows most days, but her confusion comes and goes. On 10/27/2022 at 10:15 AM, during an interview with DON and the Interim Administrator, the Interim Administrator explained the incident report was the facility's investigation and the incident with injury was not reported due to the fall report explained Resident #6 told them what happened. He confirmed the fall was unwitnessed and Resident #6 is blind and has confusion at times. Both the Interim Administrator and DON confirmed the charge cart nurse is responsible for completing the fall report and chart in the progress notes. The Interim Administrator explained the resident had tried to stand up by using the bedside table and the bedside table could not lock to prevent from rolling but there has been no documentation or interventions for new bedside table. Resident#6 was sent to hospital for evaluation. Resident #6 did have an injury at the time of the fall, an abrasion to the back of her left hand. She confirmed the resident can go to the bathroom with assistance and is capable to use call lights. DON reported her expectations if a resident is at moderate risk, including Resident #6 being blind, a fall mat should be place at bedside, she confirmed resident does not have a fall mat. Resident#6 should be placed closed to nurse's station, a fall risk assessment is completed after each fall, care plans are expected to be updated after each fall with new interventions to prevent further falls. DON confirmed new interventions were not done after Resident #6 had falls. The nurse only completed the fall report and there is no other documentation regarding all, or any interventions put in place to prevent another fall. The Administrator explained more interventions should have been put in place. The DON confirmed Resident #6 is not close to the nurse station but instead like five (5) or six (6) doors down. On 10/27/22 at 10:55 AM, during a phone interview with LPN #4, she reported the best she can remember on 08/02/2022 it was an aide or housekeeper who yelled and told the nurses that Resident #6 was on the floor. She explained she and all nurses including the DON and wound care nurse LPN #5 went to assess the resident. She can't remember if Resident #6 had any injuries. On 10/27/22 at 11:10 AM, during an interview with the MDS/Care Plan Nurse, LPN#1, she confirmed the only new intervention to prevent further falls for Resident#6 after the fall on 08/02/2022 was to continue with the at risk fall care plan and she confirmed that was not appropriate interventions to prevent Resident #6 from having other falls. On 10/28/2022 at 08:30 AM, during an interview with CNA #3, she was working on 08/02/22 when Resident #6 fell . She was walking down the hall and was Resident #6 on the floor. She called for help and three nurses came including the DON, LPN #4, and Wound Care Nurse LPN #5 to assess Resident#6. Resident#6 was here at the facility the next day with her left arm wrapped up. The Facility provided an acceptable Removal Plan 10/27/2022 which included: On 10/27/2022 at 2:28 PM the Stage Agency notified the Administrator of Immediate Jeopardy with substandard quality of care, failed to put in place appropriate interventions to prevent an incident of an unwitnessed fall on 08/02/2022 that resulted in a closed non-displaced fracture of head of left radius for Resident #6 and resident had further falls. Corrective Actions: 1. On 10/27/2022 at 3:00 PM the DON and Administrator began an investigation regarding the unwitnessed fall for Resident #6 that occurred on 08/02/2022. 2. On 10/27/2022 at 3:15 pm an Emergency Quality Assurance and Performance Improvement Committee meeting was held regarding the unwitnessed fall for Resident #6 that occurred on 08/02/2022. In attendance were the Acting Administrator, Director of Nursing, Regional Nurse Consultant, Medical Director, Social Service Director, Minimum Data Set Nurse (MDS) #1, MDS Nurse #2, Business Office Manager, Dietary Manager, Housekeeping Supervisor, Registered Nurse #1, Life Connections Coordinator, Administrator and LPN # 2. The Committee reviewed the unwitnessed fall for Resident #6 that occurred on 08/02/2022 and the Immediate Jeopardies cited by the State Agency on 10/27/2022 and the following recommendations were discussed: - Policy regarding incidents and accidents was reviewed with no changes recommended. - An investigation regarding the incident to be completed by the DON and Acting Administrator on 10/27/2022. - The incident will be reported by the Acting Administrator to the State Agency on 10/27/2022. - The DON will assign nurses to complete fall evaluations for 100% of residents on 10/27/2022. - The MDS Nurses will revise all resident care plans based on fall evaluations completed on 10/27/2022 and the care plan for Resident #6 to include falls that occurred on 08/24/2022 and 09/01/2022. - The Acting Administrator and DON will in-service all nursing staff regarding falls, interventions for falls, care plans, completing investigations and reporting. All nursing staff will receive in-service regarding falls, interventions for falls, care plans, completing investigations and reporting prior to returning to work. - The Regional Nurse Consultant will in-service the DON and Administrator regarding reporting and investigations. 3. On 10/27/2022 at 3:20 pm, the Acting Administrator reported the unwitnessed fall for Resident #6 that resulted in a closed non-displaced fracture of the head of the left radius on 08/02/2022 to the State Agency. 4. On 10/27/2022 at 3:30 pm, Minimum Data Set (MDS) Nurse #1 revised the Plan of Care for Resident #6 to include falls that occurred on 08/24/2022 and 09/01/2022 and updated interventions to prevent falls. 5. On 10/27/2022 beginning at 3:30 pm, Registered Nurse (RN) #1, LPN #2, LPN #3 and LPN #4 reevaluated all residents for fall risk and MDS Nurse #1 and #2 revised all resident care plans as indicated. 6. On 10/27/2022 at 3:45 pm, the Regional Nurse Consultant provided in-service training for the Administrator and Director of Nursing (DON) regarding reporting requirements and completing an investigation. 7. On 10/27/2022 at 3:30pm, the DON and Acting Administrator began in-servicing all nursing staff regarding falls, interventions for falls, care plans, completing investigations and reporting. All nursing staff will receive in-service regarding falls, interventions for falls, care plans, completing investigations and reporting prior to returning to work. 8. The investigation of the unwitnessed fall for Resident #6 that occurred on 08/02/2022 was completed on 10/27/2022 at 7:00 pm. 9. The facility alleges compliance on 10/28/2022. The facility alleges that all corrective actions to remove the IJ were completed on 10/27/2022 and the IJ was removed on 10/28/2022. The facility alleges that all corrective actions were completed on 10/27/2022 and the IJ was removed as of 10/28/2022. The SSA validated the facility's Corrective Actions on 10/28/2022: 1. The SSA validated through interviews and record review on 10/27/2022 the DON and Interim Administrator initiated an investigation of Resident #6's unwitnessed fall. 2. The SSA validated through interviews and record review on 10/27/2022 an Emergency Quality Assurance and Performance Improvement Committee meeting with all required members in attendance. Policy was reviewed, the DON and Interim Administrator to complete the investigation of the incident. The Interim Administrator reported the incident to the State Agency. Nurses to complete fall evaluation for 100% of residents on 10/27/2022. The MDS nurses will revise all resident care plans based on fall evaluations completed on 10/27/2022 and the care plan for Resident #6 to include falls that occurred on 08/24/2022 and 09/01/2022. The Interim Administrator and DON completed in-service for all nursing staff regarding falls, interventions for falls, care plans, completing investigations and reporting. All nursing staff will receive in-service regarding falls, interventions for falls, care plans, completing investigations and reporting prior to returning to work. The Regional Nurse Consultant in-serviced the DON and Administrator regarding reporting and investigations. 3. The SSA validated through interview with Interim Administrator the unwitnessed fall for Resident #6 that resulted in a closed non-displaced fracture of the head of the left radius, he confirmed he reported through a phone call to the State Agency. 4. The SSA validated through interviews with the MDS Nurse and record review Resident #6's care plan was revised to include falls 08/24/2022 and 09/01/2022 and updated interventions to prevent falls. 5. The SSA validated through interviews and record reviews all 100% of the residents reevaluated for fall risk and all care plans revised as needed. 6. The SSA validated through interviews the Nurse Consultant completed in-service training for the Interim Administrator and DON on reporting requirements and completing an investigation. 7. The SSA validated through staff interviews from CNAs and Nurses on both shifts the DON and Interim Administrator in-serviced them regarding falls, care plans, interventions for falls, care plans completing investigations, and reporting. 8. The SSA validated through interview and record review the DON completed the investigation of Resident #6's unwitnessed fall that occurred on 08/02/2022. 9. The SSA validated through interviews and record review no nursing staff may return to work until they have received this in-service training. The SSA validated that all corrective actions were completed on 10/27/2022 and the IJ was removed as of 10/28/2022.

Based on interviews, record review, and facility policy review the facility failed to revise a fall care plan following a fall with a major injury and two (2) additional falls for one (1) of three (3) residents reviewed for falls, Resident #6. The facility's failure to have a communication system in place with the interdisciplinary team and a system in place to ensure compliance of revising care plans with appropriate interventions following a fall placed this resident and other residents at risk for a fall in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 08/02/2022, when Resident #6 had an unwitnessed fall with fracture and the only new intervention put in place was to continue with the current fall care plan. Resident #6 had two additional unwitnessed falls which were not addressed on the care plan. On 10/27/2022 at 2:28 PM, the State Survey Agency (SSA) notified the facility's Interim Administrator and Nurse Consultant of the IJ and SQC. The facility submitted an acceptable Removal Plan on 10/27/2022, in which the facility alleged all corrective actions were completed on 10/27/2022, and the IJ removed on 10/28/2022. The SSA validated the Removal Plan and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR (s) 483.21(b)(2)-F657 Care Plan Timing and Revision was lowered from a J to a scope and severity of a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's, Care Plan Committee/Team policy, undated, revealed It is the policy of the facility for the Care Plan Committee/Team .Procedure .3. Care plan will be modified as needed to reflect residents' current status and needs. Review of the facility's, Care Plan-Comprehensive policy, undated, revealed It is the policy of this facility to develop the comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. Procedure . 2. The comprehensive care plan had been designed to: . b. Incorporate risk factors associated with identified problems . 4. Care plans are revised as changes in the resident's condition dictates . A record review of the facility's report Incidents by Incident Type from 05/01/2022 thru 10/25/2022 revealed Resident #6 had 3 falls since admission on 07/29/2022. Falls were on 08/02/2022 with abrasion, 08/24/2022 and 09/01/2022 with no injury listed. All falls were in resident's room while ambulating without assist. A record review of Progress Notes for Resident #6 revealed the only note on 08/02/2022 at 11:11 PM . Resident returned to facility per stretcher via Proper Name x 2 (times two) staff at bedside, able to communicate verbally no c/o (complaint of) pain . L (left) arm splinted and wrapped with ace bandage . DON (Director of Nursing), Administrator contacted and RP (Responsible Party) aware . Progress Notes dated 08/03/2022 at 02:14 AM revealed . Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #6's Comprehensive Care Plan revealed a care plan, undated, for Focus I am High Risk for falls related to gait/balance problems, incontinence, vision/hearing problems with the interventions Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Pt (Physical therapy) evaluates and treat as ordered or PRN (as needed). Resident #6 also had an undated care plan for Focus I had an actual fall with injury on 08/02/2022 with the interventions Check range of motion (Specify #) times daily. Continue interventions on the at-risk plan. Neuro-checks. Sent to hospital for evaluation and treatment. Vital signs obtained. Resident's other falls on 08/24/2022 and 09/01/2022 were not care planned. Resident #6 had an undated care plan for I have an Activities of Daily Living self-care performance deficit related to Disease process [CONDITION(S)] of one eye, and displace fracture of head of left radius with the interventions to include . Transfer: stand to pivot supervision x 1 assist . On 10/25/22 at 11:00 AM, during an interview with Certified Nurse Aide (CNA) #5, when asked how you know how to care for residents, she explained by following resident's care plan in the Kiosk. On 10/26/22 at 2:15 PM, during an interview with LPN#1, she explained she has been doing the Minimum Data Set (MDS) since August 2022. She reported the facility uses working care plans and update the care plans as new concerns come up. All the resident's care plans are currently in the computer under resident's care plan records and there are no care plans in the resident's chart. On 10/27/2022 at 10:15 AM, during an interview with the Director of Nursing (DON) and the Interim Administrator, the Administrator stated Resident #6 had tried to stand up by using the bedside table and the bedside table could not lock to prevent from rolling. There has been no interventions for a new bedside table. Care plans are expected to be updated after each fall with new interventions to prevent further falls. The DON confirmed that was not done after Resident #6 had falls. When the DON was asked based on the information being communicated do you see any system failures and she replied yes. The DON explained there was miscommunication regarding the fall and the injury, and everyone should have been made aware of the injury and this will need to be investigated further by Performance Improvement. On 10/27/22 at 11:00 AM, during an interview with Registered Nurse (RN) #4, South Hall Supervisor, stated during stand up meetings the MDS nurse should be notified of falls. The team will come up with care plan interventions that fits the resident. On 10/27/22 at 11:10 AM, during an interview with the Minimum Data Set (MDS)/ Care Plan Nurse, LPN#1, she explained the team will discuss the fall in stand-up meeting and come up with new interventions and she will even get therapy involved if needed. She reported the fall care plan should start on the floor by the cart nurse and the immediate interventions should be put in place. The facility uses working care plan and all care plans are listed and updated with new interventions after each fall. She confirmed the only new intervention to prevent further falls for Resident #6 after the fall on 08/02/2022 was to continue with the current fall care plan and she confirmed that was not appropriate interventions to prevent Resident #6 from having other falls and the other falls have not been care planned. On 10/28/2022 at 08:30 AM, during an interview with CNA #3, reported she knows how to care for residents by looking at the resident's plan of care and this can be assessed through the Kiosk. On 10/28/2022 at 1:30 PM, during a phone interview with CNA#4, she explained care is provided for each resident depending on the resident's needs and their care plan. All care plans are assessed through the Kiosk. Record review of Resident #6's Admission Record revealed the facility admitted resident on 07/29/2022 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Facility provided an acceptable Removal Plan, which included: On 10/27/2022 at 2:28 PM the Stage Agency notified the Administrator of Immediate Jeopardy with substandard quality of care, failed to put in place appropriate interventions and revise Resident #6's care plan to prevent an incident of an unwitnessed fall on 08/02/2022 that resulted in a closed non-displaced fracture of head of left radius for Resident #6 and resident had further falls. Corrective Actions: 1. On 10/27/2022 at 3:00 PM the DON and Administrator began an investigation regarding the unwitnessed fall for Resident #6 that occurred on 08/02/2022. 2. On 10/27/2022 at 3:15 pm an Emergency Quality Assurance and Performance Improvement Committee meeting was held regarding the unwitnessed fall for Resident #6 that occurred on 08/02/2022. In attendance were the Acting Administrator, Director of Nursing, Regional Nurse Consultant, Medical Director, Social Service Director, Minimum Data Set Nurse (MDS) #1, MDS Nurse #2, Business Office Manager, Dietary Manager, Housekeeping Supervisor, Registered Nurse #1, Life Connections Coordinator, Administrator and LPN # 2. The Committee reviewed the unwitnessed fall for Resident #6 that occurred on 08/02/2022 and the Immediate Jeopardies cited by the State Agency on 10/27/2022 and the following recommendations were discussed: - Policy regarding incidents and accidents was reviewed with no changes recommended. - An investigation regarding the incident to be completed by the DON and Acting Administrator on 10/27/2022. - The incident will be reported by the Acting Administrator to the State Agency on 10/27/2022. - The DON will assign nurses to complete fall evaluations for 100% of residents on 10/27/2022. - The MDS Nurses will revise all resident care plans based on fall evaluations completed on 10/27/2022 and the care plan for Resident #6 to include falls that occurred on 08/24/2022 and 09/01/2022. - The Acting Administrator and DON will in-service all nursing staff regarding falls, interventions for falls, care plans, completing investigations and reporting. All nursing staff will receive in-service regarding falls, interventions for falls, care plans, completing investigations and reporting prior to returning to work. - The Regional Nurse Consultant will in-service the DON and Administrator regarding reporting and investigations. 3. On 10/27/2022 at 3:20 pm, the Acting Administrator reported the unwitnessed fall for Resident #6 that resulted in a closed non-displaced fracture of the head of the left radius on 08/02/2022 to the State Agency. 4. On 10/27/2022 at 3:30 pm, Minimum Data Set (MDS) Nurse #1 revised the Plan of Care for Resident #6 to include falls that occurred on 08/24/2022 and 09/01/2022 and updated interventions to prevent falls. 5. On 10/27/2022 beginning at 3:30 pm, Registered Nurse (RN) #1, LPN #2, LPN #3 and LPN #4 reevaluated all residents for fall risk and MDS Nurse #1 and #2 revised all resident care plans as indicated. 6. On 10/27/2022 at 3:45 pm, the Regional Nurse Consultant provided in-service training for the Administrator and Director of Nursing (DON) regarding reporting requirements and completing an investigation. 7. On 10/27/2022 at 3:30 pm, the DON and Acting Administrator began in-servicing all nursing staff regarding falls, interventions for falls, care plans, completing investigations and reporting. All nursing staff will receive in-service regarding falls, interventions for falls, care plans, completing investigations and reporting prior to returning to work. 8. The investigation of the unwitnessed fall for Resident #6 that occurred on 08/02/2022 was completed on 10/27/2022 at 7:00 pm. The facility alleges compliance on 10/28/2022. The facility alleges that all corrective actions to remove the IJ were completed on 10/27/2022 and the IJ was removed on 10/28/2022. The SSA validated the facility's Corrective Actions: 1. The SSA validated through interviews and record review on 10/27/2022 the DON and Interim Administrator initiated an investigation of Resident #6's unwitnessed fall. 2. The SSA validated through interviews and record review on 10/27/2022 an Emergency Quality Assurance and Performance Improvement Committee meeting with all required members in attendance. Policy was reviewed, the DON and Interim Administrator to complete the investigation of the incident. The Interim Administrator reported the incident to the State Agency. Nurses to complete fall evaluation for 100% of residents on 10/27/2022. The MDS nurses will revise all resident care plans based on fall evaluations completed on 10/27/2022 and the care plan for Resident #6 to include falls that occurred on 08/24/2022 and 09/01/2022. The Interim Administrator and DON completed in-service for all nursing staff regarding falls, interventions for falls, care plans, completing investigations and reporting. All nursing staff will receive in-service regarding falls, interventions for falls, care plans, completing investigations and reporting prior to returning to work. The Regional Nurse Consultant in-serviced the DON and Administrator regarding reporting and investigations. 3. The SSA validated through interview with Interim Administrator the unwitnessed fall for Resident #6 that resulted in a closed non-displaced fracture of the head of the left radius, he confirmed he reported through a phone call to the State Agency. 4. The SSA validated through interviews with the MDS Nurse and record review Resident #6's care plan was revised to include falls 08/24/2022 and 09/01/2022 and updated interventions to prevent falls. 5. The SSA validated through interviews and record reviews all 100% of the residents reevaluated for fall risk and all care plans revised as needed. 6. The SSA validated through interviews the Nurse Consultant completed in-service training for the Interim Administrator and DON on reporting requirements and completing an investigation. 7. The SSA validated through staff interviews from CNAs and Nurses on both shifts the DON and Interim Administrator in-serviced them regarding falls, care plans, interventions for falls, care plans completing investigations, and reporting. The SSA validated through interviews and record review no nursing staff can return to work until they have received this in-service training. 8. The SSA validated through interview and record review the DON completed the investigation of Resident #6's unwitnessed fall that occurred on 08/02/2022. The SSA validated that all corrective actions were completed on 10/27/2022 and the IJ was removed as of 10/28/2022.

Based on observation, staff interviews, record reviews and facility policy review the facility failed to follow the comprehensive care plan by not providing pain medication prior to wound care and not securing a foley catheter strap to the leg for two (2) of six (6) care plans reviewed, Resident #19. Findings Include: Record review of the facility's Comprehensive Care Plans date?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 objectives and timeframe's to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Record review of the facility's Comprehensive Care Plan, revised 03/01/21, revealed Resident #19 has an indwelling catheter related to pressure ulcer on her sacrum. Resident #19 is at risk for complications associated with indwelling catheter, such as infections, trauma. Interventions: staff to secure the catheter tube so you do not pull or move the catheter. Record review of the facility's Comprehensive Care Plan, revised 1/21/21, revealed the focus, I am at risk for pain r/t (related to) pressure injury/ulcer . The interventions reveal to Administer medications as per orders; and anticipate my need for pain relief and respond to any complaint of pain. During an observation on 07/08/21 at 09:24 AM, of catheter care with Certified Nursing Assistant (CNA) #1 revealed Resident #19's foley catheter leg strap was not secured to the leg. The tubing was connected to the bed frame and was tight, tugging on the meatus. Observation on 07/08/21 at 02:18 PM, of wound care to the sacrum, right buttocks and left buttocks revealed Resident #19's wounds were debrided by the wound doctor. During the debridement, the resident continued with a low constant moan. The State Survey Agency (SSA) asked if the resident received anyting for pain prior to debridement. Licensed Practical Nurse (LPN) #3 said yes, the residents are medicated prior to wound care every Thursday. Observation of the resident's foley catheter strap not secured to the leg. The glue to the strap was gone and would not stick. The tubing was connected to the bed frame. The tubing was tight, tugging on the meatus. Interview on 07/08/21 at 02:20 PM with LPN #3 said the floor nurses are responsible for medicating the residents every Thursday when the Wound Doctor visit. LPN #3 also confirmed during wound care the resident's catheter strap was not secured to the leg. The glue on the strap would not stick to the leg. LPN #3 said the CNA and floor nurse that is assigned to the resident should have changed the strap. On 07/08/21 at 02:30 PM, record review of the facility's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/08/21 at 02:30 PM, with LPN #3, she said reminded the floor nurse that the Wound Doctor was coming today and to make sure the residents were medicated. LPN 3 confirmed Resident #19 was not medicated prior to the doctor [MEDICATION(S)] the wound on 7/8/21. LPN #3 said she did not know why the floor nurse did not medicate Resident #19. In an interview on 07/08/21 at 02:31 PM, with LPN #4 confirmed she failed to follow the care plan by not medicating Resident #19 prior to wound care and not securing the residents catheter strap to her leg. On 07/08/21 at 02:45 PM, during an interview with the Interim Director of Nursing (IDON) revealed the floor nurses were recently in-serviceed on providing pain medication prior to wound care. The DON confirmed the staff did not follow the care plan by not medicating th resident and securing the catheter strap. The DON said this caused the resident unnecessary pain by not giving her medication for pain prior to [MEDICATION(S)] the wound. During an interview on 07/8/21 at 03:58 PM, with LPN #5, Minimum Data Set/Care Plan Nurse, revealed she expected the staff to follow the care plan. LPN #5 said LPN # 4 should have medicated the resident before the doctor debrided her wounds and when the resident is in pain. The staff should anticipate the residents pain because she cannot tell the staff when she is in pain. LPN #5 also said she expect the facility to follow the care plan by securing the residents catheter to prevent trauma or infection.

Based on observation, staff interviews, record reviews and facility policy review the facility failed to administer pain medication prior to the surgical debridement of wounds resulting in the resident experiencing pain for one (1) of six (6) wound care observations. Resident #19. Findings Include: Review of the facility's Pain Management policy, dated January 31, 2005 revealed: Every resident has the right to be as comfortable and pain free as possible. The facility has an ongoing commitment to pain recognition and management. Pain control is essential to the continued quality and dignity of life as well as the maintenance of each resident's current level of function. The licensed nurse will screen the resident for pain a.) on admission/readmission, b.) with each quarterly, annual and or significant change of the Minimum Data Set (MDS) assessment and c) as needed with condition change. The resident's attending physician will be informed when appropriate, and orders for [MEDICATION(S)] will be obtained to promote resident comfort. Pain intensity will be measured with appropriate measurement tool. A pain scale do 0-10 (0=no pain, 10- worst pain) will be utilized for adult patient. If the resident cannot understand or is unwilling to use the scale, the following tools may be utilized such as, face pain scale (smile-frown) and residents change in behavior will be assessed. Any resident who request an as needed (PRN) pain medication will have their pain assessed using a scale 1-10 and recorded on the Medication Administration Record (MAR). Reassessment of the resident's pain will be performed within 1 hour after any PRN method of pain relief is used to determine the effectiveness pf the method. The assessment will be recorded on the PRN Medication Administration Record. Record review of the facility's Order Summary Report dated July 8, 2021 revealed the resident is ordered Acetaminophen 325 milligrams (mg) via peg (percutaneous endoscopic gastrostomy) tube every 4 hours (pain), [MEDICATION(S)] 5-325 mg ([MEDICATION(S)]/Acetaminophen) give one tablet via peg tube every 6 hours as needed (pain). Record review of the facility's MDS Pain interview, dated 6/25/21, 4/28/21, 4/19/21, 3/30/21 and 1/18/21 revealed Resident #19 was assessed for pain and pain was identified on each evaluation. During an observation on 07/08/21 at 02:18 PM, of Resident #19 wound care to the sacrum, right buttocks and left buttocks revealed License Practical Nurse (LPN) #3 removed the bandage. The Wound Doctor measured the wound to the sacrum, stage 4. measured at 6.5 centimeters (cm) length x 4.5 cm width x 4.7cm depth. The wound bed had 25 percent of yellow slough. The Wound Doctor debrided the wound. Resident #19 noted with a constant low moan. The State Survey Agency (SSA) ask if the resident was medicated prior to treatment. LPN #3 said yes, Resident #19 was medicated prior to treatment. LPN #3 cleansed the wound with wound cleanser, applied calcium alginate with silver and covered with border gauze. Resident #19 continued with a constant low moan. The doctor measured the left buttocks at 6.5 cm length x 5.4 cm width x 0.1 cm depth and debrided the wound. Resident #19 continued with constant low moan. LPN #3 cleansed the wound with wound cleanser, applied Santyl to eschar and covered the wound with bordered gauze. The Wound Doctor measured the right buttocks at 6.5 cm length x 5 cm width x 0.1 cm depth and debrided the wound. LPN #3 cleansed the wound with normal saline, applied santyl to the eschar and covered with border gauze. Resident #19 continued with a constant low moan. During 07/08/21 02:20 PM, interview with LPN #3 said the floor nurses are responsible for medicating the residents every Thursday when the wound doctor visit. Record review of the facility's Medication Administration Record (MAR) for 7/8/21 with LPN #3 after Resident #19's wound care revealed Resident #19 did not receive pain medication prior to the doctor [MEDICATION(S)] the residents wounds. Record Review of the facility's Controlled Drug Receipt/Record/Disposition (narcotic log) form revealed Resident #19's [MEDICATION(S)]/Acetaminophen 5-325 mg was signed out 7/8/21 at 15:10 (3:10 PM) after the resident wounds were debrided. Record review of the July 2021 MAR from July 1 through July 8 revealed Resident #19 experienced pain at an intesity of 8-10 on a scale of 1-10 for three (3) of the eight (8) days reviewed, requiring the adminstration of [MEDICATION(S)] 5-325 mg. Record review of the facility's Nurses Notes, dated 7/2/21 revealed Resident #19's wounds were debrided by the Wound Doctor. Review of the MAR and Narcotic Log revealed Resident #19 did not receive pain medication before the doctor debrided the wound on 7/2/21. Interview on 7/8/21 at 2:30 PM, with LPN #3 revealed she went in and talked to Resident #19. LPN #3 informed the resident that the doctor would be coming in today to look at her wounds and the bandages would be changed. The nurse asked the resident if she needed something for pain. The resident said yes. LPN #3 said she remind LPN #4 the doctor was coming today to look at the resident's wound. LPN #3 ask LPN #4 to give Resident #19 something for pain prior to wound care. LPN #3 confirmed Resident #19 was not medicated prior to the doctor [MEDICATION(S)] the wound. LPN #3 said she doesn't know why LPN #4 did not medicate Resident #19. During an interview on 07/08/21 at 02:31PM, with LPN #4 revealed she was responsible for medicating Resident #19 prior to the wound doctor providing wound care. LPN #4 confirmed she got busy and forgot to give Resident #19 pain medication prior to wound care. LPN #4 said she did not know the doctor was [MEDICATION(S)] the resident today. LPN #4 said she needed to communicate better with the wound doctor and nurse. LPN #4 confirmed because Resident #19 did not receive pain medication caused the resident unnecessary pain when the Wound Doctor debrided the wounds. During an interview on 07/08/21 at 02:45 PM, with the Interim Director of Nursing (IDON), the IDON said the floor nurses were recently in-serviced on providing pain medication prior to wound care. The IDON said LPN #4 was not present for this in-service. The IDON confirmed this caused Resident #19 unnecessary pain by not giving her pain medication prior to [MEDICATION(S)] the wound. A review of Resident #19's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/29/21, revealed Resident #19 had a Brief Interview of Mental Status (BIMS) score of 2, which indicated the resident is severely cognitively impaired.

