Every finding on record at PruittHealth - Palmyra

Based on record review, staff interviews, and review of the facility policy titled, Grievances: Healthcare Centers, the facility failed to ensure that a written grievance was addressed in a timely manner for one Resident (R) (R2) of seven sampled residents. The deficient practice had the potential to place R2 at risk of unresolved grievances. Findings include:Review of the facility policy titled, Grievances: Healthcare Centers revised 01/10/2024, documented, Definitions: A grievance includes, but is not limited to, complaints with respect to care and treatment. Documented in Procedures: .1. In the event a patient expresses a grievance or complaint to a staff member, one or more of the following actions will be taken: .Complete the Action Taken and Findings section of the Grievance/Complaint Form.2. The Administrator will be responsible for overseeing the grievance process: The Administrator or designee will track the grievance on the Grievance /Complaint Log Form. In addition, The administrator or designee will then refer the grievance to the appropriate department for investigation.5. The Grievance/Complaint should be resolved within three business days.Review of the Face Sheet revealed R2 was admitted to the facility with the following diagnoses that included, but were not limited to, paroxysmal atrial fibrillation, gastrostomy, sickle-cell disease, paranoid personality, morbid severe obesity due to excess calories, body mass index BMI 45.0 - 49.9, and hypertension.Review of a facility provided, Grievance/Complaint Form: Healthcare Centers form dated 02/27/2026 documented that R2 did not want two Certified Nursing Assistants (CNA) to give her a bath. Speech Therapist (ST) HH also noted that R2 made allegations that one of the CNAs with a ponytail tried to rape her.There was no evidence that the complaint was investigated within 72 hours.Review of the facility provided Concern/Grievance Log Form dated February 2026 revealed that there was no evidence that the R2 complaint was logged on the form.Review of the Concern/Grievance Log Form dated March 2026 revealed that there was no evidence that the R2 complaint was logged on the form.During an interview on 08/06/2026 at 12:48 PM, CNA BB revealed that she could not recall the exact date, but that she and CNA DD went to the resident's room. She stated R2 had an explosive bowel movement and was on the heavy side. She stated R2 had feces in all her cervices and folds, and we had to open her legs to get all the feces off her. CNA BB stated the linen on the bed was changed and after the resident was cleaned, we left her room. She stated she was suspended for a week after R2 said something to therapy that implied something happened during her care.During an interview on 08/06/2026 at 2:44 PM, CNA DD revealed she went to help give a bath to R2, who is big and was assisting CNA BB and when they (CNA BB and CNA DD), opened her legs, she saw feces over her. CNA DD stated R2 told therapy about a week later that CNA BB had jumped on her and raped her and we reported this immediately and were suspended for one week pending investigation.During an interview on 08/11/2026 at 10:13 AM, Assistant Social Worker (SW) FF revealed that when a resident reported to a person, that person would fill out the grievance form and give the form to the person who was to do the investigation and the investigation was to be completed within 72 hours. SW FF stated the therapist had informed her of the R2 allegations, and it should have been investigated and reported.During an interview on 08/11/2026 at 10:28 AM, Therapist HH revealed she had R2 for several months. She stated when two CNAs (CNA BB and CNA DD) came to take her for a bath, R2 told her that she did not want those two CNAs to bathe her and then said the two CNAs had raped her. Therapist HH stated R2 indicated that one got on top of her and put a finger in her vagina. Therapist HH stated that she wrote the grievance and gave it to the SW FF.During an interview on 08/11/2026 at 10:54 AM, the Social Services Director revealed that she was not aware of the grievance in February. She stated she didn't know why the grievance was not investigated, as it should have been reported as a reportable.During an interview on 08/11/2026 at 3:12 PM, Director of Health Services (DHS) revealed that the therapist was working with the resident and the resident told Therapist HH who reported to SW FF and the two CNAs reported it to her. The DHS stated R2 was obese and had feces on her.The former Administrator and former Assistant Administrator were not available for interview.Cross reference F609

Based on record review, staff interviews, and review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure that a grievance with allegations of rape was reported timely for one resident (R) (R2) of seven sampled residents. The deficient practice increased the risk for abuse to occur without proper notification and thorough investigation.Findings includeReview of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised 10/20/2025, documented Policy Statement: It is the policy of .to comply with applicable federal and state requirements regarding the reporting of patient abuse, neglect, exploitation.Review of the Face Sheet revealed R2 was admitted to the facility with the following diagnoses that included, but were not limited to, paroxysmal atrial fibrillation, sepsis due to streptococcus pneumonia, gastrostomy, sickle-cell disease, paranoid personality, morbid severe obesity due to excess calories, body mass index BMI 45.0 - 49.9, and hypertension.Review of the facility provided, Facility Incident Report Form dated 03/19/2026 documented that the incident occurred on 02/27/2026, and later R2 had alleged sexual abuse during bathing.Review of the (named) law enforcement, Incident/Investigation Report dated 03/19/2026 documented the alleged rape occurred on 02/27/2026 at 8:30 AM. The narrative noted that Licensed Practical Nurse (LPN) EE had stated that R2 had reported an allegation of rape on 02/27/2026, but the grievance recently fell into her hands and she called it in.Review of the facility provided, Witness Statement Form dated 03/19/2026 documented that LPN EE stated that R2 had reported the allegations on 02/27/2026.Review of the Director Health Services (DHS) statement documented on 02/27/2026, that the Assistant Social Work and two Certified Nursing Assistants (CNA) (CNA BB and CNA DD) came to her office and asked to see LPN EE. The two CNAs and the Assistant Social Worker went to the former Administrator's office and on 03/19/2026 the two CNAs were asked to write another statement and at that time CNA BB and CNA DD were suspended.Review of the former Administrator's statement dated 03/20/2026, documented that she had reviewed the Staff Witness Statement Form, but the statements were placed under her door and indicated they were not retrieved and that a report was not made verbally nor written to the abuse coordinator.There was no evidence to indicate that CNA BB and CNA DD were suspended on 02/27/2026 after the alleged rape.During an interview on 08/06/2026 at 12:48 PM with CNA BB, stated she was suspended for a week after R2 said something to therapy that implied something happened during her care.During an interview on 08/06/2026 at 2:44 PM with CNA DD, stated that Therapist HH had informed her that R2 had alleged rape, so she and CNA BB reported this immediately and was suspended for one week pending investigation.During an interview on 08/11/2026 at 10:13 AM, with Assistant Social worker (SW) FF revealed that Therapist HH had informed her of the R2 allegations and it should have been investigated and reported at that time.During an interview on 08/11/2026 at 10:28 AM, Therapist HH stated that she wrote the grievance and gave it to SW FF.During an interview on 08/11/2026 at 10:54 AM, the Social Services Director revealed that she was not aware of the grievance dated 02/27/2026, but that grievance should have been reported as a state reportable at that time.The former Administrator and former Assistant Administrator were not available for interview.Cross reference F585

Based on observations, resident and staff interviews, record review, review of the facility provided recipe titled Chicken and [NAME] Casserole and Broccoli and review of the facility's policies titled Puree Policy and Diet Order System, the facility failed to ensure that the puree menu was followed. The deficient practice had the potential to affect the nutritional status for 18 of 18 residents' receiving a puree diet. In addition, the facility failed to follow the diet ordered for one of 51 residents (R) (R10) related to large portions and serving food not on a renal diet placing R10 at nutritional risk. Findings include: Review of the facility's undated policy titled Puree Policy under the section titled Preparation Steps documented, 1. Depending on the resident's dietary restrictions, follow the proper recipe to prepare the regular consistency food item. 2. Portion out the prepared