Based on observation, record review and staff interview, the facility failed to provide enteral (tube) feedings for four (4) of 4 residents on the evening of 11/09/2020, and the morning of 11/10/2020, (Residents #1, #2, #3, and #5), failed to provide enteral feedings at the prescribed rate for three (3) of 4 residents, (Residents #1, #2, and #3), failed to follow Registered Dietician (RD) recommendations for significant weight loss and pressure ulcer healing for two (2) of 4 residents (Residents #1 and #2), failed to obtain weight orders as a measure to assess nutritional status for 3 of 4 residents reviewed (Residents #1, #2, and #5), failed to date, time and initial enteral feedings when they were administered for 3 of 4 residents (Residents #1, #2, and #3), and failed to obtain an order for [REDACTED]. The facility's failure to provide a licensed nurse on the 3-11 shift on 11/09/2020, and again on the 11-7 shift on 11/12/2020, to provide enteral feedings, hydration and nourishment, placed the residents at risk, and in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 11/09/2020, as a result of the facility's failure to provide a licensed nurse to administer enteral feedings which resulted in 4 residents not receiving enteral feedings per physicians orders, with two (2) of those residents currently experiencing significant weight loss. On 11/13/2020, at 1:20 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The IJ and SQC existed at: CFR(s)483.25(g)(1)(2) - Nutrition/Hydration Status Maintenance (F692) - Scope and Severity - K The facility submitted a credible Removal Plan on 11/16/2020 at 4:00 PM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of 11/16/2020. The SA validated the Removal Plan on 11/18/2020 and determined the IJ was removed prior to exit. Therefore the scope and severity for CFR(s)483.25(g)(1)(2) - Nutrition/Hydration Status Maintenance (F692), was lowered from an K level of scope and severity to a E level, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy titled, Enteral Nutrition Policy dated 5/10/2013, revealed, It is the policy of this facility that a resident that is fed by enteral means receives the appropriate treatment and services to prevent complications associated with enteral feeding and to restore normal eating if possible. Evaluations/Assessments: The Registered Dietician evaluates residents receiving enteral nutrition and makes nutritional recommendations upon admission. The RD periodically evaluates the resident thereafter. Administration: The medical order should be verified prior to administration. The medical order should include the type of formula, method of administration, route, rate, and calorie content. The nurse should label the feeding container with the rate, type of feeding if needed, date and time hung, and the nurses initials .Only licensed nurses may administer fluids and medications into the tube. Enteral Feedings - Safety Precautions Change administration sets for open-system enteral feedings at least every 24 hours. Review of facility policy titled, Weighing and Measuring the Resident dated 8/25/2014, revealed, Purpose: the purposes of this procedure are to determine the resident's weight and height to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident .Weight is usually measured upon admission and monthly during the resident's stay. Review of the facility's policy titled, Weight Loss Prevention, dated 12/27/2017, revealed, It is the policy of the facility to prevent weight loss if avoidable and if unplanned .Residents that are at risk nutritionally should be placed on weekly weights as indicated. Review of the facility's policy titled, Weights: Obtaining and Documenting Policy dated 12/27/2017 revealed, Each resident will be weighed monthly or as indicated by their condition unless contraindicated .Timing of Weights: 1. Daily: daily weights should be done if ordered by the physician. 2. Weekly: Admissions, Readmissions and residents considered at high risk for weight loss. 3. Monthly: Resident not being weighed daily or weekly are to be weighed monthly, unless contraindicated .Nursing staff will obtain monthly weights by the 10th of the month . Resident #1: During an observation on 11/11/2020, at 10:20 PM, Resident #1's enteral feeding was noted to be running at 50 ml(milliliter)/hr(hour). An observation on 11/12/2020, at 10:15 AM, revealed Resident #1's enteral feeding to be running at 50 ml/hr. On 11/12/2020 at 3:00 PM, accompanied by the Administrator and the Director of Nursing (DON), who verified Resident #1's enteral feeding was running at 50 ml/hr, and the feeding bag was not dated, timed, or initialed, and neither was the water bag dated, timed, or initialed. Review of Resident #1's Order Summary Report dated 11/12/2020 revealed the following orders: Enteral Feed Order - every shift - [MEDICATION NAME] 1.5 @ 50 ml(milliliter)/hr(hour) X 22 hours (8 am - 6 am). Resident #1 has no current order for a monthly weight. Review of Resident #1's CES Dietary Enteral assessment dated [DATE], revealed, a weight of 139 lbs at 60 days = 7.7% significant weight loss, a weight of 151 lbs at 90 days = 17% significant weight loss, and a weight of 147 lbs at 180 days = 13% significant weight loss. Tolerating TF (tube feeding) well. Noted with significant wt (weight) loss. Will recommend to increase rate to prevent further wt loss. Rec: Increase TF rate to [MEDICATION NAME] 1.5 @ 60 ml/hr X 22 hrs d/t significant wt loss. Review of Resident #1's medical record revealed his weight following the Registered Dietitian (RD) recommendations to be 131.4 lbs.(pounds) on 09/07/2020, and 126.0 lbs on 10/01/2020, a loss of 5.4 lbs. Attempted to reach the RD for interview, but she was not available. During interview with the DON on 11/13/2020, at 11:37 AM, she verified the rate should have been increased to 60 ml/hr on 08/21/2020, and Resident #1 does not have a current order for a monthly weight. Review of Resident #1's medical record revealed, he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 99, making him non-interviewable. He is totally dependant on one to two staff for all of his daily needs. He has a feeding tube and requires total assistance of one staff member for his enteral feeding. Resident # 2 On 11/11/2020, at 10:10 PM, Resident #2's enteral feeding was observed to be off, and pushed to the side, near the wall. The display screen was dark, cracked, and did not light up when moved. The tubing was not attached to Resident #2, and the bag of feeding and water hanging on the pole were not dated, timed or initialed by a nurse. On 11/12/2020 at 10:15 AM, Resident #2's enteral feeding was observed to be off, and pushed to the side, near the wall. The display was still dark, cracked and did not light up. The tubing was not attached to Resident #2, and the bag of feeding and water hanging on the pole, appeared to be the same feeding bag and water bag from the night before, still undated, no time or initials from the nurse on them. On 11/12/2020 at 1:05 PM, Resident #2's enteral feeding was observed to be off, and pushed to the side, near the wall. The display was still dark, cracked and did not light up. The tubing was not attached to Resident #2, and the bag of feeding and water hanging on the pole, appeared to be the same feeding bag and water bag from the night before, still undated, no time or initials from the nurse on them. On 11/12/2020 at 3:00 PM, during rounds with the Administrator and DON, the SA observed the pump on and running at 55 cubic centimeters (cc)/hour(hr). There was less feeding in the enteral bag, and it was still not dated, timed or initialed by the nurse. Licensed Practical Nurse (LPN) #3 was in the room at the time, and stated she had started the feeding on her afternoon round right after lunchtime. She stated she had noticed his feeding was not running and hooked it up. When asked if she had used the feeding that was hanging or started a new bag, she stated she used what was hooked up at the time, and the night shift nurse must have forgotten to date and time it. The nurse hooked up an enteral feeding that had potentially been hanging there since prior to 10:10 PM Review of Resident #2's CES Dietary Enteral assessment dated [DATE], revealed, Formula order: Diabetisource 65 cc/hr continuous. TF meeting exclusive enteral nutrition (EEN) and fluid needs. Review of Resident #2's CES Dietary Enteral assessment dated [DATE] revealed, Formula order: Diabetisource 65 cc/hr continuous. Tube feeding meeting EEN. Review of Resident #2's Consultant RD Note dated 09/04/2020 revealed, Weight Review:CBW (Current Body Weight) 131 lbs, 10.9% significant wt loss at 180 days. TF: Diabetisource @ 65 cc/hr .Recommendations: Obtain a reweight to verify significant loss. A reweight was obtained on 9/07/2020 and was less at 124.8 lbs. Review of Resident #2's CES Dietary Quarterly Evaluation Update dated 10/21/2020 revealed, Diet/Texture: Diabetisource at 55 cc/hr continuously .Stage IV pressure ulcer to Sacrum 3 x 2 x 0.7 cm. Quarterly Enteral/Wound Review: .Wt gain desired. Resident has a stage IV to Sacrum, and area to Right side of Great toe .TF below EEN to promote wound healing. Will increase TF and add supplements for healing. Recs: 1) Discontinue (D/C) Diabetisource @ 55 cc/hr continuously. 2) Provide Diabetisource @ 65 cc/hr continuously. 3) Continue flushes. 4)MVI (Multivitamin) with minerals daily. 5) Juven 1 pkt BID (twice a day) mixed with routine flush times (X) 30 days. Dietician looked at current order at 55 cc/hr and made a recommendation to increase it to 65 cc/hr. This is the amount the feeding should have been running at since February 2020. Review of Resident #2's Order Summary Report dated 11/12/2020 revealed an Enteral Feed Order - every shift - Diabetisource 55 cc/hr continuous via peg tube, Flush with 150 ml amount every four hours, Record total feeding intake Q (every) shift, and record total H2O (water) intake Q shift. There is no order for monthly weights, there was no order for Juven 1 pkt BID mixed with routine flushes x 30 days, there was no order for MVI with minerals daily. None of the dietary recommendations were implemented for Resident #2 to give nutritional support for his significant weight loss and new in-house acquired stage IV pressure ulcer. Resident #2's feeding should have been running at 65 cc/hr since February 2020, and was not changed. He experienced significant weight loss and acquired significant skin breakdown during that time. Review of Resident #2's Medication Administration Record [REDACTED]. Review of Resident #2's medical record revealed the following weights: 147.4 lbs on 03/12/2020. There are no weights recorded for April 2020, May 2020, June 2020 or July 2020. Weight is 131.0 lbs on 08/20/2020, 124.8 lbs on 09/07/2020, and 131.0 lbs on 10/10/2020. There is no weight recorded on the month of November 2020. Review of Resident #2's medical record revealed he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's MDS dated [DATE] indicated he had a BIMS score off 99 making him non-interviewable. He is totally dependent on 1-2 staff for all of his daily care needs. He has a feeding tube and requires total assistance of one staff member for his enteral feeding. Resident #3 Review of Resident #3's Order Summary Report dated 11/12/2020, revealed an Enteral Feed Order - every shift - [MEDICATION NAME] 1.5 which began on 06/30/2020. There was no rate per hour noted on the order. On 11/11/20 at 10:00 PM, Resident #3 was lying in bed, and her enteral feeding was observed to be running at 45 cc/hr. The bag of feeding and the bag of water were not dated, timed or initialed by a nurse. ON 11/12/2020 at 9:45 AM, the SA observed Resident #3's enteral feeding to be running at 45cc/hr. The bag of feeding and the bag of water were not dated, timed, or initialed by a nurse. On 11/12/2020 at 3:00 PM, on a tour with the Administrator and DON, it was observed by all that the feeding was running at 45 cc/hr, and the bag of feeding and water bag were not dated, timed, or initialed by a nurse. The DON was asked by the SA if she could tell me what rate Resident #3's feeding was to be running at. She grabbed her chart and indicated there was no order for a rate on the chart. LPN #3 stated, she just always ran it at 45 cc/hr, she didn't look at the order. Review of Resident #3's medical record revealed, she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's MDS dated [DATE], revealed her BIMS score to be 99, making her non-interviewable. She required total assistance on one to two staff members for all aspects of her daily care. She has a feeding tube which provides her with more than 51% of her daily nutritional intake. She requires the total assist of one staff member for her enteral feeding. Resident #5 Review of Resident #5's Order Summary Report dated for 11/12/2020, revealed an Enteral Feed Order - every 4 hours - Diabetisource 1 can six (6) X daily. Review of Resident #5's Medication Administration Record [REDACTED]. During an interview with Resident #5 on 11/11/2020 at 10:15 PM, he stated that he knows he misses feedings from time to time, but he couldn't remember any exact days. His BIMS score is a 4, but he is able to verbalize and make his needs known. Further review of Resident #5's Order Summary Report revealed he did not have an order for [REDACTED]. Review of Resident #5's medical record revealed he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #5's MDS dated [DATE], revealed he had a BIMS score of 4 making him non-interviewable. He required extensive to total assistance for all of his activities of daily living needs. He required total assistance of one person to administer his enteral feeding. On 11/14/2020, in an interview with the Medical Director (MD), he stated that he was made aware of the incident the following morning. He stated that it was unfortunate that it occurred and that upon review of the Medication Administration Records and Treatment Administration Records, he had uncovered some that need to be fine tuned also such as monthly weights. The facility submitted an credible Removal Plan for the IJ on 11/16/2020 . Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. The Residents on the North Hall were assessed on 11/10/2020 at 11:00 AM. There were no significant outcomes or findings noted during evaluations. The residents did not get their missed doses of medications, and the Medical Director (MD) ordered to skip the missed doses. There were no significant health issues, falls or injuries during the time there was no nurse present. The Medication Administration Records (MARs) were reviewed by the Medical Records Nurse on 11/10/2020 at 11:00 AM noting that medications, enteral feedings, treatments and monitors had not been completed. The Medical Director reviewed the complete MAR indicated [REDACTED]. The Administrator audited the schedule on 11/10/2020, at 7:30 AM, to ensure that adequate staff were scheduled for the month, there were no holes noted in the schedule. 2. The Quality Assurance Committee met on 11/13/2020, at 1:30 PM, including the Medical Director via phone, Regional Director of Operations, Administrator, Interim DIRECTOR OF NURSING, Infection Preventionist, MDS Coordinators, Social Service Director, Social Service Assistant, Dietary Manager, Life Connections, Medical Records, Business Office Manager, Human Resources Director, and Rehabilitative Services Director to discuss the IJ's noted by the survey team. The Quality Assurance Committee met and discussed the staffing, on-call procedure, and policy on reporting staffing concerns. It was noted by the Quality Assurance Committee that the policies were not being followed appropriately. There will be an on-call nurse to fill in shifts if needed. Staff will call the Staffing Aid to call in for shifts, or to report a call in received at the facility. If a staff member does not show up for work, the on-call nurse will be notified to come in for the shift. The Director of Nursing and the Administrator will be notified by the staff on duty of any staffing concerns. The facility has a staffing agency contract with Precision Staffing. In the event the Director of Nursing or the Assistant Director of Nursing works as a charge nurse, the Regional Nurse Consultant will be notified to assist in completing nurse administrative duties. 3. An in-service was initiated by the Administrator for nurses on 11/10/2020 concerning notifying the Director of Nursing and the Administrator with staffing concerns. On 11/13/2020 an in-service was initiated by the Administrator for all staff concerning the call in process, the on call process and notifying the Administrator and the Director of Nursing of any staffing concerns. An in-service was initiated on 11/10/2020 and on 11/13/2020 by the Administrator for Nurses concerning Abuse and Neglect including an explanation of the meaning of job abandonment. 4. The Board of Nursing was notified on 11/13/20 at 6:25 PM by the Administrator for 3 of 3 Nurses involved in this incident. The Attorney General's office was notified of the events concerning 41 patients on and 3 nurses on 11/16/20 by the Administrator at 1:30 PM. The State reporting Hotline was called by the Administrator on 11/14/2020 12:30 PM to report the allegations of Neglect concerning the residents on North Hall not receiving medications and treatments as ordered and the nurse abandoning her shift. The Director of Nursing was suspended pending investigation by the administrator on 11/13/2020 at 11:45 AM. The Director of Nursing was Terminated by the Administrator on 11/14/2020 at 1:41 PM. The Regional Director of Operations gave the Administrator a written warning for failing to report timely on 11/13/2020 at 7:00 PM. The facility alleges that all actions to remove the IJ on 11/13/2020 were completed as of 11/16/2020. The facility alleged that all corrective actions were completed on 11/16/2020, and removal of the Immediate Jeopardy (IJ) on 11/16/2020. On 11/18/2020, the SA surveyor validated the Removal Plan through staff interview, resident interview, record review, sign-in sheets and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): 1. The SA verified through record reviews, and staff interviews, that the residents on the North Unit were assessed on 11/10/2020. No significant outcomes or findings were noted on the evaluations. The Medical Director (MD) gave orders to skip the missed doses. The Medication Administration Records (MAR's) were reviewed by the Medical Records Nurse on 11/10/2020 noting that medications, enteral feedings, treatments and monitors had not been completed. The Medical Director reviewed the complete MAR's of all patients residing on the North Unit on 11/11/2020, with no new orders or concerns. The Administrator audited the schedule on 11/10/2020 to ensure that adequate staff were scheduled for the month, there were no holes noted in the schedule. 2. The SA verified through record review, observation of sign-in sheets, and staff interview, the Quality Assurance Committee met on 11/13/2020 at 1:30 PM, including the Medical Director via phone, Regional Director of Operations, Administrator, Interim DIRECTOR OF NURSING, Infection Preventionist, MDS Coordinators, Social Service Director, Social Service Assistant, Dietary Manager, Life Connections, Medical Records, Business Office Manager, Human Resources Director, and Rehabilitative Services Director to discuss the IJ's noted by the survey team. The Quality Assurance Committee discussed staffing, on-call procedure, and the policy on reporting staffing concerns. There will be an on-call nurse to fill in shifts if needed. Staff will call the Staffing Aid to call in for shifts, or to report a call in received at the facility. If a staff member does not show up for work, the on-call nurse will be notified to come in for the shift. The Director of Nursing and the Administrator will be notified by the staff on duty of any staffing concerns. The facility has a staffing agency contract with Precision Staffing. In the event the Director of Nursing or the Assistant Director of Nursing works as a charge nurse, the Regional Nurse Consultant will be notified to assist in completing nurse administrative duties. 3. The SA verified through review of sign-in sheets, in-service review, and staff interview, an in-service was initiated by the Administrator for nurses on 11/10/2020 concerning notifying the Director of Nursing and the Administrator with staffing concerns. On 11/13/2020 an in-service was initiated by the Administrator for all staff concerning the call in process, the on call process and notifying the Administrator and the Director of Nursing of any staffing concerns. An in-service was initiated on 11/10/2020 and on 11/13/2020 by the Administrator for Nurses concerning Abuse and Neglect including an explanation of the meaning of job abandonment. 4. The SA verified through review of personnel files, fax confirmation reviews, and staff interview that the Board of Nursing was notified on 11/13/20 at 6:25 P.M. by the Administrator for 3 of 3 Nurses involved in this incident. The Attorney General's office was notified of the events concerning 41 patients residing on the North Unit and 3 nurses on 11/16/20 by the Administrator at 1:30 PM. The State reporting Hotline was called by the Administrator on 11/14/2020, at 12:30 PM, to report the allegations of Neglect concerning the residents on North Hall not receiving medications and treatments as ordered and the nurses abandoning her shift. The Director of Nursing was suspended pending investigation by the administrator on 11/13/2020 at 11:45 AM. The Director of Nursing was Terminated by the Administrator on 11/14/2020 at 1:41 PM. The Regional Director of Operations gave the Administrator a written warning for failing to report timely on 11/13/2020 at 7:00 PM. The SA validated on 11/18/2020, that all corrective actions had been taken by the facility to remove the IJ during the extended survey on 11/13/2020 and the IJ was removed on 11/16/2020.

Based on record review, staff schedule review, staff interview, and facility policy review, the facility neglected to provide medications to 22 residents on the long hall of the North Unit with four of those residents not receiving enteral feedings on the 3-11 shift on 11/09/2020. On the 11-7 shift on 11/10/2020, 41 residents were without qualified nursing services as evidenced by the facilities failure to provife sufficient licensed nursing staff and supervision for one (1) of two (2) units observed, the North Unit. The facility's failure to provide a licensed nurse on the 3-11 shift on 11/09/2020, and again on the 11-7 shift on 11/10/2020, placed the residents at risk, and in a situation which caused and was likely to cause serious injury, harm, impairment, or death. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 11/09/2020, when the facility's failure to provide a licensed nurse to administer medications and enteral feedings resulted in four (4) residents not receiving enteral feedings per physicians orders, with two (2) of those residents currently experiencing significant weight loss. On 11/13/2020 at 1:20 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The IJ and SQC existed at: CFR(s)483.12(a)(1) - Abuse and Neglect (F600) - Scope and Severity - K, The facility submitted a credible Removal Plan on 11/16/2020, at 4:00 PM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of 11/16/2020. The SA validated the Removal Plan on 11/18/2020, and determined the IJ was removed prior to exit. Therefore the scope and severity for CFR(s)483.12(a)(1) - Abuse and Neglect (F600), was lowered for an K level of scope and severity to an E while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan .Neglect - failure of the facility, it's employees or service providers to provide goods and services to the resident, necessary to avoid physical harm, mental anguish, or emotional distress. On 11/13/2020, at 2:45 PM, during an interview with Licensed Practical Nurse (LPN) #1, he stated, he was not originally scheduled on Monday (11/09/2020), however, he was asked to pick up a 3/11 shift on the short hall. When he arrived at work, he counted the narcotics and took the keys for the short hall. The Medical Records nurse took the long hall to cover it until the second nurse arrived on duty, but she was called away to a meeting. At 3:30 PM, the second nurse had not arrived for the long hall, and the Medical Records Nurse had to leave and go home. The Director of Nursing (DON) came to the desk around 4:30 PM, after the meeting, and informed him he would be the only nurse on the 3-11 shift. LPN #1 told her he was not passing pills to all 41 residents, it was too much for one nurse. No one showed up to take the long hall. LPN #1 stated, he did not have time to pass the medications and care for the resident's on the long hall during his shift. The 11-7 nurse arrived, and when she found out she would be working the North unit alone, she refused to count narcotics and take the keys from him, clocked out, called the Administrator and went home. LPN #1 clocked out that night at 11:22 PM, but didn't leave the building because he was waiting on someone to come and count the cart with him. He went to the South unit and asked the nurse to come and count with him and she refused to, stating,if I count those with you, I will be responsible for the whole building myself, and I'm not comfortable doing that. He called the scheduler and she said to call the DON. He called the DON after 11:30 PM, and left her a voicemail that he could not stay and there was no nurse on the North unit. He attempted to call her a second time and still got no answer. He stated he felt he had notified everybody he could. When LPN #1 couldn't get anyone to count the cart with him he locked the cart keys up and left the building. He did not stay until his replacement arrived because he had to go home. On 11/12/2020 at 11:54 AM, during an interview with LPN #2, she indicated, on Monday night, (11/09/2020), she arrived at work and clocked in. She couldn't find a nurse on the unit. Call lights were going off, and residents were sitting in the hall waiting on their medications. LPN #1 was coming down the hall from the South Unit. He told her no one ever showed up to pass medications on the long hall, and he wasn't going to do it either. He said he told the DON he would hold the keys but was not giving out the meds. She told LPN #1 he needed to call the doctor and get a onetime order to give the medications late, and to pass out their medications before he left. He got upset and walked away and refused to do it. She told LPN #1 she was not working the unit alone and giving the medications for the 3-11 shift and the 11-7 shift. LPN #2 grabbed her jacket and bag and clocked back out. She called the scheduler and asked for the DON's phone number and stated the scheduler wouldn't give it to her, so she called a former employee and got the DON's number and called her. After several attempts, she answered the phone and said, well he told me he wasn't going to do it, but I didn't think he was serious. Well I don't know what to do because the Administrator doesn't want me to work the cart. LPN #2 then called the Administrator, and after a couple tries she answered, and LPN #2 told her LPN #1 had not passed medications on the 3-11 shift, and she wasn't working after that on 11-7 by herself. The following morning, at 6:45 AM, she received a call from LPN #3 asking where she was and where the keys were. LPN #2 told her she had not worked the 11-7 shift, she had left LPN #1 at the nurses station, and she would have to call him. She was told then by LPN #3 that no nurse had worked the North Unit at all that night then, and that LPN #1 had left the keys and went home too. On 11/12/2020 at 2:20 PM, during an interview with LPN #3, she indicated, on Tuesday morning, 11/10/2020, she arrived at work early at around 6:45 AM, and could not find a nurse on the North unit to get report from. She was told by a Certified Nurse Aide there had been no nurse on North unit all night after LPN #1 had left on the 3-11 shift. After searching for the keys to both carts until 8:30 AM, she went to find the Administrator and ask her to help find the keys, or to give her another key so she could pass her medications without them being late. On 11-12-2020 at 2:25 PM, during an interview with the Administrator, she indicated, she was not made aware there was not 2 nurses on the North unit for the 3-11 shift. She received a phone call from LPN #2 at around 1:00 AM on 11-10-2020, stating that LPN #1 had refused to pass meds on the long hall because he said it was too much for one nurse to do. She instructed LPN #2 to call the medical director, and get an order to give the medications late, to get a set of vitals on all the residents, to check and make sure they were doing okay, and to notify the DON. She stated she told LPN #2 she would take care of the issue with LPN #1 in the morning when she got to work. She arrived at the facility around 5:30 AM, called the DON to ask her about the situation. The DON stated she didn't know anything about it. It was not until around 8:30 AM she realized there was no nurse at all on the 11-7 shift, because that is when LPN #3 came to get her to help find the keys to both carts on the North unit. She stated LPN #3 told her she had gotten report from the three aides who had been here by themselves all night. On 11-12-2020 at 2:40 PM, during an interview with the DON she stated she had spoken to LPN #1 at around 4:30 PM before she left to go home. He was not happy about being the only nurse on the 3-11 shift, stating he wasn't going to do it again. She stated LPN #1 did not mention that he wasn't going to do it that night. She didn't hear anything else from anyone until between 10:30 - 11:00 PM when LPN #2 had called her to tell her that LPN #1 had not completed the med pass on half of the North unit, and that he was not going to do it. She told LPN #2 to call the Medical Director (Formal Name) and get an order to give the medications late, and for her to catch up as many of them as she could during her medication passes. LPN #2 told her she wasn't going to do it, it was too much to do and was unacceptable, and asked for the Administrator's phone number and was calling her to report this all to her. The DON states she thought the Administrator was going to handle the situation, so she didn't follow up or come to the building. When she arrived at the facility the following morning, she learned both LPN #1 and LPN #2 had left the building, and the South unit nurse was the only nurse left in the building all night. During an additional interview with the Administrator on 11/13/20 at 10:15 AM she confirmed that she had notified the medical director. When I came in that morning around 5:30 AM I notified my Corporate Regional Director of the incident and I notified Doctor (Formal Name), of the lack of nursing care to the residents and sent him the electronic medical record of the residents that missed medications. I notified our human resource officer and I started in-services on abuse and neglect. I also had the social worker do a psychological assessment on each of the residents and I had received a grievance from Resident #4 because she had not received her medications. I did not talk to the DON until about 7:00 AM that morning when she came to the facility. I had tried to call her prior to that but she did not answer her phone. I did not know that LPN #2 had spoken with the DON. The Administrator agrees that the DON should have come to the building when she was called at 10:30 PM by LPN #2. This is her first job as a registered nurse in a Long Term Care building and her first job as a DON. The Administrator verified that the DON had been trained and in-serviced prior to this incident of reporting neglect and had been trained in her role as a DON. During an additional interview with the DON on 11/13/20 at 10:45 AM she stated: I left that day (11/09/20) at 4:45 PM and before I left, LPN #1 was on the North hall and he told me that it was too much to take care of 43 residents and that he wasn't going to keep doing this and so I told him that other nurse's had done it in the past and that it could be done. I left after that and went home . About 10:30 PM I got a call from LPN #2, she was screaming into the phone and stated she refused to count with him. She told me that she wasn't going to take the keys to the medication cart. I thought that after she talked to the Administrator she would stay. The DON confirmed that she went back to bed and did not call the facility to check and did not come to the facility to check on the situation. I talked to the Administrator and I told her that I had talked to LPN #2 and that I had given LPN #2 her number to call her. I didn't know that I was suppose do anything, I can't make an employee work. The DON confirms that this was an allegation of neglect when the LPN reported to her at 10:30 PM that the nurse had not given medications to the resident's but she stated that she didn't know she was suppose to do anything about it, she thought that is what the Administrator does. The DON confirmed that she had spoken with LPN #2, who had called upset twice during the 10:30 PM until 11:00 PM timeframe. I'm new to this role, I thought that is what the administrator does, and I haven't been orientated to the medication cart anyway. I never talked to the Administrator that night, I thought everything was ok. The DON confirmed that the facility did have an on-call nurse that night, but she didn't call her because corporate had told them that morning to not to use the MDS nurses for on-call anymore. The DON confirmed that she has been employed by the facility for close to a month. On 11/13/2020 at 3:30 PM, during an interview with the Staffing Scheduler she stated: I received a text from LPN #2 at 11:35 PM needing the DON's phone number. I responded to her at 12:00 AM. I tried to call the DON and Administrator myself. I could not reach the DON, and when I tried to call the Administrator, she was on the phone with LPN #2. I remember seeing LPN #1 before I left to transport a [MEDICAL TREATMENT] resident that afternoon (11/09/2020), and when I called the on-call nurse, she said they had just had a meeting and was told to only staff each unit with one nurse from now on. I didn't know there was not a nurse on the 11-7 shift until the next morning (11/10/2020), when LPN #3 asked me if I had seen the North unit nurse, she needed report and the cart keys. On 11/13/2020 at 3:45 PM, during an interview with the Minimum Data Set (MDS) nurse, she stated: I was the nurse on-call for Monday (11/09/2020). I got a call from the scheduler at around 3:30 PM saying there was only one nurse on the North Unit. I explained to her we were just told in a meeting that there was only going to be one nurse per unit for 3-11 and 11-7 from now on. I explained the new staffing ratio to her, due to our current census. I didn't talk to anyone else for the remainder of the evening and night. I woke up the next morning and checked the on-call phone and there were no text messages, phone calls or voicemail. I didn't know there was not a nurse for the 11-7 shift on North unit until I arrived the next morning for work. On 11/14/2020, in an interview with the Medical Director (MD), he stated that he was made aware of the incident the following morning. He stated that it was unfortunate that it occurred and that upon review of the Medication Administration Records and Treatment Administration Records, he had uncovered some that need to be fine tuned also. Review of the facility's daily schedule for 11/09/2020 and Individual Employee Time Cards for all licensed nurses employed at the facility revealed, LPN #4 clocked in at 4:25 PM, worked on the South Unit, and clocked out at 09:31 AM on the morning of 11/10/2020. LPN #1 clocked in at 2:53 PM on 11/09/2020, and clocked out at 11:22 PM on 11/09/2020. LPN #2 clocked in at 11:03 PM on 11/09/2020, and clocked out at 11:47 PM on 11/09/2020. LPN #3 clocked in at 6:10 AM on 11/10/2020, and clocked out at 3:52 PM on 11/10/2020. The facility had one LPN on the North Unit from 2:53 PM - 11:22 PM who refused to pass medications to 22 of 41 residents. The 11-7 nurse, clocked in at 11:03 PM, and clocked back out at 11:47 PM, when she found out she would be covering medication pass for the 22 residents that did not get them on the 3-11 shift, and then passing medications and caring for the entire unit of 41 residents by herself. This left 22 residents without licensed nursing services from 3:fpm on 11/09/2020 to 6:10 AM on 11/10/2020, and 19 residents without licensed nursing services from 11:47 PM on 11/09/2020 to 6:10 AM on 11/10/2020. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. The Residents on the North Hall were assessed on 11/10/2020 at 11:00 AM. There were no significant outcomes or findings noted during evaluations. The residents did not get their missed doses of medications, and the Medical Director (MD) ordered to skip the missed doses. There were no significant health issues, falls or injuries during the time there was no nurse present. The Medication Administration Records (MAR's) were reviewed by the Medical Records Nurse on 11/10/2020 at 11:00 AM noting that medications, enteral feedings, treatments and monitors had not been completed. The Medical Director reviewed the complete MAR indicated [REDACTED]. The Administrator audited the schedule on 11/10/2020 at 7:30 AM to ensure that adequate staff were scheduled for the month, there were no holes noted in the schedule. 2. The Quality Assurance Committee met on 11/13/2020 at 1:30 PM, including the Medical Director via phone, Regional Director of Operations, Administrator, Interim DIRECTOR OF NURSING, Infection Preventionist, MDS Coordinators, Social Service Director, Social Service Assistant, Dietary Manager, Life Connections, Medical Records, Business Office Manager, Human Resources Director, and Rehabilitative Services Director to discuss the IJ's noted by the survey team. The Quality Assurance Committee met and discussed the staffing, on-call procedure, and policy on reporting staffing concerns. It was noted by the Quality Assurance Committee that the policies were not being followed appropriately. There will be an on-call nurse to fill in shifts if needed. Staff will call the Staffing Aid to call in for shifts, or to report a call in received at the facility. If a staff member does not show up for work, the on-call nurse will be notified to come in for the shift. The Director of Nursing and the Administrator will be notified by the staff on duty of any staffing concerns. The facility has a staffing agency contract with Precision Staffing. In the event the Director of Nursing or the Assistant Director of Nursing works as a charge nurse, the Regional Nurse Consultant will be notified to assist in completing nurse administrative duties. 3. An in-service was initiated by the Administrator for nurses on 11/10/2020 concerning notifying the Director of Nursing and the Administrator with staffing concerns. On 11/13/2020 an in-service was initiated by the Administrator for all staff concerning the call in process, the on call process and notifying the Administrator and the Director of Nursing of any staffing concerns. An in-service was initiated on 11/10/2020 and on 11/13/2020 by the Administrator for Nurses concerning Abuse and Neglect including an explanation of the meaning of job abandonment. 4. The Board of Nursing was notified on 11/13/20 at 6:25 PM by the Administrator for 3 of 3 Nurses involved in this incident. The Attorney General's office was notified of the events concerning 41 patients on and 3 nurses on 11/16/20 by the Administrator at 1:30 PM. The State reporting Hotline was called by the Administrator on 11/14/2020 12:30 PM to report the allegations of Neglect concerning the residents on North Hall not receiving medications and treatments as ordered and the nurse abandoning her shift. The Director of Nursing was suspended pending investigation by the administrator on 11/13/2020 at 11:45 AM. The Director of Nursing was Terminated by the Administrator on 11/14/2020 at 1:41 PM. The Regional Director of Operations gave the Administrator a written warning for failing to report timely on 11/13/2020 at 7:00 PM. The facility alleges that all actions to remove the IJ on 11/13/2020 were completed as of 11/16/2020. The facility alleged that all corrective actions were completed on 11/16/2020, and removal of the Immediate Jeopardy (IJ) on 11/16/2020. On 11/18/2020, the AS surveyor validated through staff interview, resident interview, record review, sign-in sheets and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): 1. The SA verified through record reviews, and staff interviews, that the residents on the North Unit were assessed on 11/10/2020. No significant outcomes or findings were noted on the evaluations. The Medical Director (MD) gave orders to skip the missed doses. The Medication Administration Records (MAR's) were reviewed by the Medical Records Nurse on 11/10/2020 noting that medications, enteral feedings, treatments and monitors had not been completed. The Medical Director reviewed the complete MAR's of all patients residing on the North Unit on 11/11/2020, with no new orders or concerns. The Administrator audited the schedule on 11/10/2020 to ensure that adequate staff were scheduled for the month, there were no holes noted in the schedule. 2. The SA verified through record review, observation of sign-in sheets, and staff interview, the Quality Assurance Committee met on 11/13/2020 at 1:30 PM, including the Medical Director via phone, Regional Director of Operations, Administrator, Interim DIRECTOR OF NURSING, Infection Preventionist, MDS Coordinators, Social Service Director, Social Service Assistant, Dietary Manager, Life Connections, Medical Records, Business Office Manager, Human Resources Director, and Rehabilitative Services Director to discuss the IJ's noted by the survey team. The Quality Assurance Committee discussed staffing, on-call procedure, and the policy on reporting staffing concerns. There will be an on-call nurse to fill in shifts if needed. Staff will call the Staffing Aid to call in for shifts, or to report a call in received at the facility. If a staff member does not show up for work, the on-call nurse will be notified to come in for the shift. The Director of Nursing and the Administrator will be notified by the staff on duty of any staffing concerns. The facility has a staffing agency contract with Precision Staffing. In the event the Director of Nursing or the Assistant Director of Nursing works as a charge nurse, the Regional Nurse Consultant will be notified to assist in completing nurse administrative duties. 3. The SA verified through review of sign-in sheets, in-service review, and staff interview, an in-service was initiated by the Administrator for nurses on 11/10/2020 concerning notifying the Director of Nursing and the Administrator with staffing concerns. On 11/13/2020 an in-service was initiated by the Administrator for all staff concerning the call in process, the on call process and notifying the Administrator and the Director of Nursing of any staffing concerns. An in-service was initiated on 11/10/2020 and on 11/13/2020 by the Administrator for Nurses concerning Abuse and Neglect including an explanation of the meaning of job abandonment. 4. The SA verified through review of personnel files, fax confirmation reviews, and staff interview that the Board of Nursing was notified on 11/13/20 at 6:25 P.M. by the Administrator for 3 of 3 Nurses involved in this incident. The Attorney General's office was notified of the events concerning 41 patients residing on the North Unit and 3 nurses on 11/16/20 by the Administrator at 1:30 PM. The State reporting Hotline was called by the Administrator on 11/14/2020 12:3 to report the allegations of Neglect concerning the residents on North Hall not receiving medications and treatments as ordered and the nurses abandoning her shift. The Director of Nursing was suspended pending investigation by the administrator on 11/13/2020 at 11:45 AM. The Director of Nursing was Terminated by the Administrator on 11/14/2020 at 1:41 PM. The Regional Director of Operations gave the Administrator a written warning for failing to report timely on 11/13/2020 at 7:00 PM. The SA validated on 11/18/2020, that all corrective actions had been taken by the facility to remove the IJ during the extended survey on 11/13/2020 and the IJ was removed on 11/16/2020.

Based on record review and staff interview, the facility failed to report within two (2) hours after being notified of a negligent practice As evidenced by notification by LPN that there was no licensed nurse available for 22 residents residing on the North Unit for the 3-11 shift on 11/09/2020, and no licensed nurse available for 41 residents residing on the North unit for the 11-7 shift on 11/09/2020 into 11/10/2020. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 11/09/2020, as a result of 22 residents not receiving medications, and enteral feedings on the three (3) - eleven (11) shift on 11/09/2020, and 41 residents on the 11 - seven (7) shift on 11/10/2020, related to no licensed nurse available on duty. The Director of Nursing was made aware of the negligent practice at between 10:30 - 11:00 PM on 11/09/2020, and failed start an investigation, report it to her supervisor, the administrator, or report the negligent behavior to the State Survey Agency until the following morning on 11/10/2020. The facility's failure to provide a licensed nurse on the 3-11 shift on 11/09/2020, and again on the 11-7 shift on 11/12/2020, and failure to report the negligent practice, placed the residents at risk, and in a situation which caused and was likely to cause serious injury, harm, impairment, or death. On 11/13/2020 at 1:20 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The IJ and SQC existed at: CFR(s)483.12(c)(1) - Reporting of Alleged Violations (F609) - Scope and Severity - K The facility submitted a credible Removal Plan on 11/16/2020, at 4:00 PM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of 11/16/2020. The SA validated the Removal Plan on 11/18/2020 and determined the IJ was removed prior to exit. Therefore the scope and severity for CFR(s)483.12(c)(1) - Reporting of Alleged Violations (F609) was lowered from an K level of scope and severity to an E level, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy titled, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan, dated 08/23/17, revealed: Neglect - failure of the facility, it's employees or service providers to provide goods and services to the resident, necessary to avoid physical harm, mental anguish, or emotional distress .Any employee who witnesses or has cause to suspect abuse/neglect/misappropriation of property/or exploitation of a resident must report it immediately to the Administrator/Director of Nursing .Failure by an employee to report witnessed or suspected abuse/neglect/misappropriation/or exploitation of a resident may result in termination of employment and may also be prosecuted by the law. Review of the facility policy entitled Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan, Revision Date: 08/23/2017, revealed, Reporting/Response, Policy, Elder Justice Act of 2009 (Public Act 111-148, Title VI, Subtitle H), MS Statute 43-47-7, .-mandates reporting of any suspected crime against an elder in a long-term care facility 4) .Within 2 hours (if the allegation involves abuse .) after forming our reasonable suspicion. On 11-12-2020 at 2:25 PM, during an interview with the Administrator, she indicated, she received a phone call from Licensed Practical Nurse (LPN) #2 at around 1:00 AM on 11-10-2020, stating that LPN #1 had refused to pass meds on the long hall because he said it was too much for one nurse to do. She instructed LPN #2 to call the medical director, and get an order to give the medications late, to get a set of vitals on all the residents, to check and make sure they were doing okay, and to notify the Director of Nursing (DON). She stated she told LPN #2 she would take care of the issue with LPN #1 in the morning when she got to work. She arrived at the facility around 5:30 AM, called the DON to ask her about the situation. The DON stated she didn't know anything about it. It was not until around 8:30 AM she realized there was no nurse at all on the 11-7 shift, because that is when LPN #3 came to get her to help find the keys to both carts on the North unit. She stated LPN #3 told her she had gotten report from the three aides who had been here by themselves all night. On 11-12-2020 at 2:40 PM, during an interview with the DON she stated between 10:30 - 11:00 PM, LPN #2 had called her to tell her that LPN #1 had not completed the med pass on half of the North unit, and that he was not going to do it. She told LPN #2 to call the Medical Director (Formal Name) and get an order to give the medications late, and for her to catch up as many of them as she could during her medication passes. LPN #2 told her she wasn't going to do it, it was too much to do and was unacceptable, and asked for the Administrator's phone number and was calling her to report this all to her. The DON states she thought the Administrator was going to handle the situation, so she didn't follow up or come to the building. When she arrived at the facility the following morning, she learned both LPN #1 and LPN #2 had left the building, and the South unit nurse was the only nurse left in the building all night. During an additional interview with the Administrator on 11/13/20, at 10:15 AM, she confirmed that she did not talk to the DON until about 7:00 AM that morning when she came to the facility. I had tried to call her prior to that but she did not answer her phone. I did not know that LPN #2 had spoken with the DON. The administrator agrees that the DON should have come to the building when she was called at 10:30 PM by LPN #2. This is her first job as a registered nurse in a Long Term Care building and her first job as a DON. The Administrator verified that the DON had been trained and in-serviced prior to this incident of reporting neglect and had been trained in her role as a DON. During an additional interview with the DON on 11/13/20, at 10:45 AM, she stated: . About 10:30 PM I got a call from LPN #2, she was screaming into the phone and stated she refused to count with LPN #1. She told me that she wasn't going to take the keys to the medication cart. I thought that after she talked to the Administrator she would stay. The DON confirmed that she went back to bed and did not call the facility to check and did not come to the facility to check on the situation. I talked to the Administrator and I told her that I had talked to LPN #2 and that I had given LPN #2 her number to call her. I didn't know that I was suppose do anything, I can't make an employee work. The DON confirms that this was an allegation of neglect when the LPN reported to her at 10:30 PM that the nurse had not given medications to the resident's but she stated that she didn't know she was suppose to do anything about it, she thought that is what the Administrator does. The DON confirmed that she had spoken with LPN #2, who had called upset twice during the 10:30 PM until 11:00 PM timeframe. I'm new to this role, I thought that is what the administrator does, and I haven't been orientated to the medication cart anyway. I never talked to the Administrator that night, I thought everything was ok. The DON confirmed that the facility did have an on-call nurse that night, but she didn't call her because corporate had told them that morning to not to use the MDS nurses for on-call anymore. The DON confirmed that she has been employed by the facility for close to a month. On 11/14/2020, in an interview with the Medical Director (MD), he stated that he was made aware of the incident the following morning. He stated that it was unfortunate that it occurred. Review of the DON's personnel file revealed, Job Description: Director of Nursing - Summary: To manage overall operation of the Nursing Services Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all the Residents and employee needs. Essential Duties and Responsibilities: .to carry out, coordinate, or manage assigned administrative functions and areas of programs related to Nursing Services which may include ancillary supplies or services, Care Plans, MDS's, Infection Control Program, light duty or Safety Program, Staff Scheduling and related functions . Supervisory Responsibilities: Directly supervises and is accountable for the Nursing Department and all it's employees . Further review of the DON's personnel file revealed a copy of the Freedom from Abuse/Neglect, and/or Exploitation Prevention Plan, signed by the DON on 09/30/2020, and a copy of the Vulnerable Adults Prevention Policy, signed by the DON on 09/30/2020. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. The Residents on the North Hall were assessed on 11/10/2020 at 11:00 AM. There were no significant outcomes or findings noted during evaluations. The residents did not get their missed doses of medications, and the Medical Director (MD) ordered to skip the missed doses. There were no significant health issues, falls or injuries during the time there was no nurse present. The Medication Administration Records (MAR's) were reviewed by the Medical Records Nurse on 11/10/2020, at 11:00 AM noting that medications, enteral feedings, treatments and monitors had not been completed. The Medical Director reviewed the complete MAR indicated [REDACTED]. The Administrator audited the schedule on 11/10/2020 at 7:30 AM to ensure that adequate staff were scheduled for the month, there were no holes noted in the schedule. 2. The Quality Assurance Committee met on 11/13/2020 at 1:30 PM, including the Medical Director via phone, Regional Director of Operations, Administrator, Interim DIRECTOR OF NURSING, Infection Preventionist, MDS Coordinators, Social Service Director, Social Service Assistant, Dietary Manager, Life Connections, Medical Records, Business Office Manager, Human Resources Director, and Rehabilitative Services Director to discuss the IJ's noted by the survey team. The Quality Assurance Committee met and discussed the staffing, on-call procedure, and policy on reporting staffing concerns. It was noted by the Quality Assurance Committee that the policies were not being followed appropriately. There will be an on-call nurse to fill in shifts if needed. Staff will call the Staffing Aid to call in for shifts, or to report a call in received at the facility. If a staff member does not show up for work, the on-call nurse will be notified to come in for the shift. The Director of Nursing and the Administrator will be notified by the staff on duty of any staffing concerns. The facility has a staffing agency contract with Precision Staffing. In the event the Director of Nursing or the Assistant Director of Nursing works as a charge nurse, the Regional Nurse Consultant will be notified to assist in completing nurse administrative duties. 3. An in-service was initiated by the Administrator for nurses on 11/10/2020 concerning notifying the Director of Nursing and the Administrator with staffing concerns. On 11/13/2020 an in-service was initiated by the Administrator for all staff concerning the call in process, the on call process and notifying the Administrator and the Director of Nursing of any staffing concerns. An in-service was initiated on 11/10/2020 and on 11/13/2020 by the Administrator for Nurses concerning Abuse and Neglect including an explanation of the meaning of job abandonment. 4. The Board of Nursing was notified on 11/13/20 at 6:25 PM by the Administrator for 3 of 3 Nurses involved in this incident. The Attorney General's office was notified of the events concerning 41 patients on and 3 nurses on 11/16/20 by the Administrator at 1:30 PM. The State reporting Hotline was called by the Administrator on 11/14/2020, 12:30 PM, to report the allegations of Neglect concerning the residents on North Hall not receiving medications and treatments as ordered and the nurse abandoning her shift. The Director of Nursing was suspended pending investigation by the administrator on 11/13/2020 at 11:45 AM. The Director of Nursing was Terminated by the Administrator on 11/14/2020 at 1:41 PM. The Regional Director of Operations gave the Administrator a written warning for failing to report timely on 11/13/2020 at 7:00 PM. The facility alleges that all actions to remove the IJ on 11/13/2020 were completed as of 11/16/2020. The facility alleged that all corrective actions were completed on 11/16/2020, and removal of the Immediate Jeopardy (IJ) on 11/16/2020. On 11/18/2020, the SA surveyor validated through staff interview, resident interview, record review, sign-in sheets and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): 1. The SA verified through record reviews, and staff interviews, that the residents on the North Unit were assessed on 11/10/2020. No significant outcomes or findings were noted on the evaluations. The Medical Director (MD) gave orders to skip the missed doses. The Medication Administration Records (MAR's) were reviewed by the Medical Records Nurse on 11/10/2020 noting that medications, enteral feedings, treatments and monitors had not been completed. The Medical Director reviewed the complete MAR's of all patients residing on the North Unit on 11/11/2020, with no new orders or concerns. The Administrator audited the schedule on 11/10/2020 to ensure that adequate staff were scheduled for the month, there were no holes noted in the schedule. 2. The SA verified through record review, observation of sign-in sheets, and staff interview, the Quality Assurance Committee met on 11/13/2020 at 1:30 PM, including the Medical Director via phone, Regional Director of Operations, Administrator, Interim DIRECTOR OF NURSING, Infection Preventionist, MDS Coordinators, Social Service Director, Social Service Assistant, Dietary Manager, Life Connections, Medical Records, Business Office Manager, Human Resources Director, and Rehabilitative Services Director to discuss the IJ's noted by the survey team. The Quality Assurance Committee discussed staffing, on-call procedure, and the policy on reporting staffing concerns. There will be an on-call nurse to fill in shifts if needed. Staff will call the Staffing Aid to call in for shifts, or to report a call in received at the facility. If a staff member does not show up for work, the on-call nurse will be notified to come in for the shift. The Director of Nursing and the Administrator will be notified by the staff on duty of any staffing concerns. The facility has a staffing agency contract with Precision Staffing. In the event the Director of Nursing or the Assistant Director of Nursing works as a charge nurse, the Regional Nurse Consultant will be notified to assist in completing nurse administrative duties. 3. The SA verified through review of sign-in sheets, in-service review, and staff interview, an in-service was initiated by the Administrator for nurses on 11/10/2020 concerning notifying the Director of Nursing and the Administrator with staffing concerns. On 11/13/2020 an in-service was initiated by the Administrator for all staff concerning the call in process, the on call process and notifying the Administrator and the Director of Nursing of any staffing concerns. An in-service was initiated on 11/10/2020 and on 11/13/2020 by the Administrator for Nurses concerning Abuse and Neglect including an explanation of the meaning of job abandonment. 4. The SA verified through review of personnel files, fax confirmation reviews, and staff interview that the Board of Nursing was notified on 11/13/20 at 6:25 P.M. by the Administrator for 3 of 3 Nurses involved in this incident. The Attorney General's office was notified of the events concerning 41 patients residing on the North Unit and 3 nurses on 11/16/20 by the Administrator at 1:30 PM. The State reporting Hotline was called by the Administrator on 11/14/2020, at 12:30 PM, to report the allegations of Neglect concerning the residents on North Hall not receiving medications and treatments as ordered and the nurses abandoning her shift. The Director of Nursing was suspended pending investigation by the administrator on 11/13/2020 at 11:45 AM. The Director of Nursing was Terminated by the Administrator on 11/14/2020 at 1:41 PM. The Regional Director of Operations gave the Administrator a written warning for failing to report timely on 11/13/2020 at 7:00 PM. The SA validated on 11/18/2020, that all corrective actions had been taken by the facility to remove the IJ during the extended survey on 11/13/2020 and the IJ was removed on 11/16/2020.

Based on care plan review, facility policy review, and staff interview, the facility failed to develop a nutritional care plan for two (2) of five (5) residents (Resident #2 and #5) and develop a comprehensive care plans for one (1) of five (5) residents (Resident #4) reviewed for care plans. The facility also failed to implement care plans for 22 of 79 on the 3-11 shift and 41 residents out of 79 residents in the facility on the 11-7 shifts. The facility's failure to develop and implement care plans, placed the residents at risk, and in a situation which caused and was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 11/09/2020, the facility's failure to provide a licensed nurse to implement complete comprehensive care plans resulted in 4 residents not receiving enteral feedings per physicians orders, with two (2) of those residents with a history of significant weight loss and 41 residents not receiving any medications or treatments. On 11/13/2020 at 1:20 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The IJ existed at: CFR483.21(b)(1) - Develop/Implement Comprehensive Care Plan (F656) - Scope and Severity - K The facility submitted a credible Removal Plan on 11/16/2020 at 4:00 PM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of 11/16/2020. The SA validated the Removal Plan on 11/18/2020 and determined the IJ was removed prior to exit. Therefore the scope and severity for CFR483.21(b)(1) - Develop/Implement Comprehensive Care Plan (F656) was lowered from an K level of scope and severity to an E level, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of facility policy titled Care Plans - Comprehensive, dated June 1, 2000, revealed, Policy Statement - It is the policy of this facility to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. Resident #2 Review of Resident #2's Consultant RD Note, dated 09/04/2020 revealed, 10.9% wt (weight) loss at 180 days, significant . Resident's weight on 3/12/2020 was 147.4#. His next recorded weight was 08/20/2020 and was 131.0#. His weight on 09/07/2020 was 124.8# even after a re-weight was obtained. Resident #2 had a 10.9% weight loss at 180 days, and an additional 5% weight loss at 30 days. Review of Resident #2's current care plans provided by the facility, there is no care plan to address Resident #2's significant weight loss, nor interventions done in an attempt to assist with weight maintenance. During an interview with the care plan nurse on 11/14/2020 at 1:35 PM, she indicated there was a care plan to address his peg tube, however, there is not one that addressed his significant weight loss issues. Review of Resident #2's record revealed, his was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his Order Summary indicated, Enteral Feed Order - every shift - Diabetisource 55 cc(cubic centimeters)/hour continuous via peg tube. Review of Resident #2's Minimum Data Set ((MDS) dated [DATE] indicated, Resident #2 has a Brief Interview of Mental Status (BIMS) score of 99, meaning he is not able to be interviewed due to cognitive issues, he is totally dependant on one to two staff members for all of his daily activities. He is totally dependant on one staff member to administer his enteral feedings, and it is all of his nutritional intake. Resident #4: Review of Resident #4's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's MDS dated for 08/14/2020 revealed she required extensive to total assistance of one to two staff members for all of her daily activities except for eating, in which she only needed set up assistance and was able to feed herself. Review of Resident #4's Order Summary Report dated 11/13/2020 revealed the following orders related to her [DIAGNOSES REDACTED]. Notify MD if any s/s (signs/symptoms)observed, No blood pressure in left arm, Resident is to take Auryxia ([MEDICATION NAME] Binder) to [MEDICAL TREATMENT] to take when eating snack one time every Mon. Wed. Fri., Auryxia Tablet - Give 2 tablets by mouth three times a day r/t (related to) Dependence on [MEDICAL TREATMENT], INTAKE and OUTPUT daily Q shift for [MEDICAL CONDITION], and [MEDICATION NAME]-[MEDICATION NAME] Cream 2.5-2.5% - Apply to LEFT UPPER ARM topically one time a day every Mon. Wed. Fri. for numbness - Apply 60 minutes prior to [MEDICAL TREATMENT] visit. Review of Resident #4's care plans reveals no care plan pertaining to her [DIAGNOSES REDACTED]. Further review of Resident #4's Order Summary Report dated 11/13/2020 revealed an order for [REDACTED].>Review of Resident #4's care plans revealed no care plan for FULLCODE or end of life choices. Further review of Resident #4's Order Summary dated 11/13/2020 revealed an order to transfer with total lift, XL (extra large) sling X (times) 2 assist. Review of Resident #4's care plans revealed no care plan at all regarding her Activities of Daily living (ADL) needs for assistance. Further review of Resident #4's Order Summary Report dated 11/13/2020 revealed an order for [REDACTED]. Review of Resident #4's care plans revealed no care plan at all for anti-coagulation therapy, her history or [MEDICAL CONDITION], or the medications and interventions required for her care. Further review of Resident #4's Order Summary Report dated 11/13/2020 revealed orders related to her [DIAGNOSES REDACTED].= 0 units, 151-180 = 2 units, 181-250 = 4 units, 251 - 300 = 6 units, 310-350 = 10 units, 351-400 = 12 units, if greater than 400 call provider, and [MEDICATION NAME] Solution 100 unit/ml (milliliter) - Inject 50 units subcutaneously at bedtime related to Type 2 Diabetes. Review of Resident #4's care plans revealed no care plan at all for her [DIAGNOSES REDACTED]. Further review of Resident #4's Order Summary Report dated 11/13/2020 revealed an order related to her [DIAGNOSES REDACTED]. Review of resident #4's care plans revealed no care plan at all for her [DIAGNOSES REDACTED]. Further review of Resident #4's Order Summary Report dated 11/13/2020 revealed orders related to her [DIAGNOSES REDACTED]. Review of Resident #4's care plans revealed no care plan at all for her [DIAGNOSES REDACTED]. Further review of Resident #4's Order Summary Report dated 11/13/2020 revealed and order for [MEDICATION NAME] Capsule 20 mg - give 1 capsule by mouth one time a day related to Major [MEDICAL CONDITION]. Review of Resident #4's care plans revealed no care plan at all related to her [DIAGNOSES REDACTED]. During an interview with the care plan nurse and the DON on 11/13/2020 at 10:45 AM, they both confirmed there were no care plans to address Resident #4's [DIAGNOSES REDACTED]. Resident #5: Review of Resident #5's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's MDS dated [DATE] revealed he had a BIMS score of 4 making him non-interviewable. He required extensive total assistance for all of his activities of daily living needs. He required total assistance of one person to administer his enteral feeding. Review of Resident #5's care plan revealed a care plan stating, I am at risk for nutritional problem or potential nutritional problem. I require my nutrition via a peg tube. I have a DX of Dysphagia. I have a history of weight loss. Goal: I will not have no undetected significant weight changes to next review date. Interventions: Monthly weights as ordered by MD. Review of Resident #5's weights for the last 6 months revealed a missing weight for the months of July 2020, October 2020 and November 2020 as of 11/14/2020. During an interview with the care plan nurse and the DON on 11/13/2020 at 10:45 AM, they both confirmed the care plan indicated monthly weights to be done and the months of July, October and November 2020, were not obtained. Both the DON and Care Plan Nurse confirmed that they were aware of the problems with care plans due to the Care Plan Nurse being frequently pulled on-call and having a hard time keeping up with the MDSs and Care Plans. On 11/14/2020, in an interview with the Medical Director (MD), he stated that he was made aware of the incident the following morning. He stated that it was unfortunate that it occurred and that upon review of the Medication Administration Records and Treatment Administration Records, he had uncovered some that need to be fine tuned also. The MD stated that he would have to start looking at the Care Plans to make sure everything matches up. The facility submitted a Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. The Residents on the North Hall were assessed on 11/10/2020 at 11:00 AM. There were no significant outcomes or findings noted during evaluations. The residents did not get their missed doses of medications, and the Medical Director (MD) ordered to skip the missed doses. There were no significant health issues, falls or injuries during the time there was no nurse present. The Medication Administration Records (MAR's) were reviewed by the Medical Records Nurse on 11/10/2020 at 11:00 AM noting that medications, enteral feedings, treatments and monitors had not been completed. The Medical Director reviewed the complete MAR indicated [REDACTED]. The Administrator audited the schedule on 11/10/2020 at 7:30 AM to ensure that adequate staff were scheduled for the month, there were no holes noted in the schedule. 2. The Quality Assurance Committee met on 11/13/2020 at 1:30 PM, including the Medical Director via phone, Regional Director of Operations, Administrator, Interim DIRECTOR OF NURSING, Infection Preventionist, MDS Coordinators, Social Service Director, Social Service Assistant, Dietary Manager, Life Connections, Medical Records, Business Office Manager, Human Resources Director, and Rehabilitative Services Director to discuss the IJ's noted by the survey team. The Quality Assurance Committee met and discussed the staffing, on-call procedure, and policy on reporting staffing concerns. It was noted by the Quality Assurance Committee that the policies were not being followed appropriately. There will be an on-call nurse to fill in shifts if needed. Staff will call the Staffing Aid to call in for shifts, or to report a call in received at the facility. If a staff member does not show up for work, the on-call nurse will be notified to come in for the shift. The Director of Nursing and the Administrator will be notified by the staff on duty of any staffing concerns. The facility has a staffing agency contract with Precision Staffing. In the event the Director of Nursing or the Assistant Director of Nursing works as a charge nurse, the Regional Nurse Consultant will be notified to assist in completing nurse administrative duties. 3. An in-service was initiated by the Administrator for nurses on 11/10/2020 concerning notifying the Director of Nursing and the Administrator with staffing concerns. On 11/13/2020 an in-service was initiated by the Administrator for all staff concerning the call in process, the on call process and notifying the Administrator and the Director of Nursing of any staffing concerns. An in-service was initiated on 11/10/2020 and on 11/13/2020 by the Administrator for Nurses concerning Abuse and Neglect including an explanation of the meaning of job abandonment. 4. The Board of Nursing was notified on 11/13/20 at 6:25 PM by the Administrator for 3 of 3 Nurses involved in this incident. The Attorney General's office was notified of the events concerning 41 patients on and 3 nurses on 11/16/20 by the Administrator at 1:30 PM. The State reporting Hotline was called by the Administrator on 11/14/2020, at 12:30 PM, to report the allegations of Neglect concerning the residents on North Hall not receiving medications and treatments as ordered and the nurse abandoning her shift. The Director of Nursing was suspended pending investigation by the administrator on 11/13/2020 at 11:45 AM. The Director of Nursing was Terminated by the Administrator on 11/14/2020 at 1:41 PM. The Regional Director of Operations gave the Administrator a written warning for failing to report timely on 11/13/2020 at 7:00 PM. The facility alleges that all actions to remove the IJ on 11/13/2020 were completed as of 11/16/2020. The facility alleged that all corrective actions were completed on 11/16/2020, and removal of the Immediate Jeopardy (IJ) on 11/16/2020. On 11/18/2020, the SA surveyor validated through staff interview, resident interview, record review, sign-in sheets and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): 1. The SA verified through record reviews, and staff interviews, that the residents on the North Unit were assessed on 11/10/2020. No significant outcomes or findings were noted on the evaluations. The Medical Director (MD) gave orders to skip the missed doses. The Medication Administration Records (MAR's) were reviewed by the Medical Records Nurse on 11/10/2020 noting that medications, enteral feedings, treatments and monitors had not been completed. The Medical Director reviewed the complete MAR's of all patients residing on the North Unit on 11/11/2020, with no new orders or concerns. The Administrator audited the schedule on 11/10/2020 to ensure that adequate staff were scheduled for the month, there were no holes noted in the schedule. 2. The SA verified through record review, observation of sign-in sheets, and staff interview, the Quality Assurance Committee met on 11/13/2020 at 1:30 PM, including the Medical Director via phone, Regional Director of Operations, Administrator, Interim DIRECTOR OF NURSING, Infection Preventionist, MDS Coordinators, Social Service Director, Social Service Assistant, Dietary Manager, Life Connections, Medical Records, Business Office Manager, Human Resources Director, and Rehabilitative Services Director to discuss the IJ's noted by the survey team. The Quality Assurance Committee discussed staffing, on-call procedure, and the policy on reporting staffing concerns. There will be an on-call nurse to fill in shifts if needed. Staff will call the Staffing Aid to call in for shifts, or to report a call in received at the facility. If a staff member does not show up for work, the on-call nurse will be notified to come in for the shift. The Director of Nursing and the Administrator will be notified by the staff on duty of any staffing concerns. The facility has a staffing agency contract with Precision Staffing. In the event the Director of Nursing or the Assistant Director of Nursing works as a charge nurse, the Regional Nurse Consultant will be notified to assist in completing nurse administrative duties. 3. The SA verified through review of sign-in sheets, in-service review, and staff interview, an in-service was initiated by the Administrator for nurses on 11/10/2020 concerning notifying the Director of Nursing and the Administrator with staffing concerns. On 11/13/2020 an in-service was initiated by the Administrator for all staff concerning the call in process, the on call process and notifying the Administrator and the Director of Nursing of any staffing concerns. An in-service was initiated on 11/10/2020 and on 11/13/2020 by the Administrator for Nurses concerning Abuse and Neglect including an explanation of the meaning of job abandonment. 4. The SA verified through review of personnel files, fax confirmation reviews, and staff interview that the Board of Nursing was notified on 11/13/20 at 6:25 P.M. by the Administrator for 3 of 3 Nurses involved in this incident. The Attorney General's office was notified of the events concerning 41 patients residing on the North Unit and 3 nurses on 11/16/20 by the Administrator at 1:30 PM. The State reporting Hotline was called by the Administrator on 11/14/2020, at 12:30 PM, to report the allegations of Neglect concerning the residents on North Hall not receiving medications and treatments as ordered and the nurses abandoning her shift. The Director of Nursing was suspended pending investigation by the administrator on 11/13/2020 at 11:45 AM. The Director of Nursing was Terminated by the Administrator on 11/14/2020 at 1:41 PM. The Regional Director of Operations gave the Administrator a written warning for failing to report timely on 11/13/2020 at 7:00 PM. The SA validated on 11/18/2020, that all corrective actions had been taken by the facility to remove the IJ during the extended survey on 11/13/2020 and the IJ was removed on 11/16/2020.

Based on record review and staff interview, the facility failed to update and revise care plans for four (4) of five (5) residents reviewed. Residents #1, #2, #3 and #4. The facility's failure to revise and update the resident's care plans with current orders and treatments, placed the residents at risk, and in a situation which caused and was likely to cause serious injury, harm, impairment, or death. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 11/09/2020, as a result of 22 residents not receiving medications, and four (4) enteral feedings on the 3-11 shift on 11/09/2020, and 41 residents on the 11-7 shift on 11/10/2020, related to no licensed nurse available on duty. The facility's failure to provide a licensed nurse to revise and update care plans in order to administer medications and enteral feedings resulted in 4 residents not receiving enteral feedings per physicians orders, with two (2) of those residents currently experiencing significant weight loss. On 11/13/2020 at 1:20 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The IJ existed at: CFR483.21(b)(2) - Care Plan Timing And Revision (F657) - Scope and Severity - K The facility submitted a credible Removal Plan on 11/16/2020, at 4:00 PM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of 11/16/2020. The SA validated the Removal Plan on 11/18/2020 and determined the IJ was removed prior to exit. Therefore the scope and severity for CFR483.21(b)(2) - Care Plan Timing And Revision (F657) was lowered for a K level of scope and severity to a Elevel, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy titled Care Plans - Comprehensive dated 6/01/2000, revealed, It is the policy of this facility to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. Procedure: . 4. Care plans revised as changes in the resident's condition dictates. Reviews are made at least quarterly . Resident #1: Review of Resident #1's care plan revealed, I require tube feedings r/t (related to) dysphagia, last revised on 11/10/2020. Interventions listed were, Administer my medications, feedings and flushes as oredered and [MEDICATION NAME] 1.5 @ (at) 25 ml(milliliters)/hr(hour) X(times) 22 hours (8 am - 6 am). The facility had not updated the care plan with the current enteral feeding orders. Review of Resident #1's Order Summary Report, dated 11/12/2020 revealed an Enteral Feed Order - every shift - [MEDICATION NAME] 1.5 @ 50 ml/hr X 22 hours (8 am - 6 am), with a start date of 7/01/2020. Review of Resident #1's medical record revealed, he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 99, making him non-interviewable. He is totally dependant on one to two staff for all of his daily needs. He has a feeding tube and requires total assistance of one staff member for his enteral feeding. During an interview with the Care Plan Nurse and Director of Nursing (DON) on 11/13/2020, at 10:45 AM, they both verified the care plan had not been updated to reflect the current enteral feeding rate started on 07/01/2020, and it had not been identified during the latest revision on 11/10/2020. Resident #2: Review of Resident #2's care plans revealed a care plan for (Formal name) is at risk for nutritional problem or potential nutritional problem possible complication r/t feeding tube. There was only one intervention listed on the care plan that stated, I want the staff to observe/record/report to MD (Medical Director) PRN (as needed) s/sx (signs and symptoms) of malnutrition: Significant weight loss, observe for any complication r/t (related to)feeding tube. The care plan was not updated to include giving Resident #2 his feedings as order, his medications as ordered, or observing his fluid intake every shift. Review of Resident #2's Order Summary Report dated 11/12/2020, revealed an Enteral Feed Order - every shift - Diabetisource 55 cc (cubic centimeters)/hr continuous via peg (percutaneous endoscopic gastrostomy) tube, Flush with 150 ml amount every four hours, Record total feeding intake Q (every) shift, and record total H2O (water) intake Q shift. During an interview with the care plan nurse and the DON on 11/13/2020 at 10:45 AM, they both confirmed there was only one intervention on the enteral feeding care plan, and interventions for his feeding, medications, and fluid intake should have been on the care plan and were not present. Review of Resident #2's medical record revealed he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's MDS, dated [DATE], indicated he had a BIMS score off 99 making him non-interviewable. He is totally dependent on 1-2 staff for all of his daily care needs. He has a feeding tube and requires total assistance of one staff member for his enteral feeding. Resident #3: Review of Resident #3's medical record revealed, she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's MDS dated [DATE] revealed her BIMS score to be 99, making her non-interviewable. She required total assistance on one to two staff members for all aspects of her daily care. She has a feeding tube which provides her with more than 51% of her daily nutritional intake. She requires the total assist of one staff member for her enteral feeding. Review of Resident #3's Order Summary Report dated 11/12/2020 revealed an Enteral Feed Order - every shift - [MEDICATION NAME] 1.5 which began on 06/30/2020. Review of Resident #3's care plans revealed, I require tube feeding r/t NPO (nothing by mouth) & R (right) sided [MEDICAL CONDITION]. Interventions included: Administer my medication, feedings and flushes as ordered, Provide enteral feeding of [MEDICATION NAME] 1.2 at 60 ml/hr. During an interview with the care plan nurse and the DON on 11/13/2020 at 10:45 AM, both confirmed the care plan had not been updated to reflect the current order for [MEDICATION NAME] 1.5 instead of [MEDICATION NAME] 1.2 at 60 ml/hr. Resident #4: Review of Resident #4's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's MDS dated for 08/14/2020 revealed she required extensive to total assistance of one to two staff members for all of her daily activities except for eating, in which she only needed set up assistance and was able to feed herself. Review of Resident #4's Order Summary Report Dated 11/13/2020 revealed order to Apply warm moist compresses to left armpit two to three times a day x 3 days and an order for [REDACTED]. Review of Resident #4's care plans revealed, (Formal Name) has infection of the left axilla (abscess). Date initiated: 11/13/2020 Interventions: Administer anti-[MEDICAL CONDITION] as per MD orders, Monitor/Document/report to MD PRN for s/sx of UTI: Frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain. hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes. The care plan interventions were for a Urinary Tract Infection [MEDICAL CONDITION], not an abscess under her axilla, and there was no mention of the orders for the warm compresses or the antibiotic ordered for the infection. During an interview with the care plan nurse and the DON on 11/13/2020 at 10:45 AM, both confirmed the care plan had not been updated to reflect the current orders for the warm compress, antibiotic therapy, and the error of placing interventions of a UTI on the care plan. Both the DON and Care Plan Nurse confirmed that they were aware of the problems with care plans due to the Care Plan Nurse being frequently pulled on-call and having a hard time keeping up with the MDSs and Care Plans. On 11/14/2020, in an interview with the Medical Director (MD), he stated that he was made aware of the incident the following morning. He stated that it was unfortunate that it occurred and that upon review of records, he had uncovered some that need to be fine tuned also. The MD stated that he would have to start looking at the Care Plans to make sure everything matches up. The facility submitted a credible Removal Plan for the IJ on 11/16/20. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. The Residents on the North Hall were assessed on 11/10/2020 at 11:00 AM. There were no significant outcomes or findings noted during evaluations. The residents did not get their missed doses of medications, and the Medical Director (MD) ordered to skip the missed doses. There were no significant health issues, falls or injuries during the time there was no nurse present. The Medication Administration Records (MAR's) were reviewed by the Medical Records Nurse on 11/10/2020 at 11:00 AM noting that medications, enteral feedings, treatments and monitors had not been completed. The Medical Director reviewed the complete MAR indicated [REDACTED]. The Administrator audited the schedule on 11/10/2020 at 7:30 AM to ensure that adequate staff were scheduled for the month, there were no holes noted in the schedule. 2. The Quality Assurance Committee met on 11/13/2020 at 1:30 PM, including the Medical Director via phone, Regional Director of Operations, Administrator, Interim DIRECTOR OF NURSING, Infection Preventionist, MDS Coordinators, Social Service Director, Social Service Assistant, Dietary Manager, Life Connections, Medical Records, Business Office Manager, Human Resources Director, and Rehabilitative Services Director to discuss the IJ's noted by the survey team. The Quality Assurance Committee met and discussed the staffing, on-call procedure, and policy on reporting staffing concerns. It was noted by the Quality Assurance Committee that the policies were not being followed appropriately. There will be an on-call nurse to fill in shifts if needed. Staff will call the Staffing Aid to call in for shifts, or to report a call in received at the facility. If a staff member does not show up for work, the on-call nurse will be notified to come in for the shift. The Director of Nursing and the Administrator will be notified by the staff on duty of any staffing concerns. The facility has a staffing agency contract with Precision Staffing. In the event the Director of Nursing or the Assistant Director of Nursing works as a charge nurse, the Regional Nurse Consultant will be notified to assist in completing nurse administrative duties. 3. An in-service was initiated by the Administrator for nurses on 11/10/2020 concerning notifying the Director of Nursing and the Administrator with staffing concerns. On 11/13/2020 an in-service was initiated by the Administrator for all staff concerning the call in process, the on call process and notifying the Administrator and the Director of Nursing of any staffing concerns. An in-service was initiated on 11/10/2020 and on 11/13/2020 by the Administrator for Nurses concerning Abuse and Neglect including an explanation of the meaning of job abandonment. 4. The Board of Nursing was notified on 11/13/20, at 6:25 PM, by the Administrator for 3 of 3 Nurses involved in this incident. The Attorney General's office was notified of the events concerning 41 patients on and 3 nurses on 11/16/20 by the Administrator at 1:30 PM. The State reporting Hotline was called by the Administrator on 11/14/2020, 12:30 PM, to report the allegations of Neglect concerning the residents on North Hall not receiving medications and treatments as ordered and the nurse abandoning her shift. The Director of Nursing was suspended pending investigation by the administrator on 11/13/2020 at 11:45 AM. The Director of Nursing was Terminated by the Administrator on 11/14/2020 at 1:41 PM. The Regional Director of Operations gave the Administrator a written warning for failing to report timely on 11/13/2020 at 7:00 PM. The facility alleges that all actions to remove the IJ on 11/13/2020 were completed as of 11/16/2020. The facility alleged that all corrective actions were completed on 11/16/2020, and removal of the Immediate Jeopardy (IJ) on 11/16/2020. On 11/18/2020, the AS surveyor validated through staff interview, resident interview, record review, sign-in sheets and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): 1. The SA verified through record reviews, and staff interviews, that the residents on the North Unit were assessed on 11/10/2020. No significant outcomes or findings were noted on the evaluations. The Medical Director (MD) gave orders to skip the missed doses. The Medication Administration Records (MAR's) were reviewed by the Medical Records Nurse on 11/10/2020 noting that medications, enteral feedings, treatments and monitors had not been completed. The Medical Director reviewed the complete MAR's of all patients residing on the North Unit on 11/11/2020, with no new orders or concerns. The Administrator audited the schedule on 11/10/2020 to ensure that adequate staff were scheduled for the month, there were no holes noted in the schedule. 2. The SA verified through record review, observation of sign-in sheets, and staff interview, the Quality Assurance Committee met on 11/13/2020 at 1:30 PM, including the Medical Director via phone, Regional Director of Operations, Administrator, Interim DIRECTOR OF NURSING, Infection Preventionist, MDS Coordinators, Social Service Director, Social Service Assistant, Dietary Manager, Life Connections, Medical Records, Business Office Manager, Human Resources Director, and Rehabilitative Services Director to discuss the IJ's noted by the survey team. The Quality Assurance Committee discussed staffing, on-call procedure, and the policy on reporting staffing concerns. There will be an on-call nurse to fill in shifts if needed. Staff will call the Staffing Aid to call in for shifts, or to report a call in received at the facility. If a staff member does not show up for work, the on-call nurse will be notified to come in for the shift. The Director of Nursing and the Administrator will be notified by the staff on duty of any staffing concerns. The facility has a staffing agency contract with Precision Staffing. In the event the Director of Nursing or the Assistant Director of Nursing works as a charge nurse, the Regional Nurse Consultant will be notified to assist in completing nurse administrative duties. 3. The SA verified through review of sign-in sheets, in-service review, and staff interview, an in-service was initiated by the Administrator for nurses on 11/10/2020 concerning notifying the Director of Nursing and the Administrator with staffing concerns. On 11/13/2020 an in-service was initiated by the Administrator for all staff concerning the call in process, the on call process and notifying the Administrator and the Director of Nursing of any staffing concerns. An in-service was initiated on 11/10/2020 and on 11/13/2020 by the Administrator for Nurses concerning Abuse and Neglect including an explanation of the meaning of job abandonment. 4. The SA verified through review of personnel files, fax confirmation reviews, and staff interview that the Board of Nursing was notified on 11/13/20 at 6:25 P.M. by the Administrator for 3 of 3 Nurses involved in this incident. The Attorney General's office was notified of the events concerning 41 patients residing on the North Unit and 3 nurses on 11/16/20 by the Administrator at 1:30 PM. The State reporting Hotline was called by the Administrator on 11/14/2020 12:3 to report the allegations of Neglect concerning the residents on North Hall not receiving medications and treatments as ordered and the nurses abandoning her shift. The Director of Nursing was suspended pending investigation by the administrator on 11/13/2020 at 11:45 AM. The Director of Nursing was Terminated by the Administrator on 11/14/2020 at 1:41 PM. The Regional Director of Operations gave the Administrator a written warning for failing to report timely on 11/13/2020 at 7:00 PM. The SA validated on 11/18/2020, that all corrective actions had been taken by the facility to remove the IJ during the extended survey on 11/13/2020 and the IJ was removed on 11/16/2020.

Based on record review, schedule review, resident interview, and staff interview, the facility failed to provide sufficient qualified nursing staff to provide nursing related service to assure resident safety for one (1) of two (2) units, as evidenced by 22 residents without licensed nursing services from 3:00 PM on 11/09/2020 to 6:10 AM on 11/10/2020, and 41 residents without licensed nursing services from 11:47 PM on 11/09/2020 to 6:10 AM on 11/10/2020. The North Unit. The facility's failure to provide a licensed nurse on the 3-11 shift on 11/09/2020, and again on the 11-7 shift on 11/10/2020 to administer medications, treatments, enteral feedings, and nursing services, placed the residents at risk, and in a situation which caused and was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 11/09/2020, as a result of 22 residents not receiving nursing related services on the 3-11 shift on 11/09/2020, and 41 residents on the 11-7 shift on 11/10/2020, related to no licensed nurse available on duty. The facility's failure to provide a licensed nurse to administer medications and enteral feedings resulted in 4 residents not receiving enteral feedings per physicians orders, with two (2) of those residents currently experiencing significant weight loss. On 11/13/2020, at 1:20 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The IJ existed at: CFR483.35(a)(1) - Sufficient Nursing Staff (F725) - Scope and Severity - K The facility submitted a credible Removal Plan on 11/16/2020, at 4:00 PM, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ removed as of 11/16/2020. The SA validated the Removal Plan on 11/18/2020 and determined the IJ was removed prior to exit. Therefore the scope and severity for CFR483.35(a)(1) - Sufficient Nursing Staff (F725) was lowered for a K level of scope and severity to an E level, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: On 11/13/2020, at 2:45 PM, during an interview with Licensed Practical Nurse (LPN) #1, he stated, he was not originally scheduled on Monday (11/09/2020), however, he was asked to pick up a 3-11 shift on the short hall. When he arrived at work, he counted the narcotics and took the keys for the short hall. At 3:30 PM, the second nurse had not arrived for the long hall. The Director of Nursing (DON) came to the desk around 4:30 PM, and informed him he would be the only nurse on the 3-11 shift. LPN #1 told her he was not passing pills to all 41 residents, it was too much for one nurse. LPN #1 stated, he did not have time to pass the medications and care for the resident's on the long hall during his shift. The 11-7 nurse arrived, and when she found out she would be working the North unit alone, she refused to count narcotics and take the keys from him, clocked out, called the Administrator and went home. LPN #1 clocked out that night at 11:22 PM, but didn't leave the building because he was waiting on someone to come and count the cart with him. He called the scheduler and she said to call the DON. He called the DON after 11:30 PM, and left her a voicemail that he could not stay and there was no nurse on the North unit. He attempted to call her a second time and still got no answer. He stated he felt he had notified everybody he could. When LPN #1 couldn't get anyone to count the cart with him he locked the cart keys up and left the building. He did not stay until his replacement arrived because he had to go home. On 11/12/2020 at 11:54 AM, during an interview with LPN #2, she indicated, on Monday night, (11/09/2020), she arrived at work and clocked in. LPN #1 told her no one ever showed up to pass medications on the long hall, and he wasn't going to do it either. He said he told the DON he would hold the keys but was not giving out the meds. She told LPN #1 he needed to call the doctor and get a onetime order to give the medications late, and to pass out their medications before he left. He got upset and walked away and refused to do it. She told LPN #1 she was not working the unit alone and giving the medications for the 3-11 shift and the 11-7 shift. LPN #2 grabbed her jacket and bag and clocked back out. She called the scheduler and asked for the DON's phone number. After several attempts, she answered the phone and said, well he told me he wasn't going to do it, but I didn't think he was serious. Well I don't know what to do because the Administrator doesn't want me to work the cart. LPN #2 then called the Administrator, and after a couple tries she answered, and LPN #2 told her LPN #1 had not passed medications on the 3-11 shift, and she wasn't working after that on 11-7 by herself. The following morning, at 6:45 AM, she received a call from LPN #3 asking where she was and where the keys were. LPN #2 told her she had not worked the 11-7 shift, she had left LPN #1 at the nurses station, and she would have to call him. She was told then by LPN #3 that no nurse had worked the North Unit at all that night then, and that LPN #1 had left the keys and went home too. On 11/12/2020, at 2:20 PM, during an interview with LPN #3, she indicated, on Tuesday morning, 11/10/2020, she arrived at work early at around 6:15 AM, and could not find a nurse on the North unit to get report from. She was told by a Certified Nurse Aide there had been no nurse on North unit all night after LPN #1 had left on the 3-11 shift. After searching for the keys to both carts until 8:30 AM, she went to find the Administrator and ask her to help find the keys, or to give her another key so she could pass her medications without them being late. On 11/12/2020, at 2:25 PM, during an interview with the Administrator, she indicated, she was not made aware there was not 2 nurses on the North unit for the 3-11 shift. She received a phone call from LPN #2 at around 1:00 AM on 11/10/2020, stating that LPN #1 had refused to pass meds on the long hall because he said it was too much for one nurse to do. She instructed LPN #2 to call the medical director, and get an order to give the medications late, to get a set of vitals on all the residents, to check and make sure they were doing okay, and to notify the DON. She stated she told LPN #2 she would take care of the issue with LPN #1 in the morning when she got to work. She arrived at the facility around 5:30 AM, and called the DON to ask her about the situation. The DON stated she didn't know anything about it. It was not until around 8:30 AM she realized there was no nurse at all on the 11-7 shift, because that is when LPN #3 came to get her to help find the keys to both carts on the North unit. She stated LPN #3 told her she had gotten report from the three aides who had been here by themselves all night. On 11/12/2020 at 2:40 PM, during an interview with the DON she stated she had spoken to LPN #1 at around 4:30 PM before she left to go home. He was not happy about being the only nurse on the 3-11 shift, stating he wasn't going to do it again. She stated LPN #1 did not mention that he wasn't going to do it that night. She didn't hear anything else from anyone until between 10:30 - 11:00 PM when LPN #2 had called her to tell her that LPN #1 had not completed the med pass on half of the North unit, and that he was not going to do it. She told LPN #2 to call the Medical Director (Formal Name) and get an order to give the medications late, and for her to catch up as many of them as she could during her medication passes. LPN #2 told her she wasn't going to do it, it was too much to do and was unacceptable, and asked for the Administrator's phone number and was calling her to report this all to her. The DON states she thought the Administrator was going to handle the situation, so she didn't follow up or come to the building. When she arrived at the facility the following morning, she learned both LPN #1 and LPN #2 had left the building, and the South unit nurse was the only nurse left in the building all night. During an additional interview with the Administrator on 11/13/20 at 10:15 AM she confirmed that she had notified the medical director around 5:30 AM and notified her Corporate Regional Director of the incident and Doctor (Formal Name), of the lack of nursing care to the residents and sent him the electronic medical record of the residents that missed medications. She notified the human resource officer and started in-services on abuse and neglect. She also had the social worker do a psychological assessment on each of the residents and received a grievance from Resident #4 because she had not received her medications. She did not talk to the DON until about 7:00 AM that morning when she came to the facility. She had tried to call her prior to that but she did not answer her phone. She did not know that LPN #2 had spoken with the DON. The administrator agrees that the DON should have come to the building when she was called at 10:30 PM by LPN #2. The Administrator stated, This is her first job as a registered nurse in a Long Term Care building and her first job as a DON. The Administrator verified that the DON had been trained and in-serviced prior to this incident of reporting neglect and had been trained in her role as a DON. During an additional interview with the DON on 11/13/20, at 10:45 AM, she stated: I left that day (11/09/20) at 4:45 PM and before I left, LPN #1 was on the North hall and he told me that it was too much to take care of 43 residents and that he wasn't going to keep doing this and so I told him that other nurse's had done it in the past and that it could be done. I left after that and went home . About 10:30 PM I got a call from LPN #2, she was screaming into the phone and stated she refused to count with him. She told me that she wasn't going to take the keys to the medication cart. I thought that after she talked to the Administrator she would stay. The DON confirmed that she went back to bed and did not call the facility to check and did not come to the facility to check on the situation. I talked to the Administrator and I told her that I had talked to LPN #2 and that I had given LPN #2 her number to call her. I didn't know that I was suppose do anything, I can't make an employee work. The DON confirms that this was an allegation of neglect when the LPN reported to her at 10:30 PM that the nurse had not given medications to the resident's but she stated that she didn't know she was suppose to do anything about it, she thought that is what the Administrator does. The DON confirmed that she had spoken with LPN #2, who had called upset twice during the 10:30 PM until 11:00 PM timeframe. I'm new to this role, I thought that is what the administrator does, and I haven't been orientated to the medication cart anyway. I never talked to the Administrator that night, I thought everything was ok. The DON confirmed that the facility did have an on-call nurse that night, but she didn't call her because corporate had told them that morning to not to use the MDS nurses for on-call anymore. The DON confirmed that she has been employed by the facility for close to a month. During an interview with the Assistant Director of Nursing (ADON) on 11/13/20, at 3:08 PM, she revealed that she was told by the DON on Tuesday morning that the 3-11 and 11-7 shifts were not covered. The DON informed her the Administrator had a meeting with the staff on Monday (11/09/20) and said we were not going to overstaff this building and took the schedule down to one nurse for each wing on 3-11 and 11-7 shift. The staff began getting angry. I wasn't here but I had heard about it from the DON. She said the Administrator and the Regional Director were arguing that we should only have one nurse on each unit. Then on Tuesday morning the Administrator got up and left the meeting and said she had miscalculated this 120-bed building for a 60-bed building and that she had made a mistake. So, then we went back to the original schedule of 4 nurses instead of 2 for the building. On 11/13/2020, at 3:30 PM, during an interview with the Staffing Scheduler she stated: I received a text from LPN #2 at 11:35 PM, needing the DON's phone number. I responded to her at 12:00 AM. I tried to call the DON and Administrator myself. I could not reach the DON, and when I tried to call the Administrator, she was on the phone with LPN #2. I remember seeing LPN #1 before I left to transport a [MEDICAL TREATMENT] resident that afternoon (11/09/2020), and when I called the on-call nurse, she said they had just had a meeting and was told to only staff each unit with one nurse from now on. I didn't know there was not a nurse on the 11-7 shift until the next morning (11/10/2020), when LPN #3 asked me if I had seen the North unit nurse, she needed report and the cart keys. On 11/13/2020 at 3:45 PM, during an interview with the Minimum Data Set (MDS) nurse, she stated: I was the nurse on-call for Monday (11/09/2020). I got a call from the scheduler at around 3:30 PM saying there was only one nurse on the North Unit. I explained to her we were just told in a meeting, there was only going to be one nurse per unit for 3-11 and 11-7 from now on. I explained the new staffing ratio to her, due to our current census. I didn't talk to anyone else for the remainder of the evening and night. I woke up the next morning and checked the on-call phone and there were no text messages, phone calls or voicemail. I didn't know there was not a nurse for the 11-7 shift on North unit until I arrived the next morning for work. On 11/14/2020, in an interview with the Medical Director (MD), he stated that he was made aware of the incident the following morning. He stated that it was unfortunate that it occurred. Review of the facility's daily schedule for 11/09/2020 and Individual Employee Time Cards for all licensed nurses employed at the facility revealed, LPN #4 clocked in at 4:25 PM, worked on the South Unit, and clocked out at 09:31AM on the morning of 11/10/2020. LPN #1 clocked in at 2:53 PM on 11/09/2020, and clocked out at 11:22 PM on 11/09/2020. LPN #2 clocked in at 11:03 PM on 11/09/2020, and clocked out at 11:47 PM on 11/09/2020. LPN #3 clocked in at 6:10 AM on 11/10/2020, and clocked out at 3:52 PM on 11/10/2020. The facility had one LPN on the North Unit from 2:53 PM - 11:22 PM who refused to pass medications to 22 of 41 residents. The 11-7 nurse, clocked in at 11:03 PM, and clocked back out at 11:47 PM, when she found out she would be covering medication pass for the 22 residents that did not get them on the 3-11 shift, and then passing medications and caring for the entire unit of 41 residents by herself. This left 22 residents without licensed nursing services from 3:00 PM on 11/09/2020 to 6:10 AM on 11/10/2020, and 19 residents without licensed nursing services from 11:47 PM on 11/09/2020 to 6:10 AM on 11/10/2020. The facility submitted a credible Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. The Residents on the North Hall were assessed on 11/10/2020 at 11:00 AM. There were no significant outcomes or findings noted during evaluations. The residents did not get their missed doses of medications, and the Medical Director (MD) ordered to skip the missed doses. There were no significant health issues, falls or injuries during the time there was no nurse present. The Medication Administration Records (MAR's) were reviewed by the Medical Records Nurse on 11/10/2020 at 11:00 AM noting that medications, enteral feedings, treatments and monitors had not been completed. The Medical Director reviewed the complete MAR indicated [REDACTED]. The Administrator audited the schedule on 11/10/2020 at 7:30 AM to ensure that adequate staff were scheduled for the month, there were no holes noted in the schedule. 2. The Quality Assurance Committee met on 11/13/2020, at 1:30 PM, including the Medical Director via phone, Regional Director of Operations, Administrator, Interim DIRECTOR OF NURSING, Infection Preventionist, MDS Coordinators, Social Service Director, Social Service Assistant, Dietary Manager, Life Connections, Medical Records, Business Office Manager, Human Resources Director, and Rehabilitative Services Director to discuss the IJ's noted by the survey team. The Quality Assurance Committee met and discussed the staffing, on-call procedure, and policy on reporting staffing concerns. It was noted by the Quality Assurance Committee that the policies were not being followed appropriately. There will be an on-call nurse to fill in shifts if needed. Staff will call the Staffing Aid to call in for shifts, or to report a call in received at the facility. If a staff member does not show up for work, the on-call nurse will be notified to come in for the shift. The Director of Nursing and the Administrator will be notified by the staff on duty of any staffing concerns. The facility has a staffing agency contract with Precision Staffing. In the event the Director of Nursing or the Assistant Director of Nursing works as a charge nurse, the Regional Nurse Consultant will be notified to assist in completing nurse administrative duties. 3. An in-service was initiated by the Administrator for nurses on 11/10/2020 concerning notifying the Director of Nursing and the Administrator with staffing concerns. On 11/13/2020 an in-service was initiated by the Administrator for all staff concerning the call in process, the on call process and notifying the Administrator and the Director of Nursing of any staffing concerns. An in-service was initiated on 11/10/2020 and on 11/13/2020 by the Administrator for Nurses concerning Abuse and Neglect including an explanation of the meaning of job abandonment. 4. The Board of Nursing was notified on 11/13/20 at 6:25 PM by the Administrator for 3 of 3 Nurses involved in this incident. The Attorney General's office was notified of the events concerning 41 patients on and 3 nurses on 11/16/20 by the Administrator at 1:30 PM. The State reporting Hotline was called by the Administrator on 11/14/2020, at 12:30 PM, to report the allegations of Neglect concerning the residents on North Hall not receiving medications and treatments as ordered and the nurse abandoning her shift. The Director of Nursing was suspended pending investigation by the administrator on 11/13/2020 at 11:45 AM. The Director of Nursing was Terminated by the Administrator on 11/14/2020 at 1:41 PM. The Regional Director of Operations gave the Administrator a written warning for failing to report timely on 11/13/2020 at 7:00 PM. The facility alleges that all actions to remove the IJ on 11/13/2020 were completed as of 11/16/2020. The facility alleged that all corrective actions were completed on 11/16/2020, and removal of the Immediate Jeopardy (IJ) on 11/16/2020. On 11/18/2020, the SA surveyor validated through staff interview, resident interview, record review, sign-in sheets and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): 1. The SA verified through record reviews, and staff interviews, that the residents on the North Unit were assessed on 11/10/2020. No significant outcomes or findings were noted on the evaluations. The Medical Director (MD) gave orders to skip the missed doses. The Medication Administration Records (MAR's) were reviewed by the Medical Records Nurse on 11/10/2020 noting that medications, enteral feedings, treatments and monitors had not been completed. The Medical Director reviewed the complete MAR's of all patients residing on the North Unit on 11/11/2020, with no new orders or concerns. The Administrator audited the schedule on 11/10/2020 to ensure that adequate staff were scheduled for the month, there were no holes noted in the schedule. 2. The SA verified through record review, observation of sign-in sheets, and staff interview, the Quality Assurance Committee met on 11/13/2020 at 1:30 PM, including the Medical Director via phone, Regional Director of Operations, Administrator, Interim DIRECTOR OF NURSING, Infection Preventionist, MDS Coordinators, Social Service Director, Social Service Assistant, Dietary Manager, Life Connections, Medical Records, Business Office Manager, Human Resources Director, and Rehabilitative Services Director to discuss the IJ's noted by the survey team. The Quality Assurance Committee discussed staffing, on-call procedure, and the policy on reporting staffing concerns. There will be an on-call nurse to fill in shifts if needed. Staff will call the Staffing Aid to call in for shifts, or to report a call in received at the facility. If a staff member does not show up for work, the on-call nurse will be notified to come in for the shift. The Director of Nursing and the Administrator will be notified by the staff on duty of any staffing concerns. The facility has a staffing agency contract with Precision Staffing. In the event the Director of Nursing or the Assistant Director of Nursing works as a charge nurse, the Regional Nurse Consultant will be notified to assist in completing nurse administrative duties. 3. The SA verified through review of sign-in sheets, in-service review, and staff interview, an in-service was initiated by the Administrator for nurses on 11/10/2020 concerning notifying the Director of Nursing and the Administrator with staffing concerns. On 11/13/2020 an in-service was initiated by the Administrator for all staff concerning the call in process, the on call process and notifying the Administrator and the Director of Nursing of any staffing concerns. An in-service was initiated on 11/10/2020 and on 11/13/2020 by the Administrator for Nurses concerning Abuse and Neglect including an explanation of the meaning of job abandonment. 4. The SA verified through review of personnel files, fax confirmation reviews, and staff interview that the Board of Nursing was notified on 11/13/20 at 6:25 P.M, by the Administrator for 3 of 3 Nurses involved in this incident. The Attorney General's office was notified of the events concerning 41 patients residing on the North Unit and 3 nurses on 11/16/20 by the Administrator at 1:30 PM. The State reporting Hotline was called by the Administrator on 11/14/2020, at 12:30 PM, to report the allegations of Neglect concerning the residents on North Hall not receiving medications and treatments as ordered and the nurses abandoning her shift. The Director of Nursing was suspended pending investigation by the administrator on 11/13/2020 at 11:45 AM. The Director of Nursing was Terminated by the Administrator on 11/14/2020 at 1:41 PM. The Regional Director of Operations gave the Administrator a written warning for failing to report timely on 11/13/2020 at 7:00 PM. The SA validated on 11/18/2020, that all corrective actions had been taken by the facility to remove the IJ during the extended survey on 11/13/2020 and the IJ was removed on 11/16/2020.

Based on record review, facility policy review, and staff interview, the facility failed to provide Quality Assurance (QA) programs to evaluate and monitor the behavioral programming needs for Resident #141 to prevent the sexual abuse of Resident #34 for one (1) of eight (8) residents reviewed. On Sunday, March 1, 2020 at approximately 2:00 PM, Resident #141 was witnessed by Resident #14 and Licensed Practical Nurse (LPN) #1, to be sexually, inappropriately touching/fondling Resident #34. Resident #141 had his hands inside the pants and brief of Resident #34. Resident #141 was sent out of the facility to a Behavioral Health facility in another town. Prior to the incident on 03/01/2020 between Resident #141 and Resident #34, Resident #141 had been involved in two (2) previous alleged incidents of sexual inappropriate comments/gestures toward other residents in the facility on 02/26/2020 and 02/05/2020. There was no identification of the residents involved in the incident on 02/05/2020 and no facility investigation was conducted. The facility's monitoring programs failed to identify and report the incident to the appropriate Administrative and State agencies. The facility's failure to plan and implement appropriate Quality Assurance programs after each of the incidents of inappropriate verbal abuse/gestures by Resident #141 toward other residents on 02/26/2020 and 02/05/2020, and sexual abuse on 03/01/2020 caused harm to Resident #34 and placed other residents at risk in a situation that was likely to cause serious injury, harm, impairment or death. The State Agency (SA) determined the situation to be an Immediate Jeopardy (IJ) which began on 02/05/2020, when the facility failed to plan and implement a QA monitoring program for Resident #141 sexual behaviors. The facility Administrator (ADM) was notified of the Immediate Jeopardy (IJ) on 06/30/2020 at 4:45 PM. The facility submitted an acceptable Removal Plan on 07/02/2020 at 10:00 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 07/02/2020, and the IJ removed on 07/02/2020 at 5:25 PM. The SA validated the facility's Removal Plan on 07/03/2020 and determined the IJ was removed on 07/02/2020. Therefore, the scope and severity for 42 CFR (s): 483.75 (g)(2)(ii) QAPI/QAA Improvement Activities, (F867) was lowered from a J to a scope and severity of a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's Behavior Management policy, dated November 30, 2017, revealed: The Quality Assurance/Performance Improvement (QA/PI) committee will review the Behavior Management program not less than quarterly. The review will include but is not limited to review and trending of: a) The number of residents requiring behavior management; b) The number of discharges related to behavioral issues; c) The number of incidents related to behavior; d) The relevant Quality Indicators. Based on the results of the review, the QA/PI committee will develop and implement any needed systemic changes and/or staff education. Review of the facility's Antipsychotic and Other Psychoactive Medication policy, dated July 26, 2013, revealed: The QA/PI committee will review the use psychoactive medication effectiveness in the facility at least quarterly or as often as needed. This review should include: The percentage of residents receiving antipsychotics, the percentage of residents receiving other psychoactive medications, the percentage of attempted GDR/tapering of psychoactive medications the percentage of successful reductions attempts, the number of residents that were admitted on psychoactive medications since the last review, the number of residents placed on psychoactive medication after admission since the last review, and Relevant Quality Indicators. Based on the results of the review the QA/PI committee will develop and implement any needed systemic changes and/or staff education. Record review of the nursing progress notes for Resident #141, dated 02/05/2020 at 13:35 (1:15 PM) revealed: Staff reported that another resident (unidentified) had reported that Resident #141 was making sexual remarks to them. The record review revealed that the facility did not identify the residents involved, did not indicate the incident of alleged sexual abuse was reported to the administrator (ADM). The facility did not generate an investigation and did not report the incident of verbal abuse to the appropriate State agencies. The nursing progress notes, dated 02/05/2020, for Resident #141, revealed Resident #141 denied the allegations made against him on 02/05/2020. As a result of the non-investigated and reported incident on 02/05/2020, Resident #141 was transferred to a Behavioral Health facility located out of town. The record review revealed that Resident #141 had no Behavioral monitoring documented. A record review of nursing progress notes, dated 02/26/2020 at 1622 (4:22 PM), revealed Resident #141 the Medical Director (MD) and the resident's Responsible Party (RP) had been made aware that Resident #141 had been involved in making sexually inappropriate comments and/or gestures toward several male residents. An investigation was done, but no Abuse was reported to the State agencies and no monitoring programs put in place for Resident #141. As a result of the incident on 02/26/2020 of sexually inappropriate verbal remarks and/or gestures to the other residents from Resident #141, he was prescribed Depo-[MEDICATION NAME] Suspension 150 milligrams/milliliters (MG/ML) intramuscular (IM) injection via an order from the Medical Director/Treating Physician. Review of Resident #141's nursing progress notes, revealed that on 03/01/2020, Resident #141 was observed touching Resident #34 inappropriately. After the incident occurred on 03/01/2020, Resident #141 was given an IM injection of [MEDICATION NAME] as the local police stood by. Review of the medical record of Resident #141, revealed, he was placed on several psychoactive medications after his admission to the facility on [DATE]. There was no documentation to support that the medications and/or the Behaviors had been monitored by the Quality Assurance committee after the incidents on 02/05/2020, 02/26/2020, and 03/01/2020. During an interview with the ADM, on 06/29/2020 at 2:30 PM, she revealed that she had no knowledge of the incident of verbal abuse that occurred on 02/05/2020 with Resident #141 making inappropriate sexual remarks and/or gestures toward other residents. The ADM confirmed that no Quality Assurance meetings had taken place after the incident of verbal abuse on 02/05/2020 because the incident had been unreported. In an interview with the ADM, on 06/29/2020 at 2:30 PM, she confirmed that she had not reported the incident of 02/26/2020 to the State agencies because she did not feel that there was any abuse involved in the incident. The ADM stated that no Quality Assurance meeting took place after the incident of 02/26/2020 because there was no abuse verified and no specifics were determined as a result of the resident's interviews. In an interview on 6/29/2020 at 2:20 PM the ADM stated that the behaviors of resident #141 had not been monitored as per the facility policy. The facility submitted a Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. All cognitively intact residents were interviewed on 7/1/20 9:30 AM regarding abuse, neglect and safety by Social Service Director and Social Services Assistant with no residents stating he/she had any concerns of abuse, neglect or safety. Residents stated he/she feels safe. Regarding the alleged incident of resident to resident sexual abuse from Resident #141against Resident #34 on March 1, 2020. Resident #34 was assessed by Nurse #3. With no injuries noted and no complaints of pain or discomfort. Resident #141 declined assessment by Nurse #3. 2. Regional Director of Operations called an emergency QAPI/QA meeting on 06/30/20 at 3 PM to discuss IJs called during extended survey. In attendance at the emergency QAPI/QA meeting was Medical Director, Administrator, Director of Nursing, Infection Control Nurse, Regional Director of Operations, and Regional Nurse Consultant. The topics of discussion during the meeting were aforementioned allegations of resident to resident abuse, policy review of Abuse/Neglect Policy, Reporting and Care Planning, training and education of staff, and monitoring. Another emergency QAPI/QA meeting was held on 07/01/20 at 2 PM to discuss additional IJs Abuse and Neglect Chemical Restraints, Quality Assurance and Performance Improvements, and Behavioral Health Services. A policy review of Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement was held. Additionally, training and education of staff and monitoring was discussed. The following QAPI/QA committee members were present: Administrator, Director of Nursing, Social Service Director, Life Connections, MDS Nurse #1 and #2, Social Service Assistant, Medical Director, HR/BOM, Director of Rehab, Housekeeping Supervisor, Dietary Manager, Nurse Unit Manager #5, Admissions, Medical Records Nurse, Life Connections Assistant, and Infection Control Nurse. 3. The following policies were reviewed on 06/30/20 at 3 PM during the QAPI/QA meeting: Abuse/Neglect Policy, Reporting and Care Planning. No revisions were made to the policies. On 07/01/20 at 3 P.M. during the QAPI/QA meeting, the following policies were reviewed: Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement. No revisions were made to the policies. 4. On 07/02/20 chart audits were conducted by Regional Nurse Consultant, MDS Nurse #1 and #2, and Psychiatric Nurse Practitioner at 12 PM for other incidents of abuse, chemical restraints, and care plan revisions. On 07/02/20 at 12 PM, Psychiatric Nurse Practitioner identified and conducted a medication evaluation/review of 19 residents prescribed psychotherapeutic medication. The following 19 resident charts were reviewed with 3 recommendation's for dose reductions and 2 recommendations for hospice to clarify/review orders, #45, Unsampled Resident A, Unsampled Resident BO, Unsampled Resident AR, Unsampled Resident BF, Unsampled Resident BD, Unsampled Resident AH, Unsampled Resident BP, Unsampled Resident U, #15, Unsampled Resident X, Unsampled Resident BV #79, Unsampled Resident Y, Unsampled Resident AB, Unsampled Resident AF, #9, and Unsampled Resident BK. On 07/02/20 at 12 PM MDS Nurse #1 and #2 conducted care plan reviews for residents with behavior care plans and Rx of psychotherapeutic medication to ensure least restrictive measures have been incorporated into the plan of care. The Care Plan for Resident #141 was updated by MDS Nurse #1 and #2 on 07/01/20 at 10AM inclusive of aggressive behaviors, de-escalation, grieving losses, sexual behavior with goals/interventions of utilizing life connections and social service for psychosocial well-being, leisure activities, expression of feelings, and communication with family. Interventions for Direct Care staff were included in this care plan. Resident #141 was transferred to hospital on [DATE] at 11:44 PM for chest pain at the direction of Medical Director. The Care Plan will be updated on return. On 07/02/20 Regional Nurse Consultant conducted chart review at 12 PM for other abuse incidents. There are no findings of other instances of alleged abuse that has gone unaddressed/reported at this time. 5. On 6/30/20 at 3 PM Regional Director of Operations, provided Corrective Counseling to Administrator regarding Abuse/Neglect Reporting and Investigations in accordance to the policy on Abuse and Neglect. On 07/01/20 at 3:30 PM Administrator conducted 1:1 in-service and corrective coaching with Nurse #2 on Abuse/Neglect Policy and Reporting of incidents whether or not it is known if the incident has been previously reported. Nurse #2 voiced understanding of policy and procedure. 6. An education in-service was conducted by Administrator beginning on 6/30/2020 at 5:00 PM on Care plans policy and procedure and utilizing the care plan, and reporting of changes in condition and behavioral changes. On 07/01/20 at 1 PM Regional Director of Operations and Regional Nurse Consultant in-serviced Administrator, Director of Nursing, Social Service Director and Social Services Assistant, and Life Connections on utilizing Behavior Management Plan inclusive of De-escalation procedures. On 07/01/20 at 11:30 AM an in-service was conducted by Administrator on Behavior Management and Resident Rights with staff inclusive of de-escalation techniques of aggressive behavior as a non-medication approach to promote the psycho-social well-being of a resident. Staff educated that all residents have the right before medications are given. Behavior Management training has been added to the orientation process for new hires. No employee will be allowed to return to work until he/she has completed the educational in-service.Care Plan Education was provided by Regional Nurse Consultant on 7/1/20 at 10 AM with MDS Coordinator #1 and # 2, Social Service Director and Social Services Assistant, and Life Connections to include care planning after each incident report, change of condition, change in behavior, quarterly updates, yearly updates and working with the multi-disciplinary team when care planning to include sexual behaviors, aggressive behaviors, utilizing all forms of information, collaboration, policy and procedure were reviewed. No employee will be allowed to return to work until he/she has completed the educational in-services on Care Plan Policy, Using the Care Plan, reporting of changes in condition and behavior changes, and updating the Care Plan, Abuse and Neglect Policy, Reporting Abuse and Neglect, Behavior Management Policy and De-escalation Techniques. The facility alleged that all corrective actions were completed on July 2, 2020, and removal of the Immediate Jeopardy (IJ) on July 2, 2020. On July 3, 2020, the SA surveyor validated through staff interview, resident interview, record review, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): 1. The SA verified through record reviews, staff interviews, and reviews of resident interviews, that every resident living in the facility was interviewed and/or assessed by Social Services about abuse, neglect, and safety. 2. The SA verified through staff interview and review of the sign-in sheets that the QAPI/QA meetings took place on 6/30/2020 at 3:00 PM. And on 7/01/2020 at 2:00 PM. 3. The SA verified through staff interview, record review, and policy and procedure review that the facility policies were evaluated by the facility and no new revisions in policy were made. 4. The SA verified through staff interviews, resident interviews, and record reviews, that a 100% chart audit had been completed and updates made for care plans, and for residents medications. 5. The SA verified through staff interviews documentation review that the Administrator and Nurses had received one to one (1:1) counseling regarding the reporting of Abuse, and Neglect. 6. The SA verified through staff interviews, review of the in-service educational materials and review of the in-service sign-in sheets, that all employees of the facility was in-serviced about Abuse, and Neglect; Reporting of Abuse and Neglect; Resident Behavioral Management; Chemical Restraints; Care Planning; and Residents Rights. The SA validated on 07/03/2020, that all corrective actions had been taken by the facility to remove the IJ during the extended survey on 07/02/2020, and the IJ was removed on 07/02/2020.

Based on record review, staff interview, observation, and facility policy and procedure review, the facility failed to address the behaviors of Resident #141 in a manner to promote his psychosocial well-being and failed to acquire appropriate programs and services to meet the mental health and behavior needs of Resident #141. Resident #141 was one (1) of six (6) residents reviewed for Behaviors and Mental Health services during the extended survey. The facility failed to plan and implement Behavior programs and services that would enhance the psycho-social well-being of Resident #141. The facility failed to promote the psychosocial well being of Resident #141 through non-medication approaches for his Behaviors. The facility utilized medications and chemical restraints as the first method of treatment and intervention for Resident #141's behaviors, instead of taking less invasive and less restrictive methods to treat his behaviors. The facility sent resident out to a Behavioral Health facility on several occasions beginning on September 21, 2018. Resident #141 had documented transfers out to the Behavioral Health facility on at least four (4) different occasions. After each of the Behavioral Health admissions, Resident #141 would be given additional psychiatric [DIAGNOSES REDACTED]. The facility Behavioral Health facility did not forward discharge orders and/or recommendations to the nursing home facility after Resident #141 was released from the Behavioral Health facility back to the nursing home. The nursing home facility did not seek recommendations as to Behavioral interventions and/or Behavioral programs for the treatment of [REDACTED]. The nursing home facility did not make referrals to address the [DIAGNOSES REDACTED].#141 had upon admission to the nursing home facility on 0 6/11/2018. Resident #141 did not have a Care Plan devised that addressed the Alcohol Addiction. Resident #141did not have a discharge plan documented in his medical record. Resident #141 had no referrals documented in his medical record for programs and services that possibly could be utilized while in the facility and/or upon discharge from the facility. The facility employees had no directions and/or programs to implement within the facility in order to deescalate the aggressive language and behaviors of Resident #141. There was no documentation in the medical record of Resident #141 that monitored his behaviors. Numerous transfers to a Behavioral Health facility was not effective in the treatment and management of Resident #141's behaviors. The psychiatric medications and chemical restraints caused harm to Resident #141. Resident #141 had a severe decline in his cognitive abilities and had a significant weight loss as a result of his refusal to eat and to receive care. The facility did not follow and did not implement the facility's policy and procedure for Behavioral Management of Resident #141. The facility's failure to identify and prevent the escalating aggression and abusive language toward staff and other residents lead to the sexual abuse of Resident #34, a cognitively impaired resident, by Resident #141. Abuse was caused to Resident #34 as a result of the facility's failure to appropriately address and devise behavioral management programs for Resident #141. Resident #141 severely declined and lost weight as a result of the facility not implementing appropriate services and behavioral programs for Resident #141. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 02/05/2020, when the facility failed to address Resident #141's escalating inappropriate sexual behaviors. The facility Administrator (ADM) was notified of the IJ on 06/30/2020 at 4:45 PM. The facility submitted an acceptable Removal Plan on 07/02/2020 at 10:00 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 07/02/2020, and the IJ removed on 07/02/2020 at 5:25 PM. The SA validated the facility's Removal Plan on 07/03/2020 and determined the IJ was removed on 07/02/2020. Therefore, the scope and severity for 42 CFR(s): 483.40 (b) (1)-Treatment/Services for Mental/Psychological Concerns, (F742) was lowered from a J to a scope and severity of a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's Behavior Management policy, dated November 30, 2017, revealed: It is the policy of this facility to provide the necessary behavioral health care and services to maintain the resident's highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. A behavioral management plan will be developed if a resident exhibits behavior that interfere with their ability to function, receive needed care, or pose a risk or potential risk to the safety of themselves or others. Behavior management is an individualized non-pharmacological approach that is provided as part of a supportive physical and psychosocial environment directed toward preventing, relieving, and or accommodating a resident's distressed behavior. The components include: 1) Identification of the triggers; 2) Evaluation of the triggers; 3) treatment of [REDACTED]. Non-pharmacological approaches are be a part of each behavioral management plan, even if medication is being used. A record review of the nurses progress notes for Resident #141, dated 12/25/2019 at 13:17 (1:17 PM) revealed: Attending CNA (Certified Nursing Assistant) called nurse this shift into the hallway and states, resident called me into this room to make his bed and clean the trash off his bedside dresser. Resident then began to say, You are not going to tell on me are you? Attending CNA stated resident stood up and grabbed his drawstring on his pants. Attending CNA states, I told him that I am an employee and he is a resident and that he is acting inappropriately. Resident stated, Please do not tell on me and do not be mad at me. Attending CNA states, That is when I left out of the room to come tell you. Nurse this shift asked resident about the incident and resident states, Nobody has done anything to me. Nurse asked resident have you did anything to anyone, resident states, No not yet. The facility did not do an investigation after this incident and did not put any behavior interventions in to place for the behavior management and/or education of Resident #141. No behavioral management program was devised as a result of the incident on 12/25/2019. A record review of Resident #141's nursing progress notes, revealed, on 02/05/2020 resident was reported to the nursing staff to have made inappropriate sexual comments to other residents. The other residents were not identified and an investigation did not occur. Resident #141 was transferred out to the Behavioral Health facility as a result of the incident on 02/05/2020. No behavioral management program was devised by the facility for resident #141 as a result of the incident of 02/05/2020. The nursing home facility did not obtain behavioral management recommendations from the Behavioral Health facility after Resident #141 was discharged . Record review of Resident #141's nursing progress notes, revealed, on 02/26/2020, Resident #141 made inappropriate sexual remarks to a group of residents in the bingo activity. The facility (ADM) obtained statements from the other residents that alleged Resident #141 made gestures and/or sexual comments to them. There were no behavioral programs devised and/or put in to place for Resident #141 after the alleged incident of 02/26/2020 as outlined in the facility policy and procedure titled Behavior Management. On 03/01/2020, Resident #141 was witnessed by Licensed Practical Nurse (LPN) #1 inappropriately touching another resident (Resident #34). The incident of inappropriate touching/fondling was not care planned and no behavioral management programs were devised and/or put in to place as a result of the incident of 03/01/2020 with Resident #141 and Resident #34. Resident #141 was sent out to a Behavioral Health unit. A record review revealed the facility had no documentation of monitoring the behaviors of Resident #141. An interview, on 06/29/2020 at 2:30 PM, revealed, the ADM stated the male Certified Nursing Assistant (CNA) that Resident #141 made inappropriate sexual gestures and comments toward on 12/25/2020, no longer worked at the facility. During an interview on 06/29/2020 at 3:00 PM, with Social Worker (SW) #1, she revealed the interventions that were put in to place for Resident #141 were medications. SW #1 stated Resident #141 had greatly declined and was no longer interviewable. SW #1 stated that she had asked the Psychiatric Nurse Practitioner to see Resident #141 because he was not himself and he was out of it. SW #1 stated Resident #141 had been refusing to eat and was refusing care. An observation on 06/29/2020 at 3:00 PM, revealed, Resident #141 was alone in his room. His affect was flat, and he had no facial expressions. His eyes were heavy and rolled about. He was only able to give yes and no answers to questions. Resident #141 was not interviewable. During an interview, on 7/03/2020 at 12:20 PM, the Director of Nursing (DON) that resident #141 had been transferred to a local hospital on [DATE] at 11:40 PM as a result of chest pain. The facility submitted a Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. All cognitively intact residents were interviewed on 7/1/20 9:30 A.M. regarding abuse, neglect and safety by Social Service Director and Social Services Assistant with no residents stating he/she had any concerns of abuse, neglect or safety. Residents stated he/she feels safe. Regarding the alleged incident of resident to resident sexual abuse from Resident #141against Resident #34 on March 1, 2020. Resident #34 was assessed by Nurse #3. With no injuries noted and no complaints of pain or discomfort. Resident #141 declined assessment by Nurse #3. 2. Regional Director of Operations called an emergency QAPI/QA meeting on 06/30/20 at 3 P.M. to discuss IJs called during extended survey. In attendance at the emergency QAPI/QA meeting was Medical Director, Administrator, Director of Nursing, Infection Control Nurse, Regional Director of Operations, and Regional Nurse Consultant. The topics of discussion during the meeting were aforementioned allegations of resident to resident abuse, policy review of Abuse/Neglect Policy, Reporting and Care Planning, training and education of staff, and monitoring. Another emergency QAPI/QA meeting was held on 07/01/20 at 2 P.M. to discuss additional IJs Abuse and Neglect Chemical Restraints, Quality Assurance and Performance Improvements, and Behavioral Health Services. A policy review of Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement was held. Additionally, training and education of staff and monitoring was discussed. The following QAPI/QA committee members were present: Administrator, Director of Nursing, Social Service Director, Life Connections, MDS Nurse #1 and #2, Social Service Assistant, Medical Director, HR/BOM, Director of Rehab, Housekeeping Supervisor, Dietary Manager, Nurse Unit Manager #5, Admissions, Medical Records Nurse, Life Connections Assistant, and Infection Control Nurse. 3. The following policies were reviewed on 06/30/20 at 3 P.M. during the QAPI/QA meeting: Abuse/Neglect Policy, Reporting and Care Planning. No revisions were made to the policies. On 07/01/20 at 3 P.M. during the QAPI/QA meeting, the following policies were reviewed: Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement. No revisions were made to the policies. 4. On 07/02/20 chart audits were conducted by Regional Nurse Consultant, MDS Nurse #1 and #2, and Psychiatric Nurse Practitioner at 12P.M. for other incidents of abuse, chemical restraints, and care plan revisions. On 07/02/20 at 12 P.M. Psychiatric Nurse Practitioner identified and conducted a medication evaluation/review of 19 residents prescribed psychotherapeutic medication. The following 19 resident charts were reviewed with 3 recommendation's for dose reductions and 2 recommendations for hospice to clarify/review orders, #45, Unsampled Resident A, Unsampled Resident BO, Unsampled Resident AR, Unsampled Resident BF, Unsampled Resident BD, Unsampled Resident AH, Unsampled Resident BP, Unsampled Resident U, #15, Unsampled Resident X, Unsampled Resident BV #79, Unsampled Resident Y, Unsampled Resident AB, Unsampled Resident AF, #9, and Unsampled Resident BK. On 07/02/20 at 12 P.M. MDS Nurse #1 and #2 conducted care plan reviews for residents with behavior care plans and Rx of psychotherapeutic medication to ensure least restrictive measures have been incorporated into the plan of care. The Care Plan for Resident #141 was updated by MDS Nurse #1 and #2 on 07/01/20 at 10A.M. inclusive of aggressive behaviors, de-escalation, grieving losses, sexual behavior with goals/interventions of utilizing life connections and social service for psychosocial well-being, leisure activities, expression of feelings, and communication with family. Interventions for Direct Care staff were included in this care plan. Resident #141 was transferred to hospital on [DATE] at 11:44 P.M. for chest pain at the direction of Medical Director. The Care Plan will be updated on return. On 07/02/20 Regional Nurse Consultant conducted chart review at 12 PM for other abuse incidents. There are no findings of other instances of alleged abuse that has gone unaddressed/reported at this time. 5. On 6/30/20 at 3 PM Regional Director of Operations, provided Corrective Counseling to Administrator regarding Abuse/Neglect Reporting and Investigations in accordance to the policy on Abuse and Neglect. On 07/01/20 at 3:30 PM Administrator conducted 1:1 in-service and corrective coaching with Nurse #2 on Abuse/Neglect Policy and Reporting of incidents whether or not it is known if the incident has been previously reported. Nurse #2 voiced understanding of policy and procedure. 6. An education in-service was conducted by Administrator beginning on 6/30/2020 at 5:00 PM on Care plans policy and procedure and utilizing the care plan and reporting of changes in condition and behavioral changes. On 07/01/20 at 1 PM Regional Director of Operations and Regional Nurse Consultant in-serviced Administrator, Director of Nursing, Social Service Director and Social Services Assistant, and Life Connections on utilizing Behavior Management Plan inclusive of De-escalation procedures. On 07/01/20 at 11:30 AM an in-service was conducted by Administrator on Behavior Management and Resident Rights with staff inclusive of de-escalation techniques of aggressive behavior as a non-medication approach to promote the psycho-social well-being of a resident. Staff educated that all residents have the right before medications are given. Behavior Management training has been added to the orientation process for new hires. No employee will be allowed to return to work until he/she has completed the educational in-service. Care Plan Education was provided by Regional Nurse Consultant on 07/01/20 at 10AM with MDS Coordinator #1 and # 2, Social Service Director and Social Services Assistant, and Life Connections to include care planning after each incident report, change of condition, change in behavior, quarterly updates, yearly updates and working with the multi-disciplinary team when care planning to include sexual behaviors, aggressive behaviors, utilizing all forms of information, collaboration, policy and procedure were reviewed. No employee will be allowed to return to work until he/she has completed the educational in-services on Care Plan Policy, Using the Care Plan, reporting of changes in condition and behavior changes, and updating the Care Plan, Abuse and Neglect Policy, Reporting Abuse and Neglect, Behavior Management Policy and De-escalation Techniques. The facility alleged that all corrective actions were completed on July 2, 2020, and removal of the Immediate Jeopardy (IJ) on July 2, 2020. On July 3, 2020, the SA surveyor validated through staff interview, resident interview, record review, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): 1. The SA verified through record reviews, staff interviews, and reviews of resident interviews, that every resident living in the facility was interviewed and/or assessed by Social Services about abuse, neglect, and safety. 2. The SA verified through staff interview and review of the sign-in sheets that the QAPI/QA meetings took place on 6/30/2020 at 3:00 PM and on 7/01/2020 at 2:00 PM. 3. The SA verified through staff interview, record review, and policy and procedure review that the facility policies were evaluated by the facility and no new revisions in policy were made. 4. The SA verified through staff interviews, resident interviews, and record reviews, that a 100% chart audit had been completed and updates made for care plans, and for residents' medications. 5. The SA verified through staff interviews documentation review that the Administrator and Nurses had received one to one (1:1) counseling regarding the reporting of Abuse, and Neglect. 6. The SA verified through staff interviews, review of the in-service educational materials and review of the in-service sign-in sheets, that all employees of the facility was in-serviced about Abuse, and Neglect; Reporting of Abuse and Neglect; Resident Behavioral Management; Chemical Restraints; Care Planning; and Residents Rights. The SA validated on 07/03/2020, that all corrective actions had been taken by the facility to remove the IJ during the extended survey on 07/02/2020, and the IJ was removed on 07/02/2020.

Based on facility policy and procedure review, staff interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan related to Behaviors, for two (2) of six (6) resident care plans reviewed, Resident #34 and Resident #141. On Sunday, [DATE] at approximately 2:00 PM, Licensed Practical Nurse (LPN) #1 and Resident #14 witnessed Resident #141 sitting beside Resident #34 in the South Side dayroom of the facility. Resident #141 had his hand inside the pants and brief of Resident #34, a severely cognitively impaired resident. A record review of Resident #141's progress notes, revealed the incident between Resident #141 and Resident #34, that occurred on [DATE], was not care planned. Resident #141 had also been involved in previous incidents on [DATE] and [DATE], which other unidentified residents reported to nursing staff that Resident #141 made sexual inappropriate comments/gestures toward them. The facility's failure develop and implement a comprehensive person-centered care plan to address sexual, inappropriate behaviors of Resident #141, for staff to be aware and put interventions in place to prevent further abuse, placed Resident #34 and other residents in a situation that was likely to cause serious harm, injury, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ), which began on [DATE], when the facility failed to develop and implement a comprehensive person-centered care plan to address an incident of non-consensual sexual behavior exhibited by Resident #141 towards Resident #34 on [DATE], and incidents of sexual remarks/gestures towards unidentified residents on [DATE] and [DATE]. The facility's Administrator (ADM) was notified of the IJ on [DATE] at 4:45 PM. The facility submitted an acceptable Removal Plan on [DATE] at 10:00 PM, in which the facility alleged all corrective actions to remove the IJ were completed on [DATE] at 5:25 PM, and the IJ removed on [DATE]. The State Agency (SA) validated the facility's Removal Plan on [DATE]. Therefore, the scope and severity for: 42 CFR(s): 483.21 (b)-Develop/Implement Comprehensive Care Plans, (F656) was lowered from a J to a scope and severity of a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's Care Plan-Comprehensive policy, undated, revealed: It is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. An interdisciplinary team, in coordination with the resident and his/her family or representative, develops and maintains a comprehensive care plan for each resident. The comprehensive care plan had been designed to: Incorporate identified focus areas, reflect treatment goals and objectives in measurable outcomes that incorporate the resident's personal and cultural preferences, and wishes. Care plans are revised as changes in the resident's condition dictates. Reviews are made quarterly. Resident #141 Record review of Resident #141's comprehensive care plan, revealed the incident that occurred on [DATE] of a non-consenting sexual advancement by Resident #141 toward Resident #34, had not been care planned. Resident #141's care plan also did not reflect incidents of sexual verbal/gestures towards other unidentified residents, which occurred on [DATE] and [DATE]. Record review of Resident #141's Behavior notes, revealed, on [DATE] at 13:35 (1:35 PM), Staff reported that another resident had reported that this resident (Resident #141) was making sexual remarks to them. The progress notes revealed Resident #141 was asked about the conversation he had with the other resident, and he stated, That's a got damn lie, I didn't even talk to these men, not saying they are, below me they just not worth me talking to, [***] all y'all. Incident was reported to NP (Nurse Practitioner). Record review of Resident #141's Behavior notes, dated [DATE] at 16:45 (4:45 PM), revealed Resident #141 was observed touching another resident (Resident #34) inappropriately in the South Side Dayroom. Resident #141 was immediately removed away from Resident #34 and taken to his room. During an interview, on [DATE] at 4:00 PM, the facility's Corporate Analyst and Corporate Clinical Service persons, both confirmed that the facility was without a Care Plan Nurse and that the care plans were not devised and revised due to the vacant position. The two (2) Corporate staff confirmed the facility had no full time Director of Nursing (DON) at this time or for the past 10 days, and the Assistant Director of Nursing (ADON) was home sick with the flu and unavailable for interview. The facility appointed an Acting Director of Nursing on [DATE], when the annual standard survey began. Both Corporate staff confirmed that the care plans should have been updated to reflect the current conditions of Resident #141. The Corporate staff confirmed that all resident care plans would need to be updated. The Corporate staff also stated they had been without a Minimum Data Set (MDS) Nurse and had no Care Plan nurse in the facility for quite some time, and that the DON had walked out of the facility on the Friday prior to the annual survey. They reported that the facility was interviewing and attempting to hire new staff. No observation of Resident #141 was obtained during the standard survey of [DATE]-[DATE]. Resident #141 had been transferred to a mental health unit located at an out of town hospital. Resident #141 was alleged to have been involved in a sexual encounter Resident #34, a cognitive impaired resident. The facility transferred Resident #141 for mental health evaluation as a result of his witnessed sexual involvement with a non-consenting Resident #34. A record review, of the Admission Record for Resident #141, revealed Resident #141 had a primary diagnosis, with an onset date of [DATE], of Psychological and Behavioral Factors Associated with Disorders or Diseases Classified Elsewhere. Resident #141 was readmitted by the facility on [DATE] and had an original admission date of [DATE]. The record review of the Minimum Data Set (MDS) dated [DATE], revealed that Resident #141 had a Brief Interview of Mental Status Score (BIMS) of 15 which indicated that he was cognitively intact and could make decisions for himself. Resident #34 Record review of Resident #34's care plan, revealed, it did not reflect the incident of [DATE] with the sexual inappropriateness of Resident #141 placing his hand inside the pants and brief of Resident #34. The assessment made by LPN #1 of Resident #34 was not documented on the care plan of Resident #34 after the incident of resident to resident sexual abuse which occurred on [DATE]. Record review of the Admission Record for Resident #34, he was admitted by the facility on [DATE]. A review of Resident #34's Minimum Data Set (MDS), dated [DATE], revealed he had a documented Brief Interview of Mental Status score (BIMS) of 4, which indicated that he had severe cognitive impairment and could not make decisions for himself. Record review of Resident #34's medical record, revealed he died at the facility on [DATE]. Resident #34's death certificate listed Dementia as the cause of death. During an interview, on [DATE] at 4:00 PM with the Corporate Clinical Services and the Corporate Analyst persons, the both revealed there was no one was working in the facility as a Care Plan Nurse and/or Minimum Data Set (MDS) Nurse. They both confirmed that a care plan had not been developed, reviewed, or revised after the incident of [DATE] which occurred between Resident #34 and Resident #141. Interview on [DATE], with Minimum Data Set (MDS) Nurse #1 and MDS Nurse #2, revealed they had been newly hired at the facility after the annual survey on [DATE] through [DATE]. They both confirmed they had been working hard to revise and to implement new care plans for all the residents of the facility. The facility submitted a Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. All cognitively intact residents were interviewed on [DATE] 9:30 A.M. regarding abuse, neglect and safety by Social Service Director and Social Services Assistant with no residents stating he/she had any concerns of abuse, neglect or safety. Residents stated he/she feels safe. Regarding the alleged incident of resident to resident sexual abuse from Resident #141against Resident #34 on [DATE]. Resident #34 was assessed by Nurse #3. With no injuries noted and no complaints of pain or discomfort. Resident #141 declined assessment by Nurse #3. 2. Regional Director of Operations called an emergency QAPI/QA meeting on [DATE] at 3 P.M. to discuss IJs called during extended survey. In attendance at the emergency QAPI/QA meeting was Medical Director, Administrator, Director of Nursing, Infection Control Nurse, Regional Director of Operations, and Regional Nurse Consultant. The topics of discussion during the meeting were aforementioned allegations of resident to resident abuse, policy review of Abuse/Neglect Policy, Reporting and Care Planning, training and education of staff, and monitoring. Another emergency QAPI/QA meeting was held on [DATE] at 2 P.M. to discuss additional IJs Abuse and Neglect Chemical Restraints, Quality Assurance and Performance Improvements, and Behavioral Health Services. A policy review of Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement was held. Additionally, training and education of staff and monitoring was discussed. The following QAPI/QA committee members were present: Administrator, Director of Nursing, Social Service Director, Life Connections, MDS Nurse #1 and #2, Social Service Assistant, Medical Director, HR/BOM, Director of Rehab, Housekeeping Supervisor, Dietary Manager, Nurse Unit Manager #5, Admissions, Medical Records Nurse, Life Connections Assistant, and Infection Control Nurse. 3. The following policies were reviewed on [DATE] at 3 P.M. during the QAPI/QA meeting: Abuse/Neglect Policy, Reporting and Care Planning. No revisions were made to the policies. On [DATE] at 3 P.M. during the QAPI/QA meeting, the following policies were reviewed: Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement. No revisions were made to the policies. 4. On [DATE] chart audits were conducted by Regional Nurse Consultant, MDS Nurse #1 and #2, and Psychiatric Nurse Practitioner at 12P.M. for other incidents of abuse, chemical restraints, and care plan revisions. On [DATE] at 12 P.M. Psychiatric Nurse Practitioner identified and conducted a medication evaluation/review of 19 residents prescribed psychotherapeutic medication. The following 19 resident charts were reviewed with 3 recommendation's for dose reductions and 2 recommendations for hospice to clarify/review orders, #45, Unsampled Resident A, Unsampled Resident BO, Unsampled Resident AR, Unsampled Resident BF, Unsampled Resident BD, Unsampled Resident AH, Unsampled Resident BP, Unsampled Resident U, #15, Unsampled Resident X, Unsampled Resident BV #79, Unsampled Resident Y, Unsampled Resident AB, Unsampled Resident AF, #9, and Unsampled Resident BK. On [DATE] at 12 P.M. MDS Nurse #1 and #2 conducted care plan reviews for residents with behavior care plans and Rx of psychotherapeutic medication to ensure least restrictive measures have been incorporated into the plan of care. The Care Plan for Resident #141 was updated by MDS Nurse #1 and #2 on [DATE] at 10A.M. inclusive of aggressive behaviors, de-escalation, grieving losses, sexual behavior with goals/interventions of utilizing life connections and social service for psychosocial well-being, leisure activities, expression of feelings, and communication with family. Interventions for Direct Care staff were included in this care plan. Resident #141 was transferred to hospital on [DATE] at 11:44 P.M. for chest pain at the direction of Medical Director. The Care Plan will be updated on return. On [DATE] Regional Nurse Consultant conducted chart review at 12 PM for other abuse incidents. There are no findings of other instances of alleged abuse that has gone unaddressed/reported at this time. 5. On [DATE] at 3 PM Regional Director of Operations, provided Corrective Counseling to Administrator regarding Abuse/Neglect Reporting and Investigations in accordance to the policy on Abuse and Neglect. On [DATE] at 3:30 PM Administrator conducted 1:1 in-service and corrective coaching with Nurse #2 on Abuse/Neglect Policy and Reporting of incidents whether or not it is known if the incident has been previously reported. Nurse #2 voiced understanding of policy and procedure. 6. An education in-service was conducted by Administrator beginning on [DATE] at 5:00 PM on Care plans policy and procedure and utilizing the care plan and reporting of changes in condition and behavioral changes. On [DATE] at 1 PM Regional Director of Operations and Regional Nurse Consultant in-serviced Administrator, Director of Nursing, Social Service Director and Social Services Assistant, and Life Connections on utilizing Behavior Management Plan inclusive of De-escalation procedures. On [DATE] at 11:30 AM an in-service was conducted by Administrator on Behavior Management and Resident Rights with staff inclusive of de-escalation techniques of aggressive behavior as a non-medication approach to promote the psycho-social well-being of a resident. Staff educated that all residents have the right before medications are given. Behavior Management training has been added to the orientation process for new hires. No employee will be allowed to return to work until he/she has completed the educational in-service. Care Plan Education was provided by Regional Nurse Consultant on [DATE] at 10AM with MDS Coordinator #1 and # 2, Social Service Director and Social Services Assistant, and Life Connections to include care planning after each incident report, change of condition, change in behavior, quarterly updates, yearly updates and working with the multi-disciplinary team when care planning to include sexual behaviors, aggressive behaviors, utilizing all forms of information, collaboration, policy and procedure were reviewed. No employee will be allowed to return to work until he/she has completed the educational in-services on Care Plan Policy, Using the Care Plan, reporting of changes in condition and behavior changes, and updating the Care Plan, Abuse and Neglect Policy, Reporting Abuse and Neglect, Behavior Management Policy and De-escalation Techniques. The facility alleged that all corrective actions were completed on [DATE], and removal of the Immediate Jeopardy (IJ) on [DATE]. On [DATE], the SA surveyor validated through staff interview, resident interview, record review, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): 1. The SA verified through record reviews, staff interviews, and reviews of resident interviews, that every resident living in the facility was interviewed and/or assessed by Social Services about abuse, neglect, and safety. 2. The SA verified through staff interview and review of the sign-in sheets that the QAPI/QA meetings took place on [DATE] at 3:00 PM and on [DATE] at 2:00 PM. 3. The SA verified through staff interview, record review, and policy and procedure review that the facility policies were evaluated by the facility and no new revisions in policy were made. 4. The SA verified through staff interviews, resident interviews, and record reviews, that a 100% chart audit had been completed and updates made for care plans, and for residents' medications. 5. The SA verified through staff interviews documentation review that the Administrator and Nurses had received one to one (1:1) counseling regarding the reporting of Abuse, and Neglect. 6. The SA verified through staff interviews, review of the in-service educational materials and review of the in-service sign-in sheets, that all employees of the facility was in-serviced about Abuse, and Neglect; Reporting of Abuse and Neglect; Resident Behavioral Management; Chemical Restraints; Care Planning; and Residents Rights. The SA validated on [DATE], that all corrective actions had been taken by the facility to remove the IJ during the extended survey on [DATE], and the IJ was removed on [DATE].

Based on record review, policy and procedure review, and staff interviews, the facility failed to investigate incidents of sexually, inappropriate verbal abuse and to protect and prevent residents from further abuse, for one (1) of six (6) residents reviewed, Resident #141. On February 5, 2020, Resident #141 was reported to the nursing staff for making inappropriate sexual comments and/or gestures toward residents. The facility did not identify the residents that were allegedly involved and did not document and/or investigate what exactly was said by Resident #141 toward the other residents. No statements were obtained from any of the residents making the allegations against Resident #141 as to what was heard and/or witnessed. Resident #141 was sent out of the facility to a Behavioral Health Center, as a result of the alleged incident of inappropriate sexual remarks/gestures toward residents which occurred on 02/05/2020 and 02/26/2020. The residents were not identified by the facility in an incident report or in the progress notes. The facility did not report the alleged verbal abuse (sexual remarks) of Resident #141 that occurred on 02/05/2020 or 02/26/2020 to the State Agency (SA). The facility also did not follow established policy and procedure for investigating allegations of resident abuse, neglect, and/or exploitation. The failure of the facility to protect, investigate and notify the appropriate State agencies in a timely manner of an allegation of abuse, and ensure proper measures had been addressed, placed residents at risk for the likelihood of serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 02/05/2020, when the allegation of abuse occurred. The facility Administrator (ADM) was notified of the IJ on 06/30/2020 at 4:45 PM. The facility submitted an acceptable Removal Plan on 07/02/2020 at 10:00 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 07/02/2020, and the IJ removed on 07/02/2020 at 5:25PM. The State Agency (SA) validated the facility's Removal Plan on 07/03/2020 and determined the IJ was removed on 07/02/2020. Therefore, the scope and severity for 42 CFR(s): 483.12(c)(2)-(4)-Investigate/Prevent/Correct Alleged Violation, (F610) was lowered from a J to a scope and severity of a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan-Protection policy, undated, revealed: Residents will be protected during an investigation whether it is abuse, neglect, exploitation, or mistreatment. The facility's policy revealed, the first response of all/any employee if an allegation is made, witnessed, or suspected is to protect the resident first and foremost. The Administrator of the person in charge shall separate the alleged victim and accused person(s) immediately and maintain that separation until investigations are completed. Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed, the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined below. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's mental symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardian, friends, or other individuals. The facility's policy indicated the following definitions: Abuse -The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Verbal abuse-The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Sexual abuse-Includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. A review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Reporting/Response policy, with a revision date of 08/23/2017, revealed: It is the policy of this facility that persons employed by this facility with knowledge or reasonable cause to believe that any resident has been the victim of abuse, exploitation, neglect, or mistreatment must report or cause a report to be made to appropriate state agencies as prescribed by the laws of that state. The Administrator and/or Director of Nursing will notify appropriate officials including State Survey Agency and adult protective services where state law provides for jurisdiction in accordance with State law immediately but no later than two (2) hours after the allegation/suspicion is formed if the events that cause the suspicion result in serious bodily injury (Reasonable Suspicion of Crime), or no later than 24 hours if the events that cause the allegation/suspicion do not result in serious bodily injury, in accordance with state law through established procedures (including to the state licensure and certification agency) and will take any necessary corrective action. Record review of Resident #141's Behavior notes, revealed, on 02/05/2020 at 13:35 (1:35 PM), Staff reported that another resident (unidentified) had reported that this resident (Resident #141) was making sexual remarks to them. The progress notes revealed Resident #141 was asked about the conversation he had with the other resident, and he stated, That's a got damn lie, I didn't even talk to these men, not saying they are, below me they just not worth me talking to, [***] all y'all. Incident was reported to NP (Nurse Practitioner). A record review of Resident #141's nurses progress notes, dated 02/05/2020 at 22:51 (10:51 PM) revealed, Resident received new order for mental evaluation for sexual inappropriateness with other resident/staff. RP (Responsible Party) contacted and made aware of new order and expressed cares and concerns. Record review of Resident #141's nurses progress notes, dated 02/06/2020 at 18:21 (6:21 PM), revealed, Resident #141 was transferred to Behavioral Health Facility for mental evaluation. Resident #141 returned to the facility from the Behavioral Health facility on 02/18/2020. Record review revealed Resident #141 had no care plan for the Behavioral Health interventions and/or programs that were developed upon his return on 02/18/2020 from the Behavioral Health Center. There was no documentation of recommendations for Resident #141's from the Behavioral Health, nor a discharge summary. Areview of Resident #141's progress notes, dated 02/26/2020 at 16:22 (4:22 PM), revealed, Social Worker SW #1 documented that Resident #141's RP (Responsible Party) and MD (Medical Director) were made aware of several male residents reported that Resident #141 was making sexual statements towards them. Review of Resident #141's Quarterly Minimum Data Set (MDS), dated [DATE], revealed, he had a Brief Interview of Mental Status (BIMS) score of 15, which indicated cognitively intact. Section E (Behavior) of the Quarterly MDS, dated [DATE], revealed Resident #141 had not exhibited any behaviors,hallucinations, and no delusions during the assessment period. Section I (Active Diagnoses) of the Quarterly MDS, dated [DATE], revealed Resident #141 had a [DIAGNOSES REDACTED]. On 03/04/2020 at 12:30 PM, during an interview, with the Assistant Activities Director (AAD), she stated that she saw Resident #141 roll up to a group of males during the bingo activity. She could not recall the date, but that Resident #141 said something to the male residents in the group which they did not like. The AAD stated the residents told her Resident #141 had made sexual inappropriate comments to them that they didn't like. The AAD stated the residents told her that they told Resident #141 we don't play like that. The AAD stated she reported the incident to the Assistant Director of Nursing (ADON). She revealed in-services were begun on Sexual Abuse after the alleged incident occurred. During an interview, on 03/04/2020 at 4:30 PM, the Administrator (ADM) stated Resident #141's behaviors had only begun the week of 03/01/2020. The ADM stated Resident #141 had not exhibited any behaviors of sexual inappropriateness toward any residents prior to the incident that occurred on 03/01/2020. During an interview, on 06/29/2020 at 2:00 PM, SW #1 stated that she had been at the facility for eight (8) years. She stated Resident #141's had odd mannerism and a long history of alcoholism. SW #1 stated that Resident #141 had no history of sexual acting out or gay/homosexual preferences. SW #1 stated the only aggressive behaviors that she was aware of was verbally abusive comments to staff, but never to any residents. SW #1 revealed Resident #141 would curse and threaten to hit staff. During a telephone interview, on 06/29/2020 at 2:08 PM, the Medical Director (MD) revealed that he was away from the facility and had numerous residents in several facilities. The MD stated he did not recall an incident with Resident #141 on 02/26/2020, and he did not recall the incident of 03/01/2020. He stated that he would need to review Resident #141's chart and progress notes to answer questions. An interview with the Administrator (ADM), on 06/29/2020 at 2:30 PM, revealed, she stated that she had no knowledge of any sexually inappropriate incidents that occurred with Resident #141 prior to the incident on 03/01/2020. The ADM stated that the names of the residents that Resident #141 made sexually inappropriate verbal gestures to on 02/05/2020, were not documented. The ADM stated that she had no knowledge as to what residents were involved in the incident of 02/05/2020. The ADM confirmed there was no investigation conducted by her office concerning the incident of 02/05/2020, and the incident was not reported to the State Agency (SA). She stated the incident of 02/26/2020 was reported to her on 02/27/2020, and she conducted an investigation on 02/27/2020. The ADM stated there was no evidence of any sexual abuse by Resident #141 toward any residents on 02/27/2020. The ADM confirmed she did not report the incident that occurred on 2/26/2020, because it did not involve abuse. The ADM stated that other residents in the facility did not like Resident #141, and they gave no specifics as to what was said to them by Resident #141. The ADM stated she did not feel that the incident of 02/26/2020 was Abuse and she did not report the incident to the SA. During an interview, on 06/30/2020 at 10:40 AM, the ADM stated that the facility had no surveillance cameras in the building, and that there was no video footage to review of the three (3) incidents involving the inappropriate sexual behaviors of Resident #141 toward other residents on 02/05/2020, 02/26/2020, and 03/01/2020. The facility submitted a Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. All cognitively intact residents were interviewed on 07/01/20 9:30 AM regarding abuse, neglect and safety by Social Service Director and Social Services Assistant with no residents stating he/she had any concerns of abuse, neglect or safety. Residents stated he/she feels safe. Regarding the alleged incident of resident to resident sexual abuse from Resident #141against Resident #34 on March 1, 2020. Resident #34 was assessed by Nurse #3. With no injuries noted and no complaints of pain or discomfort. Resident #141 declined assessment by Nurse #3. 2. Regional Director of Operations called an emergency QAPI/QA meeting on 06/30/20 at 3 PM to discuss IJs called during extended survey. In attendance at the emergency QAPI/QA meeting was Medical Director, Administrator, Director of Nursing, Infection Control Nurse, Regional Director of Operations, and Regional Nurse Consultant. The topics of discussion during the meeting were aforementioned allegations of resident to resident abuse, policy review of Abuse/Neglect Policy, Reporting and Care Planning, training and education of staff, and monitoring. Another emergency QAPI/QA meeting was held on 07/01/20 at 2 PM to discuss additional IJs Abuse and Neglect Chemical Restraints, Quality Assurance and Performance Improvements, and Behavioral Health Services. A policy review of Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement was held. Additionally, training and education of staff and monitoring was discussed. The following QAPI/QA committee members were present: Administrator, Director of Nursing, Social Service Director, Life Connections, MDS Nurse #1 and #2, Social Service Assistant, Medical Director, HR/BOM, Director of Rehab, Housekeeping Supervisor, Dietary Manager, Nurse Unit Manager #5, Admissions, Medical Records Nurse, Life Connections Assistant, and Infection Control Nurse. 3. The following policies were reviewed on 06/30/20 at 3 PM during the QAPI/QA meeting: Abuse/Neglect Policy, Reporting and Care Planning. No revisions were made to the policies. On 07/01/20 at 3 PM during the QAPI/QA meeting, the following policies were reviewed: Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement. No revisions were made to the policies. 4. On 07/02/20 chart audits were conducted by Regional Nurse Consultant, MDS Nurse #1 and #2, and Psychiatric Nurse Practitioner at 12 PM for other incidents of abuse, chemical restraints, and care plan revisions. On 07/02/20 at 12 PM, Psychiatric Nurse Practitioner identified and conducted a medication evaluation/review of 19 residents prescribed psychotherapeutic medication. The following 19 resident charts were reviewed with 3 recommendation's for dose reductions and 2 recommendations for hospice to clarify/review orders, #45, Unsampled Resident A, Unsampled Resident BO, Unsampled Resident AR, Unsampled Resident BF, Unsampled Resident BD, Unsampled Resident AH, Unsampled Resident BP, Unsampled Resident U, #15, Unsampled Resident X, Unsampled Resident BV #79, Unsampled Resident Y, Unsampled Resident AB, Unsampled Resident AF, #9, and Unsampled Resident BK. On 07/02/20 at 12 PM, MDS Nurse #1 and #2 conducted care plan reviews for residents with behavior care plans and Rx of psychotherapeutic medication to ensure least restrictive measures have been incorporated into the plan of care. The Care Plan for Resident #141 was updated by MDS Nurse #1 and #2 on 07/01/20 at 10 AM inclusive of aggressive behaviors, de-escalation, grieving losses, sexual behavior with goals/interventions of utilizing life connections and social service for psychosocial well-being, leisure activities, expression of feelings, and communication with family. Interventions for Direct Care staff were included in this care plan. Resident #141 was transferred to hospital on [DATE] at 11:44 PM for chest pain at the direction of Medical Director. The Care Plan will be updated on return. On 07/02/20 Regional Nurse Consultant conducted chart review at 12 PM for other abuse incidents. There are no findings of other instances of alleged abuse that has gone unaddressed/reported at this time. 5. On 6/30/20 at 3 PM Regional Director of Operations, provided Corrective Counseling to Administrator regarding Abuse/Neglect Reporting and Investigations in accordance to the policy on Abuse and Neglect. On 07/01/20 at 3:30 PM Administrator conducted 1:1 in-service and corrective coaching with Nurse #2 on Abuse/Neglect Policy and Reporting of incidents whether or not it is known if the incident has been previously reported. Nurse #2 voiced understanding of policy and procedure. 6. An education in-service was conducted by Administrator beginning on 6/30/2020 at 5:00 PM on Care plans policy and procedure and utilizing the care plan and reporting of changes in condition and behavioral changes. On 07/01/20 at 1 PM Regional Director of Operations and Regional Nurse Consultant in-serviced Administrator, Director of Nursing, Social Service Director and Social Services Assistant, and Life Connections on utilizing Behavior Management Plan inclusive of De-escalation procedures. On 07/01/20 at 11:30 AM an in-service was conducted by Administrator on Behavior Management and Resident Rights with staff inclusive of de-escalation techniques of aggressive behavior as a non-medication approach to promote the psycho-social well-being of a resident. Staff educated that all residents have the right before medications are given. Behavior Management training has been added to the orientation process for new hires. No employee will be allowed to return to work until he/she has completed the educational in-service. Care Plan Education was provided by Regional Nurse Consultant on 07/01/20 at 10 AM with MDS Coordinator #1 and # 2, Social Service Director and Social Services Assistant, and Life Connections to include care planning after each incident report, change of condition, change in behavior, quarterly updates, yearly updates and working with the multi-disciplinary team when care planning to include sexual behaviors, aggressive behaviors, utilizing all forms of information, collaboration, policy and procedure were reviewed. No employee will be allowed to return to work until he/she has completed the educational in-services on Care Plan Policy, Using the Care Plan, reporting of changes in condition and behavior changes, and updating the Care Plan, Abuse and Neglect Policy, Reporting Abuse and Neglect, Behavior Management Policy and De-escalation Techniques. The facility alleged that all corrective actions were completed on July 2, 2020, and removal of the Immediate Jeopardy (IJ) on July 2, 2020. On July 3, 2020, the SA surveyor validated through staff interview, resident interview, record review, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): 1. The SA verified through record reviews, staff interviews, and reviews of resident interviews, that every resident living in the facility was interviewed and/or assessed by Social Services about abuse, neglect, and safety. 2. The SA verified through staff interview and review of the sign-in sheets that the QAPI/QA meetings took place on 6/30/2020 at 3:00 PM and on 7/01/2020 at 2:00 PM. 3. The SA verified through staff interview, record review, and policy and procedure review that the facility policies were evaluated by the facility and no new revisions in policy were made. 4. The SA verified through staff interviews, resident interviews, and record reviews, that a 100% chart audit had been completed and updates made for care plans, and for residents' medications. 5. The SA verified through staff interviews documentation review that the Administrator and Nurses had received one to one (1:1) counseling regarding the reporting of Abuse, and Neglect. 6. The SA verified through staff interviews, review of the in-service educational materials and review of the in-service sign-in sheets, that all employees of the facility was in-serviced about Abuse, and Neglect; Reporting of Abuse and Neglect; Resident Behavioral Management; Chemical Restraints; Care Planning; and Residents Rights. The SA validated on 07/03/2020, that all corrective actions had been taken by the facility to remove the IJ during the extended survey on 07/02/2020, and the IJ was removed on 07/02/2020.

Based on record review, policy and procedure review, and staff interviews, the facility failed to report incidents of verbal abuse, for one (1) of six (6) residents reviewed, Resident #141. On February 5, 2020, Resident #141 was reported to the nursing department for making inappropriate sexual comments and/or gestures toward other residents. The facility did not identify the other residents that were allegedly involved and did not document and/or investigate what exactly was said by Resident #141 toward the other residents. No statements were obtained from any of the residents making the allegations against Resident #141 as to what was heard and/or witnessed. Resident #141 was sent out of the facility to a Behavioral Health Center, as a result of the alleged incident of inappropriate sexual remarks/gestures toward other residents that occurred on 02/05/2020 and 02/26/2020. The other residents were not identified by the facility in an incident report or in the progress notes. The facility did not report the alleged verbal abuse (sexual remarks) of Resident #141 that occurred on 02/05/2020 or 02/26/2020. The facility did not follow established policy and procedure for reporting allegations of resident abuse, neglect, and/or exploitation. The failure of the facility to notify the appropriate State agencies in a timely manner of an allegation of abuse, and ensure proper measures had been addressed, placed residents at risk for the likelihood of serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 02/05/2020, when the allegation of abuse occurred. The facility Administrator (ADM) was notified of the IJ on 06/30/2020 at 4:45 PM. The facility submitted an acceptable Removal Plan on 07/02/2020 at 10:00 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 07/02/2020, and the IJ removed on 07/02/2020 at 5:25PM. The State Agency (SA) validated the facility's Removal Plan on 07/03/2020 and determined the IJ was removed on 07/02/2020. Therefore, the scope and severity for 42 CFR(s): 483.12(c)(4)-Reporting of Alleged Violations of Abuse, Neglect, and Exploitation, (F609) was lowered from a J to a scope and severity of a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed, the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined below. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's mental symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardian, friends, or other individuals. Abuse -The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. This presumes that instances of abuse of any residents, even those in a coma, cause physical harm, or pain, or mental anguish. This includes any abuse facilitated or enabled through the use of technology. Verbal abuse-The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Sexual abuse-Includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Reporting/Response policy, with a revision date of 08/23/2017, revealed: It is the policy of this facility that persons employed by this facility with knowledge or reasonable cause to believe that any resident has been the victim of abuse, exploitation, neglect, or mistreatment must report or cause a report to be made to appropriate state agencies as prescribed by the laws of that state. Failure by staff (including management and supervisory staff) to report possible/alleged incidents of abuse/neglect to Administration per policy, will result in disciplinary action up to and including immediate termination. All alleged violations or substantiated incidents involving mistreatment, exploitation, neglect, or abuse, including injuries of an unknown origin are reported to the Administrator of the facility. The Administrator and/or Director of Nursing will notify appropriate officials including State Survey Agency and adult protective services where state law provides for jurisdiction in accordance with State law immediately but no later than two (2) hours after the allegation/suspicion is formed if the events that cause the suspicion result in serious bodily injury (Reasonable Suspicion of Crime), or no later than 24 hours if the events that cause the allegation/suspicion do not result in serious bodily injury, in accordance with state law through established procedures (including to the state licensure and certification agency) and will take any necessary corrective action. Record review of Resident #141's Behavior notes, revealed, on 02/05/2020 at 13:35 (1:35 PM), Staff reported that another resident had reported that this resident (Resident #141) was making sexual remarks to them. The progress notes revealed Resident #141 was asked about the conversation he had with the other resident, and he stated, That's a got damn lie, I didn't even talk to these men, not saying they are, below me they just not worth me talking to, [***] all y'all. Incident was reported to NP (Nurse Practitioner). Record review of Resident #141's nurses progress notes, dated 02/05/2020 at 22:51 (10:51 PM) revealed, Resident received new order for mental evaluation for sexual inappropriateness with other resident/staff. RP (Responsible Party) contacted and made aware of new order and expressed cares and concerns. Record review of Resident #141's nurses progress notes, dated 02/06/2020 at 18:21 (6:21 PM), revealed, Resident #141 was transferred to Behavioral Health Facility for mental evaluation. Record review of Resident #141's nurses progress notes, dated 02/18/2020 at 10:43 AM, revealed, the resident came back from the Behavioral Health facility at 8:00 AM. A record review revealed that Resident #141 had no care plan for the Behavioral Health interventions and/or programs that were devised upon his return on 02/18/2020 from the Behavioral Health Center. There was no documentation of recommendations for Resident #141's Behavioral Health. There was no discharge summary or recommendations from the Behavioral Health facility to the nursing home facility. Record review of Resident #141's progress notes, dated 02/26/2020 at 16:22 (4:22 PM), revealed, Social Worker SW #1 documented that Resident #141's RP (Responsible Party) and MD (Medical Director) were made aware that several male residents stated Resident #141 was making sexual statements towards them. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed, Resident #141 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Section E (Behavior) of the Quarterly MDS, dated [DATE], revealed Resident #141 had no behaviors, no hallucinations, and no delusions. Section I (Active Diagnoses) of the Quarterly MDS, dated [DATE], revealed Resident #141 had a [DIAGNOSES REDACTED]. During an interview, on 03/04/2020 at 12:30 PM, with the Assistant Activities Director (AAD), she stated that she saw Resident #141 roll up to a group of males during the bingo activity. She could not recall the date, but that Resident #141 said something to the males in the group that they did not like. The AAD stated the residents told her that Resident #141 said sexual inappropriate comments to them that they did not like, and they told Resident #141 we don't play like that. The AAD stated she reported the incident to the Assistant Director of Nursing (ADON), the ADM, and to the doctor. She stated in-services were begun on Sexual Abuse after the alleged incident occurred. In an interview, on 03/04/2020 at 4:30 PM, the Administrator (ADM) stated that the behaviors of Resident #141 had only begun the week of 03/01/2020. The ADM stated Resident #141 had not exhibited any behaviors of sexual inappropriateness toward any residents prior to the incident of 03/01/2020. The ADM stated Resident #141 had a long history of aggression toward staff. During an interview, on 06/29/2020 at 2:00 PM, SW #1 stated that she had been at the facility for eight (8) years. She stated Resident #141's had odd mannerism and a long history of alcoholism. SW #1 stated that Resident #141 had no history of sexual acting out or gay/homosexual preferences. SW #1 revealed she has had family conferences with Resident #141's family and they denied any history of homosexual activity by Resident #141. SW #1 stated the only aggressive behaviors that she was aware of was verbally abusive comments to staff, but never to any residents. SW #1 revealed Resident #141 would curse and threaten to hit staff. Interview via telephone, on 06/29/2020 at 2:08 PM, with the Medical Director (MD), he revealed that he was away from the facility and had numerous residents in several facilities. The MD stated he did not recall an incident with Resident #141 on 02/26/2020, and he did not recall the incident of 03/01/2020. He stated that he would need to review Resident #141's chart and progress notes to answer questions. In an interview with the Administrator (ADM) on 06/29/2020 at 2:30PM she stated that she had no knowledge of any sexually inappropriate incidents that occurred with Resident #141 prior to the incident on 03/01/2020. She stated that the names of the residents that Resident #141 made sexually inappropriate verbal gestures to on 02/05/2020 were not documented and she had no knowledge as to who was involved in the incident of 02/05/2020. The ADM confirmed that there was no investigation conducted by her office concerning the incident of 02/05/2020 and the incident was not reported to the State Agency (SA). The ADM stated the incident of 02/26/2020, was reported to her on 02/27/2020, and she conducted an investigation on 02/27/2020. She stated there was no evidence that there was any sexual abuse by Resident #141 toward any residents on 02/27/2020. The ADM confirmed that she did not report the incident that occurred on 2/26/2020 because it did not involve abuse. The ADM stated that the other residents in the facility did not like Resident #141 and they gave no specifics as to what was said to them by Resident #141. The ADM stated she did not feel that the incident of 02/26/2020 was Abuse and she did not report the incident to the SA. On 06/30/2020 at 10:40 AM, during an interview, the ADM stated that the facility had no surveillance cameras in the building, and that there was no video footage to review of the three (3) incidents involving the inappropriate sexual behaviors of Resident #141 toward other residents on 02/05/2020, 02/26/2020, and 03/01/2020. The facility submitted a Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. All cognitively intact residents were interviewed on 7/1/20 9:30 A.M. regarding abuse, neglect and safety by Social Service Director and Social Services Assistant with no residents stating he/she had any concerns of abuse, neglect or safety. Residents stated he/she feels safe. Regarding the alleged incident of resident to resident sexual abuse from Resident #141against Resident #34 on March 1, 2020. Resident #34 was assessed by Nurse #3. With no injuries noted and no complaints of pain or discomfort. Resident #141 declined assessment by Nurse #3. 2. Regional Director of Operations called an emergency QAPI/QA meeting on 06/30/20 at 3 P.M. to discuss IJs called during extended survey. In attendance at the emergency QAPI/QA meeting was Medical Director, Administrator, Director of Nursing, Infection Control Nurse, Regional Director of Operations, and Regional Nurse Consultant. The topics of discussion during the meeting were aforementioned allegations of resident to resident abuse, policy review of Abuse/Neglect Policy, Reporting and Care Planning, training and education of staff, and monitoring. Another emergency QAPI/QA meeting was held on 07/01/20 at 2 P.M. to discuss additional IJs Abuse and Neglect Chemical Restraints, Quality Assurance and Performance Improvements, and Behavioral Health Services. A policy review of Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement was held. Additionally, training and education of staff and monitoring was discussed. The following QAPI/QA committee members were present: Administrator, Director of Nursing, Social Service Director, Life Connections, MDS Nurse #1 and #2, Social Service Assistant, Medical Director, HR/BOM, Director of Rehab, Housekeeping Supervisor, Dietary Manager, Nurse Unit Manager #5, Admissions, Medical Records Nurse, Life Connections Assistant, and Infection Control Nurse. 3. The following policies were reviewed on 06/30/20 at 3 P.M. during the QAPI/QA meeting: Abuse/Neglect Policy, Reporting and Care Planning. No revisions were made to the policies. On 07/01/20 at 3 P.M. during the QAPI/QA meeting, the following policies were reviewed: Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement. No revisions were made to the policies. 4. On 07/02/20 chart audits were conducted by Regional Nurse Consultant, MDS Nurse #1 and #2, and Psychiatric Nurse Practitioner at 12P.M. for other incidents of abuse, chemical restraints, and care plan revisions. On 07/02/20 at 12 P.M. Psychiatric Nurse Practitioner identified and conducted a medication evaluation/review of 19 residents prescribed psychotherapeutic medication. The following 19 resident charts were reviewed with 3 recommendation's for dose reductions and 2 recommendations for hospice to clarify/review orders, #45, Unsampled Resident A, Unsampled Resident BO, Unsampled Resident AR, Unsampled Resident BF, Unsampled Resident BD, Unsampled Resident AH, Unsampled Resident BP, Unsampled Resident U, #15, Unsampled Resident X, Unsampled Resident BV #79, Unsampled Resident Y, Unsampled Resident AB, Unsampled Resident AF, #9, and Unsampled Resident BK. On 07/02/20 at 12 P.M. MDS Nurse #1 and #2 conducted care plan reviews for residents with behavior care plans and Rx of psychotherapeutic medication to ensure least restrictive measures have been incorporated into the plan of care. The Care Plan for Resident #141 was updated by MDS Nurse #1 and #2 on 07/01/20 at 10A.M. inclusive of aggressive behaviors, de-escalation, grieving losses, sexual behavior with goals/interventions of utilizing life connections and social service for psychosocial well-being, leisure activities, expression of feelings, and communication with family. Interventions for Direct Care staff were included in this care plan. Resident #141 was transferred to hospital on [DATE] at 11:44 P.M. for chest pain at the direction of Medical Director. The Care Plan will be updated on return. On 07/02/20 Regional Nurse Consultant conducted chart review at 12 PM for other abuse incidents. There are no findings of other instances of alleged abuse that has gone unaddressed/reported at this time. 5. On 6/30/20 at 3 PM Regional Director of Operations, provided Corrective Counseling to Administrator regarding Abuse/Neglect Reporting and Investigations in accordance to the policy on Abuse and Neglect. On 07/01/20 at 3:30 PM Administrator conducted 1:1 in-service and corrective coaching with Nurse #2 on Abuse/Neglect Policy and Reporting of incidents whether or not it is known if the incident has been previously reported. Nurse #2 voiced understanding of policy and procedure. 6. An education in-service was conducted by Administrator beginning on 6/30/2020 at 5:00 PM on Care plans policy and procedure and utilizing the care plan and reporting of changes in condition and behavioral changes. On 07/01/20 at 1 PM Regional Director of Operations and Regional Nurse Consultant in-serviced Administrator, Director of Nursing, Social Service Director and Social Services Assistant, and Life Connections on utilizing Behavior Management Plan inclusive of De-escalation procedures. On 07/01/20 at 11:30 AM an in-service was conducted by Administrator on Behavior Management and Resident Rights with staff inclusive of de-escalation techniques of aggressive behavior as a non-medication approach to promote the psycho-social well-being of a resident. Staff educated that all residents have the right before medications are given. Behavior Management training has been added to the orientation process for new hires. No employee will be allowed to return to work until he/she has completed the educational in-service. Care Plan Education was provided by Regional Nurse Consultant on 07/01/20 at 10AM with MDS Coordinator #1 and # 2, Social Service Director and Social Services Assistant, and Life Connections to include care planning after each incident report, change of condition, change in behavior, quarterly updates, yearly updates and working with the multi-disciplinary team when care planning to include sexual behaviors, aggressive behaviors, utilizing all forms of information, collaboration, policy and procedure were reviewed. No employee will be allowed to return to work until he/she has completed the educational in-services on Care Plan Policy, Using the Care Plan, reporting of changes in condition and behavior changes, and updating the Care Plan, Abuse and Neglect Policy, Reporting Abuse and Neglect, Behavior Management Policy and De-escalation Techniques. The facility alleged that all corrective actions were completed on July 2, 2020, and removal of the Immediate Jeopardy (IJ) on July 2, 2020. On July 3, 2020, the SA surveyor validated through staff interview, resident interview, record review, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): 1. The SA verified through record reviews, staff interviews, and reviews of resident interviews, that every resident living in the facility was interviewed and/or assessed by Social Services about abuse, neglect, and safety. 2. The SA verified through staff interview and review of the sign-in sheets that the QAPI/QA meetings took place on 6/30/2020 at 3:00 PM and on 7/01/2020 at 2:00 PM. 3. The SA verified through staff interview, record review, and policy and procedure review that the facility policies were evaluated by the facility and no new revisions in policy were made. 4. The SA verified through staff interviews, resident interviews, and record reviews, that a 100% chart audit had been completed and updates made for care plans, and for residents' medications. 5. The SA verified through staff interviews documentation review that the Administrator and Nurses had received one to one (1:1) counseling regarding the reporting of Abuse, and Neglect. 6. The SA verified through staff interviews, review of the in-service educational materials and review of the in-service sign-in sheets, that all employees of the facility was in-serviced about Abuse, and Neglect; Reporting of Abuse and Neglect; Resident Behavioral Management; Chemical Restraints; Care Planning; and Residents Rights. The SA validated on 07/03/2020, that all corrective actions had been taken by the facility to remove the IJ during the extended survey on 07/02/2020, and the IJ was removed on 07/02/2020.

Based on record review, staff interview, and policy and procedure review, the facility failed to ensure Resident #141 was free from being chemically restrained for one (1) of six (6) residents reviewed for Resident Rights. The facility called the local police department and allowed the policemen to stand in Resident #141's bedroom while he was administered an intramuscular (IM) injection of [MEDICATION NAME] for the purpose of calming/controlling his behavior. On Sunday, March 1, 2020, Resident #141 was witnessed by Licensed Practical Nurse (LPN) #1 and Resident #14 to be inappropriately, sexually touching/fondling a severely cognitively impaired, Resident #34. LPN #1 separated the two residents and rolled Resident #141 in his wheelchair to his room. LPN #1 placed Resident #141 on one to one (1:1) close observation by staff. Resident #141 denied that he was touching/fondling Resident #34 inappropriately. He became angry, verbally aggressive, and was cursing loudly in the facility at the staff. LPN #1 called the facility's Administrator (ADM) and reported the incident which had occurred between Resident #141 and Resident #34. The ADM instructed LPN #1 to call the local police department to report the abuse of Resident #34. LPN #1 stated Resident #141 was threatening, cursing, and refusing to take the medication ([MEDICATION NAME] IM) that had been ordered by the physician. Upon the appearance of the policemen in Resident #141's bedroom, Resident #141 volunteered to take the [MEDICATION NAME] IM medication. There was no police report generated and no facility documentation for the measures that were taken when the police arrived in the facility on Sunday, 03/01/2020. The facility had no documentation as to the name and/or badge numbers of the officers who were present in Resident #141's bedroom while he received the IM medication of [MEDICATION NAME] on 03/01/2020. There were no surveillance cameras inside the facility on 03/01/2020. The facility was unable to produce any documentation to verify the reason (s) for the policemen to be called to the facility. The facility had no documentation of what occurred and how the situation was handled after the policemen arrived at the facility. Resident #141's right to refuse medication and his right to be free from chemical restraints were violated through police intimidation. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 03/01/20 when Resident #141 was chemically restrained as a result of intimidation by law enforcement officers standing in his bedroom while he was given an IM injection of [MEDICATION NAME]. The ADM was notified of the IJ and SQC on 06/30/2020 at 4:45 PM. The facility submitted an acceptable Removal Plan on 07/02/2020 at 10:00 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 07/02/2020, and IJ removed on 07/02/2020 at 5:25 PM. The SA validated the facility's Removal Plan on 07/03/2020 and determined the IJ was removed on 07/02/2020. Therefore, the scope and severity for 42 CFR(s): 483.10 (e)(1) - Right to be Free from Chemical Restraints, (F605) was lowered from J to a scope and severity of a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed: The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined below. This includes but is no limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardian, friends, or other individuals. A review of the facility's Resident Rights, revised and implemented on 11/28/2016, revealed: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. The right to request, refuse, and/or discontinue treatment. The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. Review of the facility's Chemical Restraints policy, dated November 1, 2000, revealed: It is the policy of this facility to not use chemical restraints. If [MEDICAL CONDITION] medications are ordered by the attending physician, a valid [DIAGNOSES REDACTED]. Regarding the use of antipsychotic drugs, a comprehensive assessment of the resident must be made to ensure that: a) Residents that have not been receiving this class of drug will not be treated with this class of drugs unless a specific approved condition is present; and b) Those residents that do have a specific condition who receive this class of drugs will receive gradual dose reduction s and behavioral programming unless clinically contraindicated in an effort to discontinue these drugs. Psychomotor symptoms not exhibited as specific behaviors listed above, but which cause the resident frightful distress will have the specific behavior monitored and documented every shift by the nursing staff on the Psychoactive Drug Monitoring Record or Medication Administration Record [REDACTED]. Record review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Protection policy, undated, revealed: Residents will be protected during an investigation whether it is abuse, neglect, exploitation, or mistreatment. Record review of information obtained from the website, Drugs.com, revealed [MEDICATION NAME] ([MEDICATION NAME]) belongs to a group of drugs called benzodiazepines. [MEDICATION NAME] may be habit-forming and should be used only by the person it was prescribed for. Misuse of habit-forming medicine can cause addiction, overdose, or death. Fatal side effects can occur if you take [MEDICATION NAME] with alcohol, opioid medicine, or other drugs that cause drowsiness or slow your breathing. Common side effects of [MEDICATION NAME] included sedated state and dizziness. A record review of Resident #141's nursing progress notes, dated on 03/01/2020 at 16:45 (4:45 PM), revealed, Resident was observed touching another resident inappropriately on the South Side Dayroom. Resident immediately removed from other resident and taken to his room on North Side. The progress notes revealed, on 03/01/2020 at 18:00 (6:00 PM), Remains on 1:1 (one to one) close observation, Resident is being noncompliant by not listening to staff on where he is able to go in the facility. On 03/01/2020 at 18:40 (6:40 PM), Resident #141's progress notes indicated, the NP (Nurse Practitioner) was notified of the resident's behavior, and stated to give resident [MEDICATION NAME] 2 mg (milligrams) IM (intramuscular) injection now. On 03/01/2020 at 18:50 (6:50 PM), the progress notes revealed, Resident #141 refused IM injection times three (x3) and stated NO. Resident had fist up in air and was very aggressive. The local police department was notified to assist with resident. Documentation in Resident #141's progress notes on 03/01/2020 at 19:05 (7:05 PM) revealed, the local police department in the building to assist with resident IM injection for aggressive behavior. Resident was informed again about the IM injection he had to get while police department was standing in the room and voluntarily let the nurse give him the [MEDICATION NAME] 2 mg IM in left deltoid. No problem noted. Resident remains on 1:1 observation. On 03/01/2020 at 19:30 (7:30 PM), the progress notes revealed, Resident remains on 1:1 observation. No problems noted related to IM injection. Resident appears calm. Resident has gotten in bed and is resting. Record review of the facility Administrator's (ADM) Investigation Report, dated 3/10/2020, which was faxed to the State Agency, revealed, a narrative account of the incident on 03/01/2020 of the inappropriate sexual touching/fondling of Resident #34 by Resident #141. The narrative report did not document that the local police department was called to report the incident of Abuse. There was no mention of the local police department being contacted for any reason during the investigation. The narrative report contained information that substantiated the event of sexual abuse and listed all agencies that were contacted of the Abuse incident. There was no Law Enforcement agency other than the State Attorney General's Office listed as being contacted. The ADM's narrative report dated 3/10/2020 revealed, Resident #141 was interviewed by LPN #1 on March 1, 2020. Resident #141 denied touching Resident #34 inappropriately and became verbally aggressive. Resident #141's aggression was reported to the Medical Director (MD) and an order for [REDACTED]. During an interview on 06/30/2020 at 12:25 PM, LPN #1 stated that she called the local police department, because when Abuse of a resident occurs in the facility, the police are to be called. LPN #1 stated Resident #141 was upset and was refusing to take the [MEDICATION NAME] IM injection ordered by the physician. She stated the local police department did come into Resident #141's bedroom and with them present and standing by, Resident #141 volunteered to allow the [MEDICATION NAME] IM injection to be administered. LPN #1 revealed the police officers did not hold Resident #141 down or physically force the resident in any way. During an interview with the ADM, on 6/29/2020 at 2:30 PM, she confirmed that on 03/01/2020 the police did come to the facility, because it is the policy of the facility to call law enforcement to report Abuse of a resident. The ADM revealed the police did come to the facility on [DATE], but they did not physically assist with giving Resident #141 medications against his will. The ADM stated there was no police report generated as a result of them coming to the facility on [DATE]. The ADM confirmed the facility had no cameras or surveillance equipment inside the facility. There was no video footage available to review the events of 03/01/2020. Interview on 06/29/2020 at 3:00 PM, with Social Services Director (SW) #1, revealed, she stated Resident #141 had greatly declined and was not acting like his usual self. SW #1 stated that she had made a request for the psychiatric Nurse Practitioner (NP) to review Resident #141's medications because he seemed out of it. SW #1 stated Resident #141 was not eating and was refusing care. An observation of Resident #141, on 06/29/2020 at 3:00 PM, revealed, Resident #141 was not interviewable. He presented as very sleepy and his eyes were heavy and rolling about. Resident #141 presented with no facial expressions, flat affect, and he was not animated upon observation. Resident #141 was lying in bed with the covers up around his neck and no body parts were visible. Resident #141 could answer yes or no only to questions asked. During an interview, on 07/03/2020 at 12:20 PM, the Director of Nursing (DON) stated that Resident #141 had been sent out to a local hospital on [DATE] at 11:40 PM as a result of chest pains. The DON stated Resident #141 would be returning to the facility after he was medically evaluated. The facility submitted a Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. All cognitively intact residents were interviewed on 7/1/20 9:30 A.M. regarding abuse, neglect and safety by Social Service Director and Social Services Assistant with no residents stating he/she had any concerns of abuse, neglect or safety. Residents stated he/she feels safe. Regarding the alleged incident of resident to resident sexual abuse from Resident #141against Resident #34 on March 1, 2020. Resident #34 was assessed by Nurse #3. With no injuries noted and no complaints of pain or discomfort. Resident #141 declined assessment by Nurse #3. 2. Regional Director of Operations called an emergency QAPI/QA meeting on 06/30/20 at 3 P.M. to discuss IJs called during extended survey. In attendance at the emergency QAPI/QA meeting was Medical Director, Administrator, Director of Nursing, Infection Control Nurse, Regional Director of Operations, and Regional Nurse Consultant. The topics of discussion during the meeting were aforementioned allegations of resident to resident abuse, policy review of Abuse/Neglect Policy, Reporting and Care Planning, training and education of staff, and monitoring. Another emergency QAPI/QA meeting was held on 07/01/20 at 2 P.M. to discuss additional IJs Abuse and Neglect Chemical Restraints, Quality Assurance and Performance Improvements, and Behavioral Health Services. A policy review of Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement was held. Additionally, training and education of staff and monitoring was discussed. The following QAPI/QA committee members were present: Administrator, Director of Nursing, Social Service Director, Life Connections, MDS Nurse #1 and #2, Social Service Assistant, Medical Director, HR/BOM, Director of Rehab, Housekeeping Supervisor, Dietary Manager, Nurse Unit Manager #5, Admissions, Medical Records Nurse, Life Connections Assistant, and Infection Control Nurse. 3. The following policies were reviewed on 06/30/20 at 3 P.M. during the QAPI/QA meeting: Abuse/Neglect Policy, Reporting and Care Planning. No revisions were made to the policies. On 07/01/20 at 3 P.M. during the QAPI/QA meeting, the following policies were reviewed: Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement. No revisions were made to the policies. 4. On 07/02/20 chart audits were conducted by Regional Nurse Consultant, MDS Nurse #1 and #2, and Psychiatric Nurse Practitioner at 12P.M. for other incidents of abuse, chemical restraints, and care plan revisions. On 07/02/20 at 12 P.M. Psychiatric Nurse Practitioner identified and conducted a medication evaluation/review of 19 residents prescribed psychotherapeutic medication. The following 19 resident charts were reviewed with 3 recommendation's for dose reductions and 2 recommendations for hospice to clarify/review orders, #45, Unsampled Resident A, Unsampled Resident BO, Unsampled Resident AR, Unsampled Resident BF, Unsampled Resident BD, Unsampled Resident AH, Unsampled Resident BP, Unsampled Resident U, #15, Unsampled Resident X, Unsampled Resident BV #79, Unsampled Resident Y, Unsampled Resident AB, Unsampled Resident AF, #9, and Unsampled Resident BK. On 07/02/20 at 12 P.M. MDS Nurse #1 and #2 conducted care plan reviews for residents with behavior care plans and Rx of psychotherapeutic medication to ensure least restrictive measures have been incorporated into the plan of care. The Care Plan for Resident #141 was updated by MDS Nurse #1 and #2 on 07/01/20 at 10A.M. inclusive of aggressive behaviors, de-escalation, grieving losses, sexual behavior with goals/interventions of utilizing life connections and social service for psychosocial well-being, leisure activities, expression of feelings, and communication with family. Interventions for Direct Care staff were included in this care plan. Resident #141 was transferred to hospital on [DATE] at 11:44 P.M. for chest pain at the direction of Medical Director. The Care Plan will be updated on return. On 07/02/20 Regional Nurse Consultant conducted chart review at 12 PM for other abuse incidents. There are no findings of other instances of alleged abuse that has gone unaddressed/reported at this time. 5. On 6/30/20 at 3 PM Regional Director of Operations, provided Corrective Counseling to Administrator regarding Abuse/Neglect Reporting and Investigations in accordance to the policy on Abuse and Neglect. On 07/01/20 at 3:30 PM Administrator conducted 1:1 in-service and corrective coaching with Nurse #2 on Abuse/Neglect Policy and Reporting of incidents whether or not it is known if the incident has been previously reported. Nurse #2 voiced understanding of policy and procedure. 6. An education in-service was conducted by Administrator beginning on 6/30/2020 at 5:00 PM on Care plans policy and procedure and utilizing the care plan and reporting of changes in condition and behavioral changes. On 07/01/20 at 1 PM Regional Director of Operations and Regional Nurse Consultant in-serviced Administrator, Director of Nursing, Social Service Director and Social Services Assistant, and Life Connections on utilizing Behavior Management Plan inclusive of De-escalation procedures. On 07/01/20 at 11:30 AM an in-service was conducted by Administrator on Behavior Management and Resident Rights with staff inclusive of de-escalation techniques of aggressive behavior as a non-medication approach to promote the psycho-social well-being of a resident. Staff educated that all residents have the right before medications are given. Behavior Management training has been added to the orientation process for new hires. No employee will be allowed to return to work until he/she has completed the educational in-service. Care Plan Education was provided by Regional Nurse Consultant on 07/01/20 at 10AM with MDS Coordinator #1 and # 2, Social Service Director and Social Services Assistant, and Life Connections to include care planning after each incident report, change of condition, change in behavior, quarterly updates, yearly updates and working with the multi-disciplinary team when care planning to include sexual behaviors, aggressive behaviors, utilizing all forms of information, collaboration, policy and procedure were reviewed. No employee will be allowed to return to work until he/she has completed the educational in-services on Care Plan Policy, Using the Care Plan, reporting of changes in condition and behavior changes, and updating the Care Plan, Abuse and Neglect Policy, Reporting Abuse and Neglect, Behavior Management Policy and De-escalation Techniques. The facility alleged that all corrective actions were completed on July 2, 2020, and removal of the Immediate Jeopardy (IJ) on July 2, 2020. On July 3, 2020, the SA surveyor validated through staff interview, resident interview, record review, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): 1. The SA verified through record reviews, staff interviews, and reviews of resident interviews, that every resident living in the facility was interviewed and/or assessed by Social Services about abuse, neglect, and safety. 2. The SA verified through staff interview and review of the sign-in sheets that the QAPI/QA meetings took place on 6/30/2020 at 3:00 PM and on 7/01/2020 at 2:00 PM. 3. The SA verified through staff interview, record review, and policy and procedure review that the facility policies were evaluated by the facility and no new revisions in policy were made. 4. The SA verified through staff interviews, resident interviews, and record reviews, that a 100% chart audit had been completed and updates made for care plans, and for residents' medications. 5. The SA verified through staff interviews documentation review that the Administrator and Nurses had received one to one (1:1) counseling regarding the reporting of Abuse, and Neglect. 6. The SA verified through staff interviews, review of the in-service educational materials and review of the in-service sign-in sheets, that all employees of the facility was in-serviced about Abuse, and Neglect; Reporting of Abuse and Neglect; Resident Behavioral Management; Chemical Restraints; Care Planning; and Residents Rights. The SA validated on 07/03/2020, that all corrective actions had been taken by the facility to remove the IJ during the extended survey on 07/02/2020, and the IJ was removed on 07/02/2020.

Based on record review, facility policy review, resident Interview, and staff Interview, the facility failed to protect Resident #34, a cognitively impaired resident, from non-consensual, sexual abuse by Resident #141, for one (1) of six (6) residents reviewed for abuse, neglect, and exploitation, Resident #34. On Sunday [DATE] after the noon meal at approximately 2:00PM, Resident #141 was observed to be sitting in a wheelchair beside Resident #34 in the South Wing Day Hall/Dining Room. Resident #141 was a resident of the North Wing of the facility. Licensed Practical Nurse (LPN) #1 observed that Resident #34's pants were un-zipped and Resident #141, a cognitively intact resident, had his hand inside the brief of Resident #34. LPN#1 immediately called out to Resident #141 to stop and she removed Resident #141 from the area, took him to his room on the North Wing of the facility, and placed Resident #141 on 1:1 close observation. Resident #141 was subsequently sent out to a Behavioral Health facility. The incident was witnessed by LPN #1 and Resident #14. A record review revealed Resident #141 had been involved with inappropriate verbal sexual behaviors and gestures toward other unidentified residents on [DATE] and [DATE]. The facility's failure to protect Resident #34 from inappropriate sexual behaviors by Resident #141, resulted in Resident #34 being sexually abused, on [DATE], by Resident #141, and placed other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on [DATE], when Resident #141 exhibited inappropriate sexual behavior towards unidentified residents, and again on [DATE]. On [DATE], Resident #141 was witnessed with his hands inside the brief of Resident #34, who was a cognitively impaired resident. The facility failed to put measures and interventions in place to protect residents from sexual behaviors exhibited by Resident #141. The facility's Administrator (ADM) was notified of the IJ on [DATE] at 4:45 PM. The facility submitted an acceptable Removal Plan on [DATE] at 10:00 PM, in which the facility alleged all corrective actions to remove the IJ were completed on [DATE], and the IJ removed on [DATE] at 5:25 PM. The State Agency (SA) validated the facility's Removal Plan on [DATE] and determined the IJ was removed on [DATE]. Therefore, the scope and severity for 42 CFR(s): 483.12(a)(1)-Free from Abuse, Neglect, and Exploitation, (F600) was lowered from a J to a scope and severity of a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed, the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's mental symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardian, friends, or other individuals. The policy revealed: Abuse -The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. This presumes that instances of abuse of any residents, even those in a coma, cause physical harm, or pain, or mental anguish. This includes any abuse facilitated or enabled through the use of technology. Verbal abuse-The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Sexual abuse-Includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. A record review of the State Agency's Complaint/Incident Investigation Report, revealed, that on [DATE], it was reported by the complainant (allegedly LPN #1), that Resident #141 was observed touching Resident #34 inappropriately and performing oral sex. The report revealed, the complainant notified the Administrator (ADM) and was told by the ADM not to document on the incident nor let the family or doctor know. The complainant also reported that this type of incident had happened many times. During the original annual survey, on [DATE] through [DATE], the reported complaint of oral sex and touching was not substantiated. The facility was in the middle of their initial investigation which was to be completed after the exit of the State Agency (SA) on [DATE]. The SA interviewed various staff and Resident #14 (witness), and determined the complaint was inconclusive. During the original annual survey, the SA confirmed that there were no facility reports of oral sex being performed on Resident #34 by Resident #141. The SA confirmed the facility Administrator had personally called in the incident of alleged inappropriate sexual behaviors of fondling/touching to the SA at 4:00 PM on [DATE], which was within the two (2) hour time frame for reporting abuse to the SA. The SA confirmed through interviews and record reviews that LPN #1 had been told by the Administrator to conduct a full investigation of the alleged incident between Resident #141 and Resident #34 and to contact the local police per established policy and procedure. After administrative review from CMS (Centers of Medicare and Medicaid Services), the annual survey was extended to re-evaluate the incident of [DATE] (CI MS # ). The extended survey took place on [DATE] through [DATE]. Record review of Resident #34's nursing progress notes, dated [DATE] at 17:00 (5:00 PM) and signed by LPN #1, revealed: Resident was observed being inappropriately touched by another resident on the South Side Dayroom. Resident #34 was removed from other resident and taken to his room to be examined. Head to toe assessment done by nurse. Resident denies pain/discomfort. No bruising or skin issues noted. NP (Nurse Practitioner) notified and stated to continue to observe resident. Record review of the nursing progress notes for Resident #141, dated [DATE] at 16:45 (4:45 PM), documented Resident was observed touching another resident inappropriately on the South Side Dayroom. Resident immediately removed from other resident and taken to his room on the North side. Record review of Resident #141's interdisciplinary progress notes, revealed, on [DATE] at 13:35 (1:35 PM), Staff reported that another resident had reported that this resident (Resident #141) was making sexual remarks to them, went into resident's room he was lying in bed, asked how he was feeling he said just fine, you Asked resident about conversation he had with said resident, resident sat up in the middle of the bed and stated very loudly That's a got damn lie, I didn't even talk to these men, not saying they are, below me they just not worth me talking to, [***] all y'all' Explained to resident I understood he was upset but it was not acceptable for him to curse and no need for him to get upset, I just needed to know what happened resident stated Yeah, ok I guess asked res (resident) if he needed anything, res denies any needs at this time. Incident reported to NP (Nurse Practitioner). Record review of Resident #141's Social Worker's progress notes, dated [DATE] at 16:22 (4:22 PM), revealed, the RP (Responsible Party) and MD (Medical Director) was made aware that several male (unidentified) residents had stated that Resident #141 was making sexual statements towards them. Record review of Resident #141's comprehensive care plan, revealed the incident that occurred on [DATE] of a non-consenting sexual advancement by Resident #141 toward Resident #34, had not been care planned. Resident #141's care plan also did not reflect incidents of sexual verbal/gestures towards other unidentified residents, which occurred on [DATE] and [DATE]. The record contained no monitoring or interventions in place to protect other residents from Abuse by Resident #141. There was no observation or interview conducted, during the original annual survey, on [DATE] through [DATE], due to Resident #141 was sent out of the facility to a Behavioral Health facility in another town. Observation of Resident #34, on [DATE] at 2:30 PM, revealed, he was lying in his bed with his eyes closed. Resident #34 did not open his eyes or respond when his name was called, nor did he respond to touch. Resident #34 died at the facility on [DATE]. A record review of the Death Certificate listed Dementia as the cause of Resident #34's death. Interview on [DATE] at 11:30 AM, with Social Worker (SW) #1, revealed, she stated Resident #141 was witnessed by Resident #14, to have his hands inside the brief of Resident #34. SW #1 stated there were no reports of oral sex by Resident #141. SW #1 stated the sexual behaviors of Resident #141 had just surfaced and it all was gay in nature or male on male advances. She stated Resident #141 was not gay and had no history of ever being gay. SW #1 stated Resident #141's RP (Responsible Party) felt that Resident #141 was trying to get discharged from the facility because the (RP) would not let him live with her, and he had no placement or home to return to upon leaving the facility. Interview on [DATE] at 12:30 PM, with the Assistant Activities Director (AAD), revealed, she stated that she saw Resident #141 roll up to a group of males during the bingo activity, but was unable to recall the date. The AAD revealed Resident #141 said something to the males in the group that they did not like. The AAD stated they told her Resident #141 had made sexual inappropriate comments to them, and they told Resident #141 we don't play like that. The AAD stated that she reported the incident to the Assistant Director of Nursing (ADON), and she (ADON) reported it to the ADM and to the doctor. The AAD revealed in-services were begun on Sexual Abuse following the incident. The AAD stated she did not hear Resident #141 say anything, but the male residents had reported it to her after the bingo activity. On [DATE] at 4:30 PM, the Administrator (ADM) stated the behaviors of Resident #141 had only begun the week of [DATE]. The ADM stated Resident #141 had not exhibited any behaviors of sexual inappropriateness toward any residents prior to the incident of [DATE]. The ADM stated Resident #141 had a long history of aggression toward staff, but never toward another resident. The ADM stated there had never been any reports of oral sex by Resident #141. An interview, on [DATE] at 10:00 AM, with Resident #14, revealed, she stated that she was sitting in the Day Hall when she observed Resident #141 put his hands inside the brief of Resident #34. Resident #14 stated LPN #1 saw Resident #141 with his hands inside the pants of Resident #34. Resident #14 stated she felt safe at the facility as long as Resident #141 was out of the facility. During an interview, on [DATE] at 11:15 AM, LPN #1 revealed she worked as needed (PRN) only a few hours on weekends as the Wound Care Nurse. LPN #1 stated, on [DATE], she worked from 9:00 AM until 10:50 PM in order to complete the investigation and complete the required paperwork following the incident she witnessed between Resident #141 and Resident #34. LPN #1 stated she saw Resident #141 with his hands inside the brief of Resident #34. LPN #1 revealed she immediately separated the residents. LPN #1 stated she assessed Resident #34 and did not find any physical injury to Resident #34. LPN #1 stated she did not call the incident in to the State Agency (SA) because she was not instructed to, nor did she have knowledge that she was to report the incident to the SA. LPN #1 revealed she reported the incident to the ADM, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Family Nurse Practitioner (FNP); and the doctor (MD) on call. LPN #1 stated she had never witnessed anything like this at the facility before [DATE]. During an interview on [DATE] at 2:00 PM, SW #1 stated she had been employed at the facility for eight (8) years. She stated Resident #141 had always been an unusual guy with an odd manner of behavior and a long history of [MEDICAL CONDITION]. SW #1 stated Resident #141 was not gay and with family conferences, the family denied any knowledge of Resident #141 [MEDICATION NAME] a gay lifestyle. SW #1 stated the only aggressive behaviors that she was aware of, was verbal inappropriate comments to staff, but never to any residents. SW #1 stated Resident #141 was verbally abusive and would curse and threaten to hit staff. SW #1 stated after the sexual abuse of Resident #34, by Resident #141 on [DATE], she contacted the family of Resident #34 and informed them of the incident. She stated Resident #34's family was not upset nor did they issue any complaints about the incident of Abuse on [DATE]. During an interview, via telephone on [DATE] at 2:08 PM, with the Medical Director (MD), revealed that he was away from the facility, and did not have the medical records of Resident #141 and Resident #34 with him to review. The MD stated he did not recall the incident of [DATE], nor could he recall the incident which occurred on [DATE]. The MD stated he would have to review his progress notes in order to answer questions about the incidents. In an interview, with the Administrator (ADM), on [DATE] at 2:30 PM, she stated that she had no knowledge of the incident that occurred on [DATE]. The ADM stated the nurses never reported the incident to her. She stated that the names of the residents that Resident #141 made sexually inappropriate verbal gestures to on [DATE], were not documented and she had no knowledge as to who was involved in the incident. The ADM confirmed that there was no investigation conducted by her office concerning the incident of [DATE] and the incident was not reported to the State Agency. The ADM stated the incident on [DATE] was reported to her on [DATE], and she conducted an investigation on [DATE]. She stated there was no evidence that there was any sexual abuse by Resident #141 toward any residents on [DATE]. The ADM stated the other residents in the facility did not like Resident #141, and they gave no specifics as to what was actually said to them by Resident #141. The ADM stated she did not feel the incident which occurred on [DATE] was Abuse, and she did not report the incident to the SA. The ADM confirmed she conducted an investigation of the incidents of sexual abuse, that occurred on [DATE] at approximately 2:00 PM between Resident #141 and Resident #34. She confirmed Resident #141 had sexually, inappropriately fondled/touched a cognitively impaired, Resident #34, without his consent. During an observation, on [DATE] at 3:00 PM, revealed, Resident #141 revealed was lying in his bed. Resident #141 presented as sleepy, with a flat affect. Resident #141 was not interviewable. An interview on [DATE] at 10:40 AM, with the ADM, revealed, she stated the facility had no surveillance system inside of the facility, such as cameras and/or recording devices. She stated there was no video footage to review for any of the three (3) incidents involving the inappropriate sexual behaviors of Resident #141 toward other residents on [DATE]; [DATE]; and of Resident #34 on [DATE]. During an interview, on [DATE] at 12:25 PM, LPN #1 revealed she was not assigned to work with Resident #141 on [DATE]. LPN #1 stated she was the treatment nurse on North Side of the facility on [DATE]. LPN #1 stated she was looking for another resident when she entered the Day Hall on the South side of the facility and saw Resident #141 with his hands inside the pants of Resident #34. She stated she immediately separated the residents. LPN #1 revealed she assessed Resident #34 and found no physical injury. She stated Resident #141 was immediately placed in his North Side room and put on one to one (1:1) close observation by staff, and she called the physician and the ADM. LPN #1 stated that Resident #141 was not on any one to one and/or close observation prior to the incident on [DATE]. Record review of Resident #34' Quarterly Minimum Data Set (MDS), dated [DATE], revealed, he had a Brief Interview of Mental Status (BIMS) score of 4, which indicated severe cognitive impairment and the inability to make decisions. A review of Resident #141's Quarterly Minimum Data Set (MDS), dated [DATE], revealed he had a BIMS score of 15, which indicated he was cognitively intact, able to make his needs known, and to make decisions for himself. The facility submitted a Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: 1. All cognitively intact residents were interviewed on [DATE] 9:30 A.M. regarding abuse, neglect and safety by Social Service Director and Social Services Assistant with no residents stating he/she had any concerns of abuse, neglect or safety. Residents stated he/she feels safe. Regarding the alleged incident of resident to resident sexual abuse from Resident #141against Resident #34 on [DATE]. Resident #34 was assessed by Nurse #3. With no injuries noted and no complaints of pain or discomfort. Resident #141 declined assessment by Nurse #3. 2. Regional Director of Operations called an emergency QAPI/QA meeting on [DATE] at 3 P.M. to discuss IJs called during extended survey. In attendance at the emergency QAPI/QA meeting was Medical Director, Administrator, Director of Nursing, Infection Control Nurse, Regional Director of Operations, and Regional Nurse Consultant. The topics of discussion during the meeting were aforementioned allegations of resident to resident abuse, policy review of Abuse/Neglect Policy, Reporting and Care Planning, training and education of staff, and monitoring. Another emergency QAPI/QA meeting was held on [DATE] at 2 P.M. to discuss additional IJs Abuse and Neglect Chemical Restraints, Quality Assurance and Performance Improvements, and Behavioral Health Services. A policy review of Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement was held. Additionally, training and education of staff and monitoring was discussed. The following QAPI/QA committee members were present: Administrator, Director of Nursing, Social Service Director, Life Connections, MDS Nurse #1 and #2, Social Service Assistant, Medical Director, HR/BOM, Director of Rehab, Housekeeping Supervisor, Dietary Manager, Nurse Unit Manager #5, Admissions, Medical Records Nurse, Life Connections Assistant, and Infection Control Nurse. 3. The following policies were reviewed on [DATE] at 3 P.M. during the QAPI/QA meeting: Abuse/Neglect Policy, Reporting and Care Planning. No revisions were made to the policies. On [DATE] at 3 P.M. during the QAPI/QA meeting, the following policies were reviewed: Abuse and Neglect and Reporting, Behavior Management, and Quality Assurance and Performance Improvement. No revisions were made to the policies. 4. On [DATE] chart audits were conducted by Regional Nurse Consultant, MDS Nurse #1 and #2, and Psychiatric Nurse Practitioner at 12P.M. for other incidents of abuse, chemical restraints, and care plan revisions. On [DATE] at 12 P.M. Psychiatric Nurse Practitioner identified and conducted a medication evaluation/review of 19 residents prescribed psychotherapeutic medication. The following 19 resident charts were reviewed with 3 recommendation's for dose reductions and 2 recommendations for hospice to clarify/review orders, #45, Unsampled Resident A, Unsampled Resident BO, Unsampled Resident AR, Unsampled Resident BF, Unsampled Resident BD, Unsampled Resident AH, Unsampled Resident BP, Unsampled Resident U, #15, Unsampled Resident X, Unsampled Resident BV #79, Unsampled Resident Y, Unsampled Resident AB, Unsampled Resident AF, #9, and Unsampled Resident BK. On [DATE] at 12 P.M. MDS Nurse #1 and #2 conducted care plan reviews for residents with behavior care plans and Rx of psychotherapeutic medication to ensure least restrictive measures have been incorporated into the plan of care. The Care Plan for Resident #141 was updated by MDS Nurse #1 and #2 on [DATE] at 10A.M. inclusive of aggressive behaviors, de-escalation, grieving losses, sexual behavior with goals/interventions of utilizing life connections and social service for psychosocial well-being, leisure activities, expression of feelings, and communication with family. Interventions for Direct Care staff were included in this care plan. Resident #141 was transferred to hospital on [DATE] at 11:44 P.M. for chest pain at the direction of Medical Director. The Care Plan will be updated on return. On [DATE] Regional Nurse Consultant conducted chart review at 12 PM for other abuse incidents. There are no findings of other instances of alleged abuse that has gone unaddressed/reported at this time. 5. On [DATE] at 3 PM Regional Director of Operations, provided Corrective Counseling to Administrator regarding Abuse/Neglect Reporting and Investigations in accordance to the policy on Abuse and Neglect. On [DATE] at 3:30 PM Administrator conducted 1:1 in-service and corrective coaching with Nurse #2 on Abuse/Neglect Policy and Reporting of incidents whether or not it is known if the incident has been previously reported. Nurse #2 voiced understanding of policy and procedure. 6. An education in-service was conducted by Administrator beginning on [DATE] at 5:00 PM on Care plans policy and procedure and utilizing the care plan and reporting of changes in condition and behavioral changes. On [DATE] at 1 PM Regional Director of Operations and Regional Nurse Consultant in-serviced Administrator, Director of Nursing, Social Service Director and Social Services Assistant, and Life Connections on utilizing Behavior Management Plan inclusive of De-escalation procedures. On [DATE] at 11:30 AM an in-service was conducted by Administrator on Behavior Management and Resident Rights with staff inclusive of de-escalation techniques of aggressive behavior as a non-medication approach to promote the psycho-social well-being of a resident. Staff educated that all residents have the right before medications are given. Behavior Management training has been added to the orientation process for new hires. No employee will be allowed to return to work until he/she has completed the educational in-service. Care Plan Education was provided by Regional Nurse Consultant on [DATE] at 10AM with MDS Coordinator #1 and # 2, Social Service Director and Social Services Assistant, and Life Connections to include care planning after each incident report, change of condition, change in behavior, quarterly updates, yearly updates and working with the multi-disciplinary team when care planning to include sexual behaviors, aggressive behaviors, utilizing all forms of information, collaboration, policy and procedure were reviewed. No employee will be allowed to return to work until he/she has completed the educational in-services on Care Plan Policy, Using the Care Plan, reporting of changes in condition and behavior changes, and updating the Care Plan, Abuse and Neglect Policy, Reporting Abuse and Neglect, Behavior Management Policy and De-escalation Techniques. The facility alleged that all corrective actions were completed on [DATE], and removal of the Immediate Jeopardy (IJ) on [DATE]. On [DATE], the SA surveyor validated through staff interview, resident interview, record review, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): 1. The SA verified through record reviews, staff interviews, and reviews of resident interviews, that every resident living in the facility was interviewed and/or assessed by Social Services about abuse, neglect, and safety. 2. The SA verified through staff interview and review of the sign-in sheets that the QAPI/QA meetings took place on [DATE] at 3:00 PM and on [DATE] at 2:00 PM. 3. The SA verified through staff interview, record review, and policy and procedure review that the facility policies were evaluated by the facility and no new revisions in policy were made. 4. The SA verified through staff interviews, resident interviews, and record reviews, that a 100% chart audit had been completed and updates made for care plans, and for residents' medications. 5. The SA verified through staff interviews documentation review that the Administrator and Nurses had received one to one (1:1) counseling regarding the reporting of Abuse, and Neglect. 6. The SA verified through staff interviews, review of the in-service educational materials and review of the in-service sign-in sheets, that all employees of the facility was in-serviced about Abuse, and Neglect; Reporting of Abuse and Neglect; Resident Behavioral Management; Chemical Restraints; Care Planning; and Residents Rights. The SA validated on [DATE], that all corrective actions had been taken by the facility to remove the IJ during the extended survey on [DATE], and the IJ was removed on [DATE].

Based on observation, interview, record review, facility policy review, Operational Manual review, and National Health Institute of Health website article review, it was determined the facility failed to provide treatment and services, in accordance with the comprehensive assessment, to promote healing of pressure sores for four (4) of four (4) sampled residents. (Resident #74, Resident #50, Resident #57, and Resident #83) 1. Resident #74 was readmitted from the hospital with a Stage II wound to her left buttock and a skin tear on her sacrum. Her wounds were not assessed accurately at readmission. Resident #74's skin tear progressed into an unstageable pressure sore. She had an intervention in her care plan to have an air mattress to relieve pressure on the resident's body. The air mattress was not set in accordance with the manufacturer's recommendations and was set 150 pounds too firm. 2. Resident #50 utilized an air mattress to relieve pressure on the resident's wounds on her sacrum and right and left heels. The resident air mattress was set at 184 pounds too firm. 3. Resident # 57 had a wound on her sacrum and a care planned intervention of an air mattress to relieve pressure to the sacrum. The air mattress was set to be 50 pounds too firm. 4. Resident #83 utilized an air mattress to relieve pressure on the resident's sacral, right buttock, and left heel wound. The resident air mattress was set too firm. This deficient practice contributed to the deterioration of Resident #74's wound and had the potential to affect six (6) residents in the facility who utilized an air mattress for wound healing. Therefore, this deficiency is cited at the harm level. Findings include: Review of the Operation Manual for the Model B air mattress (undated) revealed to Press up or down buttons to adjust settings to relative patient weight. The manual also said that Caregivers should always perform a 'hand check' to ensure patients are not bottoming out. A 'hand check' should be performed when the patient is on the support surface by placing a hand below the air cells beneath the pelvic area of the patient. Ensure that there is an adequate amount of air supporting the patient, so they are not bottoming out. Review of the Operation Manual for the Model A air mattress (undated) revealed the control dial should be used to adjust pressure of mattress according to patient's weight. Review of the article Alternating pressure air mattresses as prevention for pressure ulcers: a literature review, published by the National Institute of Health (retrieved 4/11/19 from https://www.ncbi.nlm.nih.gov/books/NBK /#_d 4_implications_), revealed health organizations must ensure that nurses were trained in the correct use of different alternating pressure air mattresses. Review of the facility's policy titled, Alternating Pressure Air Mattress, dated 8/25/14, revealed the purpose was to redistribute pressure and aid in healing and/or prevention of pressure ulcers. Procedures include to 1. Follow manufacturer's instructions for use. 1. Review of Resident #74's Face Sheet, dated 4/1/19, documented she was readmitted by the facility, on 2/20/19, with [DIAGNOSES REDACTED]. Review of Resident #74's admission Progress Note, dated 2/20/19, documented the admission skin assessment noted red open areas to left and right buttocks. Review of the resident's Nursing Progress Note, dated 2/21/19, revealed Resident #74 had a skin tear that measured 0.6 centimeter (cm) by 0.5 cm. There were no other notes about the skin tear until 3/8/19, when it was noted she had a Stage II wound to her sacrum. Review of Resident #74's readmission Braden Scale, dated 2/26/19, documented she was at moderate risk of developing pressure sores. Review of Resident #74's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and no behaviors. The MDS noted she weighed 138 pounds and had a Stage II pressure sore and a skin tear that were present on readmission. The MDS indicated she was at risk for developing pressure ulcers/injuries and she had one or more unhealed pressure ulcers. The MDS documented the use of a pressure reducing device for bed, pressure ulcer/injury care, application of ointments, medications and nonsurgical dressings. Review of Resident #74's Care Area Assessment for Pressure Ulcers, dated 3/6/19, documented the resident had a Stage II wound. The assessment noted the wound was on the right buttock instead of the left buttock. The assessment noted that the resident was at risk for further skin impairment, and she had a pressure reducing mattress to her bed. Review of Resident #74's Weekly Pressure Injury Reports for the resident's sacrum revealed the following: 3/7/19- Stage II sacral wound, 1.5 cm x 0.9 cm 3/14/19- Stage II sacral wound, 1.3 cm x 0.7 cm with 10% eschar and 90% granulation 3/21/19 - Stage III sacral wound, 3.5 cm x 3.4 cm with moderate serosanguinous exudate, with eschar in the wound bed, 80% eschar and 20% granulation. Noted air mattress added to bed. 3/28/19 at 4:02 p.m.- Stage III sacral wound, 2.5 cm x 3.5, with moderate odor, moderate serosanguinous exudate, and 100% slough 3/28/19 at 10:03 PM.- Restaged Sacral wound to unstageable wound, serous exudate, and 100% slough on the wound bed Observation on 4/1/19 at 9:13 AM., revealed Resident #74 in bed. Her air mattress was set to 285 pounds. The mattress label indicated it was air mattress type Model A. Observation on 4/1/19 at 10:46 AM., revealed Resident #74 in bed. Her air mattress was set to 285 pounds. Observation on 4/1/19 at 3:27 PM., revealed Resident #74 was in bed, and her air mattress was set to 285 pounds. Observation on 4/2/19 at 9:31 AM., revealed Resident #74 in bed. Her air mattress was set to 285 pounds. On 4/3/19 at 10:36 AM., in an interview with Registered Nurse (RN) #4, the South Hall Wound Nurse, she said when Resident #74 was readmitted , she had a skin tear to her sacrum. She said the skin tear was superficial, that the top layer of skin had been taken off, and it was pink around the edges. She said the wound got worse. She said it grew into a Stage II, then a Stage III and that it was now considered unstageable because slough covered 100% of the wound bed. She said the resident got an air mattress when the sore on her sacrum turned into a Stage III, and that the mattress should be set according to the person's weight. She said neither the nurse practitioner nor the physician has assessed the wound with her, and that Resident #74 has not gone to the wound clinic. In an interview on 4/4/19 at 8:42 AM., Licensed Practical Nurse (LPN) #1 said it was the nurses' responsibility to monitor the air mattresses. She said she was not aware the mattress had been set at 285 pounds. On 4/4/19 at 11:10 AM., during an interview LPN #2 said she knew of nowhere to monitor the settings on the air mattress and she did not know how to tell what the mattress was set to. She said if the mattress was set too high, the mattress would not be doing what it was supposed to do, that it would be too firm, and it would increase the pressure on the resident's wounds. In an interview on 4/4/19 at 11:19 AM., Nurse Consultant #5 said there was no place to document the specific settings of an air mattress, just to make sure the care plan said a pressure relieving mattress. An interview on 4/4/19 at 11:40 AM., the Director of Nursing (DON) revealed the settings of the air mattresses should be done by the resident's body weight. She said the vendor will come to the facility, place the mattress on the bed, and set it up. She said when an air mattress was used, it would be an intervention on the care plan and an order would be obtained for informational purposes. She said if the air mattress was not at the right setting, the mattress would not relieve the pressure on the resident. The DON said when staff was first hired and as needed there would be training on using air mattresses. She said when the physician and the nurse practitioner round on the residents' wounds, they will write progress notes. She said they also had a wound care group that would come and do rounds on residents with wounds, and a wound clinic resident can go to. She said Resident #74 did not go to the wound clinic. During an interview on 4/4/19 at 12:00 PM., RN #6 said Resident #74's bed was delivered by the vendor, who set the bed to firm, at 285 pounds. She said she did not know why the bed was set to 285 pounds. An interview on 4/4/19 at 2:38 PM., with the Nurse Practitioner revealed she had assessed Resident #74's wound, but she had not seen it recently. She said the air mattress was in place to relieve pressure on the sacrum, and that, while still better than a regular mattress, if the bed was set too firm, the firmness could inhibit wound healing. On 4/4/19 at 3:25 PM., interview with Resident #74's Physician revealed Resident #74 came back to the facility in a more frail condition. He stated the air mattresses are used to help relieve pressure. He also stated because of the resident's declining condition, he did not think that anything would help the wound heal. 2. Review of the clinical record revealed Resident #50 was admitted by the facility on 5/12/03, and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 4/1/19 at 9:15 AM., revealed Resident #50 in bed with an air mattress on the bed. The air mattress was noted to be set at [PHONE NUMBER] pounds. The mattress label indicated it was air mattress type Model B. Observation conducted with RN #6/RN Supervisor, on 4/2/19 at 10:10 AM, revealed Resident #50 was lying in a bed utilizing a pressure mattress. The setting was noted set on at 100 pounds (lbs). Observation conducted during the medication pass with RN #6/ RN Supervisor on 4/3/19 at 8:10 AM., revealed Resident #50 lying in bed. The pressure mattress setting was noted to be set at [PHONE NUMBER] pounds. RN #6 looked at the setting and stated this was an incorrect setting due to the resident weight being at 116 pounds. RN #6 fixed the setting to the 100-pound selection. Observation on 4/3/19 at 9:45 AM., during the wound dressing change with RN #4, the South Hall treatment nurse and RN #7, the North Hall treatment nurse revealed the air mattress was set at the 100-pound selection. RN #7 stated Resident #50's wounds are healing and looking much better. The two (2) sacral wounds observed appeared to be two (2) small scratches. Review of the resident's Annual MDS, with an assessment reference date (ARD) of 2/18/19, revealed Resident #50 was assessed as having one (1) Stage II Pressure Ulcer and two (2) Stage III pressure ulcers, that were present upon admission/entry or reentry to the facility. Resident #50 was assessed as weighing 118 pounds during the assessment period. The following care areas were triggered and marked for care planning on the Annual MDS with an ARD of 2/18/19: cognitive loss/dementia, ADL (Activities of Daily Living)/rehabilitation, urinary incontinence and indwelling catheter, falls, nutritional status, and pressure ulcer. Review of the Quarterly MDS with an ARD of 11/20/18, revealed: Resident #50 was assessed as severe impairment in cognitive skills for daily decision making. Resident #50 was assessed as having two (2) Stage II Pressure Ulcer and one (1) Unstageable pressure ulcers. Resident #50 was assessed as having the following ulcer treatments: pressure reducing device for chair and bed and pressure ulcer/injury care. The resident was assessed as being 115 pounds during the assessment period Review of Resident #50's Care Plan without an onset date, provided by the facility, revealed several Focus areas related to the residents four (4) Stage III pressure ulcers. The care plans contained the following intervention Utilize appropriate measures in bed and if seated in chair to prevent further complications of pressure wound (such as mattres (sic) & chair cushion). Further review of the Care Plan revealed no instructions to the staff about the manufacture's recommendations, or the staff checking to see if the settings were correct. Review of the Task List for the Certified Nursing Assistants revealed Pressure reducing devices while in bed and while up in chair and check every shift. Review of the Electronic Medical Record, on 4/2/19, revealed Resident #50's weight at 116 pounds. On 4/3/19 at 12:34 PM., interview with LPN #16, working on the short North Hall, revealed she was not sure what the air mattress setting would be for Resident #50, but would look in the orders. The nurse stated there was no order in the medical record for the setting on Resident #50's air mattress. The nurse asked the Unit Manager what the setting should be. LPN #16 stated the unit manager stated the setting would go by the resident weight. On 4/3/19 at 12:38 PM., interview with North Unit Manager, who stated the air mattress settings would be based on the resident's weight, and the nurse can find the resident's weight in the medical chart. On 4/4/19 at 11:19 AM., Nurse Consultant #5 said there was no place to document the specific settings of an air mattress, just making sure the care plan said a pressure relieving mattress. Review of Resident #50's Electronic Medical Record and hard chart failed to reveal any settings or recommendations for the air mattress. Resident #50 had two (2) wounds on her sacrum and one (1) wound on each heel, a care planned intervention of an air mattress to relieve pressure to the areas of the wounds. The air mattress was set at 300 pounds. Resident #50's weight was 116 pounds. The air mattress was observed set 184 pounds too firm. 3. Review of Resident #57's Admission Summary, dated 2/18/19, revealed the resident was readmitted by the facility on 2/18/19 after hospitalization [MEDICAL CONDITION]. The summary noted the resident had a sacral wound (no stage noted), and utilized an air mattress on her bed. Review of Resident #57's Significant Change MDS, dated [DATE], revealed she had severely impaired cognition and she did not refuse care. The MDS noted she required extensive assistance of two (2) people to move in bed, and her weight was 112 pounds. The MDS indicated she was at risk of developing pressure ulcers, and had one or more unhealed pressure ulcers. The MDS noted she had two (2) Stage IV pressure ulcers, and needed pressure reducing devices for her bed and chair. Review of Resident #57's Comprehensive Care Plan, no date but was printed on 4/3/19, revealed she had a Stage IV wound to her sacrum, and utilized a pressure reducing bed mattress. Observation on 4/1/19 at 9:31 AM., revealed Resident #57 was in bed on an air mattress. The air mattress was set to 180 pounds. The mattress label indicated it was air mattress type Model B. Observation on 4/1/19 at 3:26 PM., revealed Resident #57 was in bed on an air mattress. The air mattress was set to 180 pounds. During an interview on 4/4/19 at 8:42 AM., LPN #1 said it was the nurses' responsibility to monitor the air mattresses. She said she was not aware the mattress had been set at 180 pounds. She said she did not have training on the settings of the mattress and was not taught to do a hand check on the mattress. In an interview on 4/4/19 at 11:10 AM., LPN #2 said she knew of nowhere to monitor the settings on the air mattress, and she did not know how to tell what the mattress was set to. 4. Review of the clinical record revealed Resident #83 was admitted by the facility on 10/17/13, and readmitted by the facility on 1/25/19 with [DIAGNOSES REDACTED]. Observation starting around 4/1/19 at 9:35 AM., revealed Resident #83 in bed with the head of the bed elevated and the resident was asleep. There was an air mattress on the bed, the left side of bed was near the wall, but not against the wall, and a fall mat on the right side of the bed. The air mattress setting was at 120-520 pounds for the patient weight. Observation on 4/1/19 at 12:00 PM., revealed Resident #83 in bed with the air mattress setting at 120-520 pounds. The mattress label indicated it was air mattress type Model B. On 04/2/19 10:00 AM., a dressing change to the sacral wound, right buttocks, and left heel for Resident #83 was observed. Observed RN #5 the wound nurse for the South Hall and RN #7 the wound nurse for the North Hall, perform the dressing changes to the three wounds on Resident #83, with no noted issues. The air mattress setting was at 120-520 pounds. RN #5 was asked about the air mattress setting and if the setting was correct, RN #5 stated there should be orders in the chart for the settings, she was not sure what the setting should be. On 4/4/19 at 8:47 AM., Resident #83 was observed in bed with the air mattress setting at 100-430 pounds. Review of the Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/4/18, revealed: Resident #83 was assessed as moderately impaired in cognitive skills for daily decision making. Resident #83 was assessed as not having any pressure ulcers during the look back period. The following care areas were triggered, and marked for care planning on the Significant Change MDS with an ARD of 7/4/18: cognitive loss/dementia, visual function, communication, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer, and [MEDICAL CONDITION] drug use. The following care area was triggered but not marked for care planning dehydration/fluid maintenance. Review of the Quarterly MDS, with ARD of 3/15/19, revealed: Resident #83 was assessed as severe impairment in cognitive skills for daily decision making. Resident #83 was assessed as not having any behaviors. Resident #83 was assessed as having three Stage III pressure ulcers, that were present upon admission/entry or reentry to the facility. Resident #83 was assessed as having pressure reducing devices for the chair and bed, being on a turning/repositioning program, nutrition or hydration intervention, and pressure ulcer/injury care. Review of Resident #83's Care Plan without an onset date, provided by the facility, revealed several Focus areas related to the resident's two (2) Stage III pressure ulcers and a deep tissue injury. The care plans contained the following intervention Administer treatments as ordered and monitor for effectiveness. Review of Order Summary Report, dated 12/1/17, revealed the resident was to have a low air mattress to his bed. Review of Resident #83's Electronic Medical Record, revealed on 3/25/19 the resident weighed 101.1 pounds. Review of the Task List for the Certified Nursing Assistants revealed Pressure reducing device. On 4/3/19 at 12:34 PM., interview with LPN #16, working on the short North Hall, revealed LPN #16 stated Resident #83's air mattress setting would be set at 100 pounds, which would be based off of the resident's weight. On 4/3/19 at 12:38 PM., interview with the North Unit Manager, revealed the air mattress settings would be based on the resident's weight and the nurse can find the resident's weight in the medical chart. During an interview, on 4/4/19 at 11:19 AM., Nurse Consultant #5 said there was no place to document the specific settings of an air mattress, just making sure the care plan said a pressure relieving mattress. Review of Resident #83's Electronic Medical Record and hard chart revealed no settings or recommendations for the air mattress. 5. On 4/4/19 at 11:40 AM in an interview, the Director of Nurses (DON) said the settings of the air mattresses should be done by the resident's body weight. She said the vendor will come to the facility, place the mattress on the bed, and set it up. She said if the air mattress was not at the right setting, the mattress would not relieve the pressure on the resident. The DON said when staff was first hired and as needed there would be training on using air mattresses. On 4/4/19 at 11:58 AM., in an interview the Assistant Director of Nursing (ADON) said the vendor would deliver the mattress and put the settings into the bed. She said he would tell the nurses who were working at that time about the settings. She said she was not taught to do a hand check to check the inflation on the mattress. On 4/4/19 at 12:00 PM., in an interview RN #6 said she was not taught to do a hand check on the mattress. Review of the facility's In-service record dated 4/3/19 titled Air Mattress Settings did not address how to determine the correct settings for the air mattresses or the manufacturer recommendations for the different air mattress models.

Based on observation, interview, record review, and Operation Manual review, National Institute of Health article review, and facility policy review, the facility failed to provide services by qualified staff and in accordance with the plan of care for four (4) of four (4) residents sampled for pressure sores. (Resident #74, Resident #50, Resident #57, and Resident #83). Resident #74, Resident #50, Resident #57, and Resident #83 utilized air mattresses for pressure relief. Staff was not trained in the different types of air mattresses, and how to check the settings to ensure the mattresses were inflated to the manufacturer recommended settings. This deficient practice contributed to the deterioration of Resident #74's skin tear to an unstageable wound to her sacrum and placed six (6) residents at risk of wound deterioration. Therefore this standard is cited at the harm level. Findings include: Review of the Operation Manual for the Model A air mattress (undated) revealed the control dial should be used to adjust pressure of mattress according to patient's weight. The manual also said that Caregivers should always perform a 'hand check' to ensure patients are not bottoming out. A 'hand check' should be performed when the patient is on the support surface by placing a hand below the air cells beneath the pelvic area of the patient. Ensure that there is an adequate amount of air supporting the patient, so they are not bottoming out. Review of the Operation Manual for the Model B air mattress (undated) revealed to Press up or down buttons to adjust settings to relative patient weight. The manual also said that Caregivers should always perform a 'hand check' to ensure patients are not bottoming out. A 'hand check' should be performed when the patient is on the support surface by placing a hand below the air cells beneath the pelvic area of the patient. Ensure that there is an adequate amount of air supporting the patient, so they are not bottoming out. Review of the article Alternating pressure air mattresses as prevention for pressure ulcers: a literature review, published by the National Institute of Health (retrieved 4/11/19 from https://www.ncbi.nlm.nih.gov/books/NBK /#_d 4_implications_), revealed health organizations must ensure that nurses were trained in the correct use of different alternating pressure air mattresses. Review of the facility's policy titled, Alternating Pressure Air Mattress, dated 8/25/14 revealed the purpose was to redistribute pressure and aid in healing and/or prevention of pressure ulcers. Procedures include to 1. Follow manufacturer's instructions for use. 1. Review of Resident #74's Face Sheet, dated 4/1/19, revealed she was readmitted by the facility, on 2/20/19, with [DIAGNOSES REDACTED]. Review of Resident #74's admission Progress Note, dated 2/20/19, revealed the admission skin assessment noted red open areas to the left and right buttocks. Review of Nursing Progress Note, dated 2/21/19, revealed Resident #74 had a skin tear that measured 0.6 centimeters (cm) by 0.5 cm. There were no other notes about the skin tear until 3/8/19, when it was noted she had a stage II wound to her sacrum. Review of Resident #74's Significant Change Minimum Data Set (MDS), dated [DATE], revealed the resident had a Stage II pressure sore and a skin tear that were present on readmission. Interventions listed on the MDS were pressure reducing device for bed, pressure ulcer/injury care, application of ointments, medications and nonsurgical dressings. Review of Resident #74's Weekly Pressure Injury Reports from 3/7/19 to 3/28/19 revealed the resident's sacral ulcer progressed from Stage II to an unstageable wound. Observation on 4/1/19 at 9:13 AM, revealed Resident #74 in bed. Her air mattress was set to 285 pounds. The mattress label indicated it was air mattress type Model A. Observation on 4/1/19 at 10:46 AM, revealed Resident #74 in bed. Her air mattress was set to 285 pounds. Observation on 4/1/19 at 3:27 PM, revealed Resident #74 was in bed, and her air mattress was set to 285 pounds. Observation on 4/2/19 at 9:31 AM, revealed Resident #74 in bed. Her air mattress was set to 285 pounds. An interview, on 4/3/19 at 10:36 AM, with Registered Nurse (RN) #4, the South Unit Wound Nurse, revealed when Resident #74 was readmitted , she had a skin tear to her sacrum. She said the wound got worse. She said it grew into a Stage II, then a Stage III, and that the wound was now considered unstageable because slough covered 100% of the wound bed. She said she was not aware of what the settings should be because she thought they were always correct. On 4/4/19 at 8:42 AM, an interview with LPN (Licensed Practical Nurse) #1 revealed it was the nurses' responsibility to monitor the air mattresses. She said she was not aware the mattress had been set at 285 pounds. LPN #1 said she did not have training on the settings of the mattress, and was not taught to do a hand check on the mattress. On 4/4/19 at 12:00 PM, an interview with RN #6 revealed Resident #74's bed was delivered by the vendor, who set the bed to firm, at 285 pounds. She said she did not know why the bed was set to 285 pounds. She said she was not taught to do a hand check on the mattress. The facility's failure to provide care by qualified staff for Resident #74's air mattress contributed to the skin tear on her sacrum deteriorating to an unstageable pressure ulcer. 2. Review of the Clinical Record revealed Resident #50 was admitted by the facility on 5/12/03, and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 4/1/19 at 9:15 AM, revealed Resident #50 in bed with an air mattress on the bed. The air mattress was noted to be set at [PHONE NUMBER] pounds. The mattress label indicated it was air mattress type Model B. Observation conducted with RN #6/RN Supervisor, on 4/2/19 at 10:10 AM, revealed Resident #50 was lying in a bed utilizing a pressure mattress. The setting was noted on at 100 pounds. Observation conducted during the medication pass with RN #6/ RN Supervisor, on 4/3/19 at 8:10 AM, revealed Resident #50 lying in bed. The pressure mattress setting was noted to be set at [PHONE NUMBER] pounds. RN #6 looked at the setting and stated this was an incorrect setting due to the resident weight being at 116 pounds. RN #6 fixed the setting to the 100-pound selection. Review of the Electronic Medical Record, on 4/2/19, revealed Resident #50's weight at 116 pounds. Further review of the Electronic Medical Record revealed no Physician order for [REDACTED].>Review of the Resident #50's Care Plan, undated, revealed the following intervention for the pressure ulcers: Utilize appropriate measures in bed and if seated in chair to prevent further complications of pressure wound (such as mattres (sic) & chair cushion). Review of the Task List for the Certified Nursing Assistants, dated 2/20/19, revealed Pressure reducing devices while in bed and while up in chair and check every shift. On 4/3/19 at 12:34 PM, an interview with LPN #16, working on the short North Hall, revealed she was not sure what the air mattress setting would be for Resident #50, but would look in the orders. The LPN also stated there was no order in medical record for the setting on Resident #50's air mattress. The LPN #16 asked the Unit Manager what the setting should be. LPN #16 stated the Unit Manager said the setting would go by the resident's weight. Resident #50 had two (2) wounds on her sacrum and one (1) wound on each heel, a care planned intervention of an air mattress to relieve pressure to the areas of the wounds. The air mattress was set at 300 pounds. Resident #50's weight was 116 pounds. The air mattress was observed set 184 pounds too firm. 3. Review of Resident #57's Admission Summary, dated 2/18/19, revealed the resident was readmitted by the facility, on 2/18/19, after hospitalization [MEDICAL CONDITION]. The summary noted the resident had a sacral wound (no stage noted) and utilized an air mattress on her bed. Review of Resident #57's Significant Change MDS, dated [DATE], revealed she had severely impaired cognition and she did not refuse care. The MDS noted she required extensive assistance of two (2) people to move in bed, and her weight was 112 pounds. The MDS indicated she was at risk of developing pressure ulcers, and had one or more unhealed pressure ulcers. The MDS noted she had two (2) Stage IV pressure ulcers, and needed pressure reducing devices for her bed and chair. Review of Resident #57's Comprehensive Care Plan, no date but was printed on 4/3/19, revealed she had a Stage IV wound to her sacrum, and utilized a pressure reducing bed mattress. Observation on 4/1/19 at 9:31 AM, revealed Resident #57 was in bed on an air mattress. The air mattress was set to 180 pounds. The mattress label indicated it was air mattress type Model B. Observation on 4/1/19 at 3:26 PM, revealed Resident #57 was in bed on an air mattress. The air mattress was set to 180 pounds. An interview on 4/4/19 at 8:42 AM, with LPN #1 revealed it was the nurses' responsibility to monitor the air mattresses. LPN #1 said she was not aware the mattress had been set at 180 pounds. LPN #1 said she did not have training on the settings of the mattress, and was not taught to do a hand check on the mattress. 4. Review of the Clinical Record revealed Resident #83 was admitted by the facility on 10/17/13, and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation starting around 4/1/19 at 9:35 AM, revealed Resident #83 in bed with the head of the bed elevated and the resident was asleep. There was an air mattress on the bed, the left side of bed was near the wall, but was not against the wall, and a fall mat on the right side of the bed. The air mattress settings were at 120-520 pounds for the patient weight. The mattress label indicated it was air mattress type Model B. Observation on 4/1/19 at 12:00 PM, revealed Resident #83 in bed with the air mattress set at 120-520 pounds. Review of Resident #83's Care Plan, without an onset date, provided by the facility, revealed several Focus areas related to the residents two (2) Stage III pressure ulcers, and a deep tissue injury. The care plans contained the following intervention Administer treatments as ordered and monitor for effectiveness. Review of Resident #83's Electronic Medical Record revealed on 3/25/19 the resident weighed 101.1 pounds. Review of Order Summary Report revealed the following: 12/1/17-Apply low air loss mattress to bed. On 4/3/19 at 12:34 PM, an interview with LPN #16 working on the short North Hall, revealed Resident #83's air mattress setting would be set at 100 pounds, which would be based off of the resident's weight. Resident #83 had a sacral wound, right buttock wound, and left heel wound, a care planned intervention of an air mattress to relieve pressure to the areas of the wounds. The air mattress was observed set at 120 pounds. The resident weight was 101 pounds. The air mattress was set 19 pounds too firm. 5. In an interview, on 4/4/19 at 11:10 AM, LPN #2 said she knew of nowhere to monitor the settings on the air mattress, and she did not know how to tell what the mattress was set to. On 4/4/19 at 11:40 AM, an interview with the Director of Nurses (DON) revealed the settings of the air mattresses should be done by the resident's body weight. The DON said the vendor will come to the facility, place the mattress on the bed, and set it up. The DON stated if the air mattress was not at the right setting, the mattress would not relieve the pressure on the resident. The DON said when staff was first hired and as needed there would be training on using air mattresses. During an interview, on 4/4/19 at 11:58 AM, the Assistant Director of Nursing (ADON) revealed the vendor would deliver the mattress, and put the settings into the bed. The ADON said he would tell the nurses who were working at that time about the settings. The ADON stated she was not taught to do a hand check to check the inflation on the mattress. In an interview, on 4/4/19 at 12:00 PM, RN #6/North hall Unit Manager, said the vendor would deliver the mattress and put the settings into the bed. She said he would tell the nurses who were working at that time about the settings. In an interview, on 4/4/19 at 12:04 PM, LPN #16, North hall Unit Manager, said the vendor would deliver the mattress and put the settings into the bed. She said he would tell the nurses who were working at that time about the settings. She said she had not read the manufacturer's recommendations. On 4/4/19 at 12:05 PM, during an interview LPN #1 said the vendor would deliver the mattress and put the settings into the bed. She said he would tell the nurses who were working at that time about the settings. 6. Review of In-service Record, dated 4/3/19 titled Air Mattress Settings, revealed the in-service did not address how to determine the correct settings for the air mattresses or the manufacturer recommendations for the different air mattress models. No other in-service documentation was provided by the facility.

Based on interview, record review, and review of facility policy, it was determined the facility failed to develop a comprehensive care plan to address resident needs for one (1) of four (4) residents sampled for pressure sores. (Resident #74) Resident #74 was readmitted to the facility, on 2/20/19, with a skin tear on her sacrum. The facility failed to develop a care plan to address the resident's skin tear. The skin tear developed to an unstageable pressure sore. The failure to create a plan of care to address the skin tear helped contribute to the deterioration of Resident #74's wound. Therefore, this standard was cited at harm level. Findings include: Review of the Skin Care Process policy, dated 1/17/18, revealed the skin care process had six (6) components, including 3. Developing and implementing an individualized plan of care. The policy noted the Registered Nurse Serves as part of the care planning team to create the care plan based on identified risk or actual problems. Review of Resident #74's Face Sheet, dated 4/1/19, revealed she was readmitted by the facility, on 2/20/19, with [DIAGNOSES REDACTED]. Review of Resident #74's admission Progress Note, dated 2/20/19, revealed the admission skin assessment noted red open areas to the left and right buttocks. There was no documentation of a skin tear on the resident's sacrum. Resident #74's Nursing Progress Note, dated 2/21/19, revealed Resident #74 had a skin tear that measured 0.6 centimeters (cm) by 0.5 cm. Review of Resident #74's readmission Braden Scale (which measures the risk a person has of developing pressure sores), dated 2/26/19, revealed she scored a 13, which the assessment indicated was a moderate risk of developing pressure sores. Review of Resident #74's Significant Change Minimum Data Set (MDS), dated [DATE], revealed the resident had a Stage II pressure sore and a skin tear that were present on readmission. The MDS indicated she was at risk for developing pressure ulcers/injuries and she had one (1) or more unhealed pressure ulcers. Interventions listed in the MDS were pressure reducing device for bed, pressure ulcer/injury care, application of ointments, medications and nonsurgical dressings. Review of Resident #74's Care Area Assessment for Pressure Ulcers, dated 3/6/19, revealed the resident had a Stage II wound. The assessment noted the wound was on the right buttock instead of the left buttock. The assessment did not address the resident's skin tear. The assessment noted that the resident was at risk for further skin impairment, and she had a pressure reducing mattress to her bed. Review of Resident #74's Comprehensive Care Plan, revised 3/30/19, revealed there was no care plan provided that addressed the resident's skin tear that was identified in the 2/21/19 nursing progress note. On 4/3/19 at 10:36 AM, in an interview Registered Nurse (RN) #4/South Hall Wound Nurse, said when Resident #74 was readmitted , she had a skin tear to her sacrum. She said the skin tear was superficial, that the top layer of skin had been taken off, and it was pink around the edges. She said the wound got worse. She said it grew into a Stage II, then a Stage III and that the wound was now considered unstageable because slough covered 100% of the wound bed. She said a care plan was made for the Stage II wounds to her buttocks, but not for the skin tear on her sacrum until it grew worse. Interview conducted, on 4/3/19 at approximately 2:00 PM, with MDS Coordinator #20 revealed the MDS team consists of all new staff. She was trying to make the residents' care plans more individualized and personalized due to the previous MDS Coordinator did not personalize the care plans which resulted in more generalized care plans. She stated the new MDS team is doing a better job, and care plans will be much better going forward. MDS Coordinator #20 stated the MDS Coordinators are responsible for keeping residents' care plans current through oversight, and nursing staff input updated information as it occurs. The facility's failure to develop a care plan with interventions to address Resident #74's skin tear resulted in the area deteriorating to an unstageable pressure ulcer.

Based on staff and resident interview, record review, policy review, and facility investigation review, the facility failed to follow the plan of care for Resident #1, for one (1) of four (4) residents reviewed for the use of Total Lifts with transfers with two (2) person assist. Findings include: Review of the facility's policy, titled, Using the Care Plan, dated (MONTH) 1, 2000, revealed: Policy Statement: It is the policy of this facility that the care plan be used in developing the resident's daily care routines. Procedure: 2. The nurse supervisor and/or charge nurse shall be responsible for developing the nurse aide's daily/weekly work assignment sheets and/or flow sheets from the care plan. 5. Daily care and documentation must be consistent with resident's care plan. Review of Resident #1's Plan of Care, with an onset date of 9/5/17, revealed Resident #1 was to be transferred by use of a Full Body Lift with two (2) person assist. Review of the Care Kiosk for Resident #1 revealed when transferring Resident #1 the staff is to use a Total Lift with an Extra Large (XL) sling with two (2) person assist. Review of the facility's investigation dated and signed by the Administrator and Director of Nurses (DON), on 4/18/18, revealed: On 4/16/18, between 5:30 AM to 6:00 AM, CNA #1 and Licensed Practical Nurse (LPN) #1 were transferring Resident #1 from the bed to a wheel chair with the total lift. As CNA #1 pulled the lift from under the bed, and opened the base wide, the leg tilted, and the lift fell over, thus causing the resident to fall on the floor, resulting in a scalp hematoma per the emergency room evaluation on 4/16/18. Further review of the facility's investigation, staff and resident interviews revealed LPN #1 and CNA #1 were present in the room, but LPN #1 was did not assist CNA #1 with the transfer. The Administrator revealed she knew LPN #1 was in the room at this time, but did not know LPN #1 did not actually assist CNA #1 with the transfer. The Administrator stated she was not aware of that fact at the beginning of the investigation. Phone interview with CNA #1, on 5/3/18 at 10:12 AM, revealed Resident #1's Plan of Care was not followed related to only one person was at the lift when Resident #1 fell to the floor. CNA #1 reported the care plan was on the computer, and it says what type of lift to use, and how many people to assist. CNA #1 stated she was operating the lift alone when Resident #1 fell to the floor, and hit his head. CNA #1 stated LPN #1 was in the room, she was right there, just a few steps away in the room. A phone interview with LPN #1, on 5/2/18 at 3:26 PM, revealed she was in Resident #1's room at the time of the fall, but did not assist CNA #1. LPN #1 confirmed she was not within reach, or beside the lift when Resident #1 fell from the lift. LPN #! stated she couldn't get to him in time to help stop him from turning over. They never said we had to be beside the lift, just two (2) people to be in the room. An interview with Resident #1, on 5/2/18 at 12:30 PM, revealed on 4/16/18, CNA #1 and LPN #1 was getting him ready to go to [MEDICAL TREATMENT] when the lift tipped over. Resident #1 stated he did not fall out of the lift sling. Resident #1 stated, It was still on me when I fell , I fell on top of (Name of CNA #1), she was trying to break my fall, but I hit my head on the floor. Resident #1 stated CNA #1 was at the lift, and LPN #1 was at the door when he fell , but both were in the room. An interview, on 5/4/18 at 11:05 AM, with Licensed Practical Nurse (LPN) #2/ Minimum Data Set (MDS) Nurse, revealed information was collected from resident observations, staff interviews, resident interviews, and orders to determine what goes on the care plans. LPN #2 stated it is standard that if the total lift is used for lifts and/or transfers, there should be two person assist. LPN #2 stated two people should be at the lift. LPN #2 stated the care plans included the type of lift, the size of the sling, and how many people needed to assist. LPN #2 confirmed the care plan was not followed if the right lift, right size sling, and number of people to assist were not used. LPN #2 confirmed the Kiosk Care has the right type of lift, sling size, and number of people required for the resident's lift and/or transfer. An interview with the Director of Nursing (DON), on 5/4/18 at 11:30 AM, revealed if the staff does not have the right lift, the right size sling, or the right number of staff to assist, then they are not following the resident's Care Plan. The DON also stated it was facility policy to always have at least two persons present when using the Total Lift. The DON confirmed this could have been a serious injury since Resident #1 was on a blood thinner, [MEDICATION NAME], and Aspirin which also thins the blood. The DON confirmed this would put Resident #1 at a greater risk for a brain bleed and death. The DON stated during the initial investigation CNA #1 and LPN #1 confirmed they were in the room when Resident #1 fell to the floor. LPN #1 was a few steps away when the fall occurred. Review of Resident #1's (MONTH) (YEAR) Cumulative physician's orders [REDACTED]. Review of the (MONTH) (YEAR) Cumulative physician's orders [REDACTED].#1 to be transferred with two person assist with a Total Lift. Review of the Admission Record revealed Resident #1 was admitted by the facility, on 9/5/17, with the included [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 2/28/18, revealed Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS), which indicated he was cognitively intact Further review of the MDS revealed Resident #1 was totally dependent on staff with two person physical assistance with transfers, extensive assistance with two person physical assistance with bed mobility and dressing, extensive assistance with one person physical assistance with toilet use, and was totally dependent on staff for toilet use, and bathing.

Based on observation, staff and resident interview, record review, policy review, and facility investigation review, the facility failed to use two (2) person assist to lift and transfer Resident #1 with a Total Body Lift resulting in a fall with injury. This concern was identified for one of four residents reviewed for the use of a Total Body Lift with two (2) person assist. Findings include: Review of the facility's policy titled, Mechanical Lifts, dated 3/23/14, stated in order to facilitate a safe lifting environment for staff and residents, mechanical lifts are to be utilized for lifting and transferring residents whenever possible, and the mechanical lift program will include resident assessment and staff training for safety and operation of mechanical lifting devices. Review of the facility's investigation, signed and dated 4/18/18, by the Director of Nurses and the Administrator revealed, on 4/16/18, between 5:30 AM to 6:00 AM, Certified Nursing Assistant (CNA) #1, and Licensed Practical Nurse (LPN) #1 transferred Resident #1 from the bed to the wheelchair with the total lift. As CNA #1 pulled the lift from under the bed, the leg tilted and the lift fell over causing the resident to fall on to the floor. Resident #1 was immediately assessed by LPN #1, and no injuries were observed initially. Neuro checks were initiated, and were within normal limits. Resident #1 denied any pain/discomfort after the fall, and was able to move all extremities without discomfort. Staff were getting Resident #1 up and ready to go to [MEDICAL TREATMENT]. (Review of later staff interviews and statements revealed Resident #1 stated he was alright, and wanted to go on to [MEDICAL TREATMENT] since his transportation was there.) LPN #1 notified the Nurse Practitioner (NP) of the fall. LPN #1 also informed the NP of Resident #1's neuro checks and vital signs, and no sign of injury, or pain/discomfort. LPN #1 informed the NP Resident #1 wanted to go on to [MEDICAL TREATMENT], and the NP informed LPN #1 to send the resident on to [MEDICAL TREATMENT], but to call the [MEDICAL TREATMENT] unit. LPN #1 called the [MEDICAL TREATMENT] unit, but there was no answer. After Resident #1 arrived to the [MEDICAL TREATMENT] unit he began to complain of a headache, and was sent to the hospital emergency room for evaluation. Interview with Resident #1 revealed he was running his mouth with CNA #1 when the fall occurred, and could not remember if he moved or reached for something when he started swinging, and fell on the floor. The facility's maintenance did a 100% inspection of all lifts and slings, and no faulty equipment was found. The Therapy Director inspected, and cleared the lift sling used during Resident #1's transfer. All staff were in-serviced on the correct way to transfer a resident using a total lift. (Later staff interviews revealed LPN #1 was in the room, but did not assist CNA #1 with Resident #1's transfer with the total lift.) Review of the (Name of Ambulance Company's) Pre-Hospital Care Report revealed Resident #1 was transported to the emergency room , on 4/16/18 at 7:35 AM, with a complaint of a knot on the head, and head pain. The resident was alert, and responsive. The Narrative Note revealed the pt (patient) presented with a hematoma to the top of his head, no hemorrhage noted. Pt stated he was being moved from his bed to the wheelchair via patient lift when the lift tipped and fell with him, and he struck his head. Review of the (Name of Hospital)'s Admission record revealed Resident #1 was admitted , on 4/16/18 at 7:42 AM, with a [DIAGNOSES REDACTED]. Review of the (Name of Hospital) Nurse's Notes (NNs), dated 4/16/18 at 7:40 AM, revealed a [DIAGNOSES REDACTED]. Patient hit the top of his head on the floor. Patient has a large hematoma on the top of his head. Interpretation of the Computerized Tomography (CT) of the head revealed no acute disease, and no acute intracranial abnormality. Patient was discharged to home, on 4/16/18 at 8:37 AM, with a [DIAGNOSES REDACTED]. On 5/2/18 at 12:30 PM, an interview with Resident #1 revealed, on 4/16/18, CNA #1 and LPN #1 was getting him ready to go to [MEDICAL TREATMENT] when the lift tipped over. Resident #1 said CNA #1 was at the lift, and LPN #1 was at the door when he fell , but both were in the room. Resident #1 stated he did not have a headache until he arrived at the [MEDICAL TREATMENT] Unit, and stated he requested to be sent to [MEDICAL TREATMENT] after the fall. Resident #1 stated, I think they just got in too big a hurry. Resident #1 stated, The whole thing just tipped over. Resident #1 confirmed he did not fall out of the lift sling and stated, It was still on me when I fell , I fell on top of (proper name for CNA #1), she was trying to break my fall but I hit my head on the floor. On 5/2/18 at 3:26 PM, a phone interview with LPN #1 revealed she stated she was in the room, but she couldn't get to him in time to help stop him from turning over. LPN #1 confirmed she was not within reach, or beside the lift when Resident #1 fell from the lift. LPN #1 stated, I could have been a little closer, I couldn't catch him. LPN #1 stated she had been in-serviced on the use of the lifts when hired, but could not recall the specifics of the in-service. LPN #1 stated they had been told only two persons needed to be present in the room, not that both persons had to assist with the transfer. On 5/3/18 at 10:12 AM, a phone interview with CNA #1 revealed the Kiosk had Resident #1 assessed for a Total Lift with two (2) person assist with an Extra Large (XL) sling. CNA #1 reported she was operating the total lift when Resident #1 fell to the floor, and hit his head. CNA #1 stated, LPN #1 was in the room, she was right there just a few steps away in the room. CNA #1 stated, Accidents happen and it just tipped over. Review of the Care Kiosk for Resident #1 revealed, when transferring Resident #1, the staff was to use a Total Lift with an Extra Large (XL) sling with two (2) person assist. On 5/2/18 at 9:26 AM, an interview with Resident #3 (Resident #1's roommate) revealed he was in his room when Resident #1 fell from the lift. Resident #3 stated there was two (2) staff present in the room. Resident #3 stated, One at the door. Review of the Quarterly Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 3/25/18, revealed Resident #3 scored 11 on the Brief Interview for Mental Status (BIMS), which indicated he was moderately cognitively impaired. During an interview with the Nurse Practitioner (NP), on 5/2/18 at 3:40 PM, the NP revealed she was notified by a phone call from LPN #1 that Resident #1 had fell from the lift. The NP stated LPN #1 informed her of the resident's neurological checks, and vital signs with no identified concerns. The NP stated LPN #1 had informed her Resident #1 continued to request to be transferred to the [MEDICAL TREATMENT] Unit, so he was transferred at that time. The NP stated the facility was to notify the [MEDICAL TREATMENT] Unit of the fall, but there was no answer at that time. The NP stated she was notified of Resident #1 complaining of a headache when reaching the [MEDICAL TREATMENT] Unit, and he was transferred to the Emergency Department (ER) for an evaluation that revealed a negative CT (Computerized Tomography) of the Head, and was released with the [DIAGNOSES REDACTED]. A review of Resident #1's Neurological Assessment Flow Sheet revealed neuro checks and vital signs were documented from 4/16/18 at 6:00 AM thru 1:00 PM, on 4/19/18. No Problems were documented in the Observation column. An interview, on 5/4/18 at 11:30 AM, with the Director of Nurses (DON) revealed the DON stated it was facility policy to always have at least two persons present when using the Total Lift. The DON stated this could have been a serious injury since Resident #1 was on [MEDICATION NAME], a blood thinner, and Aspirin which can also thin the blood. The DON stated this placed Resident #1 at a greater risk for a brain bleed and death. The DON stated during the initial investigation, LPN #1 and CNA #1 did not reveal to the facility that LPN #1 was present in the room, but did not assist while CNA #1 was operating the lift. Review of Resident #1's (MONTH) (YEAR) Cumulative physician's orders [REDACTED]. Review of Resident #1's (MONTH) (YEAR) Cumulative physician's orders [REDACTED]. Review of the Admission Record revealed Resident #1 was admitted by the facility, on 9/5/17, with the included [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 2/28/18, revealed Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS), which indicated he was cognitively intact Further review of the MDS revealed Resident #1 was totally dependent on staff with two person physical assistance with transfers, extensive assistance with two person physical assistance with bed mobility and dressing, extensive assistance with one person physical assistance with toilet use, and was totally dependent on staff for toilet use, and bathing.

Based on observation, record review, interview, and review of the manufacturer's recommendation for the Stand Up Patient Lift, the facility failed to provide required supervision along with the designated lift as determined necessary for transfer by assessment for one (1) of five (5) sampled residents with falls resulting in a fall with injuries. (Resident #3) Findings include: Review of the Stand Up Patient Lift Owner's Operator and Maintenance Manual in Section 4-lifting the patient revealed "Individuals that use the standing patient sling MUST be able to support the majority of their own weight, otherwise injury may occur." Review of an incident reported by the facility for Resident #3 dated 3/20/14 revealed: "On 3/19/14, it was reported that after the completion of resident ...(Resident #3's) bath, Certified Nurse Aide (CNA) #6 and CNA #7 were transferring her from the shower chair to her wheelchair using the sit to stand mechanical lift. It was reported that as they lifted resident from chair, she stated that her right foot was slipping. CNA #7 was controlling the lift and started to lower resident back into the shower chair, when the control became stuck in the up position. Resident began to panic and started jerking causing her foot to slip more until she was moving toward the kneeling position." The report continued stating that the resident complained of pain in the right leg, and was transported to the hospital for assessment and treatment. Interview on 9/24/14 at 7:20 PM with CNA #7 and 9/24/14 at 7:55 PM with CNA #6 confirmed that Resident #3 was being transferred from the shower chair to her wheelchair with the sit to stand lift and the lift failed to lower the resident and she landed on her knees. Review of the 3/19/14 report of the right femur x-ray from the hospital revealed " Impression: Comminuted fracture of the distal right femur angulation and some overriding of the fracture fragments and associated soft tissue swelling. " Review of the Mechanical Lift Assessment for Resident #3 dated 9/10/13, 12/7/13, and 1/16/14 revealed that she was dependent in the level of assistance need to transfer and that she was non-weight bearing. The condition that affected transfer/positioning was identified as "morbid obesity". The plan for transfer was a total lift. The 9/10/13 assessment stated that four (4) staff were needed for transfer. The 12/7/14 and 1/16/14 assessment stated that two (2) staff were needed for transfer. Although the 12/7/13 assessment originally stated that a total lift was needed, this was marked through and stand up lift was added. Review of the care plan in effect prior the fracture revealed the problem of self care deficit r/t (related to) decreased mobility was identified 9/10/13. The Stand up lift x 2-3 person assist with all transfers was care planned. The lift assessment revealed a Hoyer lift was determined to be needed on 1/16/14. Review of the Nurse Aides' Information Sheet for the period of the femur fracture indicated Standup Lift x2 (two staff). In the Comment section of the Nurse Aides' Information Sheet it stated "will require 4+ (four plus staff) to assist mostly in ADLS (Activities of Daily Living). This statement was marked out." Although the Mechanical Lift Assess for this resident indicated the resident was non-weight bearing and needed the Hoyer Lift for transfers, the use of the Hoyer Lift was discontinued and the Stand Up Lift was used. Interview, on 9/25/14 at 4:25 PM with the Director of Nursing (DON), revealed she had changed the resident from a total lift to a Stand Up lift. She stated she tried the resident on the Stand Up lift and she thought the resident was safe on it. The resident wanted the Stand Up Lift. The DON stated she had not informed the resident of the safety concerns of the Stand Up Lift. The DON stated she did not know that the resident should be able to support her weight on her legs, and she had used her own judgment and changed to the Stand Up Lift. Interview, on 9/24/14 at 4:15 PM with Resident #3 regarding the 3/19/14 incident, revealed she remembered the date and approximate time of the incident, the names of CNA #6 and #7, and that the ambulance staff and fire department both assisted to get her on the stretcher for transport to the hospital. Resident #3 explained she told the CNAs her right foot was slipping and the CNAs tried to sit her back into the shower chair. Resident #3 said the lift would not lower her back into the chair, her foot slipped, and she fell with the strap holding her. Resident #3 was observed on 9/24/14 at 4:15 PM in the hallway in a large sized wheelchair with a black boot on her right leg. The facility admitted Resident #3 on 9/10/13 with [DIAGNOSES REDACTED].

Based on observation, record review, and interview, the facility failed to review and revise the care plan for Resident #3 to reflect the need for a Total Lift for Resident #3 for transfers. This resulted in a fall with a fracture on 3/19/14 when Resident #3 was transferred with a Stand Up lift. The facility also failed to revise Resident #13's care plan related to weight loss. This was for two (2) of 20 residents reviewed for care plan revisions. (Residents #3 and #13) Findings include: Review of the Care Plan revealed the problem of "Self care deficit r/t (related to) decreased mobility" was identified on 9/10/13. The care plan had revision dates of 9/24/13 and 12/7/13. On 12/7/13 the Hoyer lift was discontinued and the "Stand up lift x (times) 2-3 person assist with all transfers" was revised as the Mechanical Lift Assessment indicated was needed. There was no revision of the care plan for 1/16/14 to indicate the need for the total lift as indicated by the 1/16/14 Mechanical Lift Assessment. The Mechanical Lift Assessment for this resident, dated 9/10/13 (date of admission), 12/7/13, and 1/16/14 indicated the resident was non-weight bearing. The assessments indicated for 9/10/13 and 1/16/14, the total lift was needed for transfer. The type of lift for 12/7/13 was changed from the total lift to the stand-up lift although the resident was marked as non weight bearing. The Nurse Aide's Information Sheet also indicated the need for a Stand Up lift and was not revised on 1/16/14 to indicate the use of the Total Lift. A facility self reported incident for Resident #3, dated 3/19/14, stated the type of incident was "Fracture of fight Femur". The report stated "Certified Nurse Aide (CNA) #6 and CNA #7 were transferring her (Resident #3) from the shower chair to her wheelchair using the sit to stand mechanical lift. It was reported as they lifted resident from chair, she stated that her right foot was slipping. CNA #7 was controlling the lift and started to lower resident back into the shower chair, when the control became stuck in the up position. Resident began to panic and started jerking causing her foot to slip more until she was moving toward a kneeling position. Staff called for help and four other CNAs and 3 nurses came to assist with the incident." The 3/20/14 x-ray of the right knee reported "Comminuted impacted [MEDICAL CONDITION] diametaphysis right femur." Interview, on 9/25/14 at 4:25 PM, with the Director of Nursing (DON) revealed she had changed the resident from the total lift to the stand up lift prior to the 3/19/14 accident. The DON stated she had tried the resident with the stand up lift and thought she was safe on it, so the total lift was changed to the stand up lift. The DON stated she did not know the resident should be able to support her weight on her legs. The facility admitted Resident #3 on 9/10/13 with [DIAGNOSES REDACTED]. Resident #13 Review of the current care plan for Resident #13 revealed the problem of "Resident is at risk for nutritional problems secondary to receiving a therapeutic diet" which was identified on 10/14/2013. There was no update to the care plan to address the significant weight loss. Record review for Resident #13 revealed on 8/20/14, the Registered Dietitian (RD) identified a significant weight loss of 27.5 pounds (15%) in 90 days and 33.3 pounds (18.1 %) in 90 days. The RD stated this weight loss was "undesired". Interview on 9/25/14 at 11:25 AM, with Registered Nurse (RN) #2/Care Plan Nurse, confirmed the care plan was not updated to address the undesired significant weight loss. The facility admitted Resident #13 on 10/14/13 with [DIAGNOSES REDACTED].

Based on observation, interview, record review and policy review, the facility failed to ensure that one (1) of four (4) residents reviewed was provided the required supervision and assistance with devices to prevent an avoidable accident (Resident #2). On 12/12/10 at 7:00 p.m. CNA #3 transferred Resident #2 using a lift with the incorrect sling and without assistance. Resident #2 sustained a fall resulting in a fracture of the right femur. Findings Include: Record review revealed that Resident #2 was admitted to the facility on [DATE] with an was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/10 revealed that Resident #2 could not recall two (2) items after a brief period of time but was otherwise cognitive. She required two (2) person assistance with transfers, dressing and bathing. The previous MDS with ARD of 10/8/10 revealed that Resident #2 was unable to recall the day of the week but was otherwise cognitively intact and required total assistance with one (1) person for transfers. Observation and interview with Resident #2 on 2/22/11 at 1:10 p.m. revealed that she was alert and oriented to person and place. Resident #2 was seated in a geri-chair with a lift pad underneath her. She denied complaints. Further observation and interview on 2/22/11 at 1:40 p.m. revealed that she was assisted to transfer from the geri-chair to the bed with two (2) person assist, Certified Nursing Assistant (CNA) #4 and CNA #5, using the Hoyer lift and a large sling that criss crossed at the resident's thigh area. The transfer was without incident. Resident #2 had a brace/immobilizer to the right leg and stated that her leg was broken when that girl had put her back to bed. Interview with both CNA #4 and #5 on 2/22/11 at 1:40 p.m. revealed that it required two (2) person assist with any Hoyer lift to transfer any Resident. Review of an X-ray report dated 12/12/10 revealed that Resident #2 had an oblique fracture of the distal shaft of the right femur with mild posterior displacement. Review of an "Unusual Incident Report" for Resident #2 dated 12/12/10 at 7:00 p.m. revealed that a "CNA transferred with Hoyer lift, did not follow care plan R/T (related to) # (number) of people. Resident slipped out of sling, resulting in Transfer to hospital. Resident landed on CNA. CNA suspended indefinitely pending conclusion of investigation." Review of a "Fall Investigation" for Resident #2 dated 12/12/10 revealed that Resident #2 was positioned correctly, one (1) assist was used, the correct lift was used and the correct sling was used. "No" was circled for correct sling used and a hand written note dated 12/13/10 at 1140 (11:40 a.m. revealed that per CNA #3's phone conversation the correct sling was not used. Under the "Conclusion" section was documented "to change resident to a two (2) person assist with use of the Hoyer lift". Review of the "ADL Plans of Care" revealed that the Hoyer lift with two (2) person assist had been in place for Resident #2 from 4/8/09 until present time. Review of a "7-Day Assessment Report" dated 12/6/10 - 12/12/10 revealed that Resident #2 had been transferred with one (1) person assistance on the day shift on 12/6/10, 12/8/10, 12/9/10, 12/10/10, 12/11/10 and 12/12/10 and had been transferred on the evening shift with one (1) person assist on 12/12/10. Review of the Nurse's Notes dated 12/12/10 at 6:40 p.m. revealed that Resident #2 was on the floor on her back with the right leg straight without injury noted at the time. CNA #3 said that the resident was in the total lift sling properly but somehow resident slid out on (the CNA's) lap and she had eased her down to the floor. Resident was complaining of right leg pain. Resident's daughter stated that her mother was crying in pain and that her leg was bent. Resident sent to hospital at 7:30 p.m. Review of the Mechanical Lift/Resident Assessment form dated 6/18/10 revealed that Resident #2 required the use of a Hoyer lift and Large Sling. There was no designation of the number of assistance needed/required, this information was blank. On 12/12/10 the assessment documented the use of two (2) persons for transfer assistance and on 12/17/10 there was documentation for two (2) person maximum assistance. Review of Resident #2's care plan dated 3/17/06 and updated on 12/2/10 revealed that Resident #2 required two (2) person assist with transfers, bed mobility, and toileting. A handwritten addition under 11/23/09 was documented as "Hoyer lift x 2 person assist". The care plan was updated on 12/12/10 for the use of the Hoyer lift with the proper size sling and two (2) person assist with all transfers on an "Instant Care Plan." Interview with the Director of Nursing (DON) on 2/22/11 at 2:45 p.m. revealed that she had talked with CNA #3 the day after the incident with Resident #2's fall was told that she had transferred Resident #2 by herself. The DON stated that CNA #3 used the wrong lift pad, that it may have been the pad for the stand up lift. The DON stated that CNA #3 reported that she was aware there were supposed to be two (2) persons for the transfer per the care plan but didn't give a reason as to why she had transferred Resident #2 by herself. The DON stated that they were not short staffed. The DON stated that CNA #3 was terminated due to the incident. The DON stated that Resident #2 was sent to the hospital with a fractured femur. The DON stated that it was policy and procedure to use two (2) person assist with all mechanical lifts. Interview with CNA #3 on 2/23/11 at 1:35 p.m. revealed that she used the all over total lift to get Resident #2 up with the assistance of the resident's daughter. CNA #3 stated that she used the sling that had been in the room all day. CNA #3 stated that she had needed to use the sling that criss crossed over the resident's legs but it had not been in the room. CNA #3 stated that she just used the one that was in there. CNA #3 described the sling as the one that could be hooked up around the shoulders and then hooked up at the bottom but it didn't criss cross. CNA #2 stated that there was supposed to be two (2) people to use the lift, that she just didn't have anyone at the time to help because they were at supper. CNA #3 stated that two (2) nurses were there and that LPN #1 told her to go ahead and get the resident back to bed. CNA #3 stated that she had not been trained on the lifts at the facility but had been trained and used similar lifts at another facility. She stated that nurse's had observed her using the lift on more than one (1) occasion. CNA #3 stated that she transferred Resident #2 by herself with the lift before but had always used the criss-cross sling. CNA #3 stated that she shouldn't have done it, but, it was too late now. CNA #3 stated that when she realized it was the wrong sling and the resident started sliding that she let the resident fall on her body. CNA #3 stated that the Acu-Nurse system had in the care plan the required number of people for transfer for Resident #2 and it was two (2) person assist. Review of CNA #3's personnel file revealed that she had signed a "Modified Lifting Policy" on 8/19/10 indicating that she acknowledged and understood the policy and had been fully trained on equipment usage. Interview with LPN #2 on 2/23/11 at 2:40 p.m. revealed that she was working the night that Resident #2 had fallen from the lift. LPN #2 stated that when she got to Resident #2's room the resident was on the floor and CNA #3 was standing by the Hoyer lift. LPN #2 stated that it looked like the sling had come loose. LPN #2 stated that she did not recall that the sling being broken, that it was hanging on the lift. She stated that the sling was blue in color. She stated that Resident #2 was assessed by the supervisor and was sent to the hospital after the daughter came to the facility. She stated that Resident #2 did not initially complain of pain and then later she did and was sent to the hospital. LPN #2 stated that she had observed CNA #3 use the Hoyer lift before and had not seen just one (1) CNA use the lift by themselves. Interview with CNA #6 on 2/23/11 at 3:35 p.m. revealed that Resident #2 was a total lift with two (2) person assist and the use of the full sling, the criss/cross sling. CNA #6 stated that it was always supposed to be two (2) persons when using the lifts. She stated that CNA #3 had asked her to assist with transferring Resident #2 when they had first came on the shift. CNA #6 stated that she told CNA #3 to let her know when she was ready. She stated that CNA #3 had never come to get her until after Resident #3 had fallen. She stated that when she came to Resident #2's room the resident had fell from the sling. CNA #6 stated that they got the criss cross sling to get Resident #2 from the floor. She stated that the full body sling was on the Hoyer lift when she first entered the room. Interview with CNA #7 on 2/23/11 at 4:00 p.m. revealed that she had trained CNA #3 during orientation and to the best of her knowledge she had trained her on the use of both mechanical lifts. This was not documented anywhere. Interview with RN #1 on 2/23/11 at 9:30 a.m. revealed that she had worked 11-7 shift and was told that Resident #2 had fallen out of the lift due to one (1) person transferring her and it was supposed to be two (2) persons transferring. RN #1 stated that she made sure that the care plan, Acu-Nurse (CNA care plan and charting system) and assessments had two (2) person assist documented. She stated that all staff knew to use two (2) persons with the lifts. Interview with CNA #8 on 2/24/11 at 9:45 a.m. revealed that the Acu-Nurse system worked in two (2) ways. First, a care plan is asked for and it tells the person what is required; and second when a task is done it will ask how many people was required for the task. The answer is documented on the ADLs. She stated that if anything was changed in the system that it would immediately let the staff know when the headset was turned on. She stated that it had always taken two (2) person assist with Resident #2 and the use of the criss cross sling. She stated that she had never transferred anyone with the Hoyer lift by herself and had not seen anyone do it either. Interview with the Administrator on 2/24/11 at 10:00 a.m. revealed that CNA #3 had signed the "Modified Lifting Policy" which indicated that she was trained on the proper lifting equipment and was trained by CNA #7. She was also trained on the equipment. She did acknowledge that other CNAs had documented that one person had assisted with the transfer of Resident #2 during the week of 12/12/10. The surveyor explained that there was a lack of supervision for the staff to have been transferring with the mechanical lift with only one (1) person instead of the required two (2) persons for more than just an isolated event. Interview with MDS Nurse #1 on 2/24/11 at 9:00 a.m. revealed that the MDS with ARD 10/8/10 was coded in error for one (1) person assist with transfers and should have been coded for two (2) person assist. She stated that the person who was doing MDSs at that time had a hard time with coding and that she had to tell her more than once that "2" didn't mean two (2) persons. She stated that two (2) persons was required with the use of the Hoyer and Stand Up lifts. Review of the facility's policy for "Mechanical Lifts" dated 4/15/09 revealed that "Residents will be assessed upon admission, quarterly, and with any significant change in condition for lifting and transferring needs and to determine the appropriate method and equipment needed to lift/transfer the resident. This assessment is to be completed by the Registered Nurse or Licensed Physical Therapist. This assessment will identify the type of equipment needed, sling type and size, and number of staff needed to complete the lift or transfer. The assessment will become part of the resident's medical record."

Based on observation and interview, the facility neglected to ensure that one (1) of four (4) residents reviewed (Resident #2) was transferred with the correct lift sling and the assistance of two (2) persons. On 12/12/10 at 7:00 p.m. CNA #3 transferred Resident #2 using a lift with the incorrect sling and without assistance. Resident #2 sustained a fall resulting in a [MEDICAL CONDITION] femur. Findings Include: Cross refer findings to F-323 for the facility's failure to ensure that Resident #2 was transferred with the correct lift sling and the assistance of two (2) persons.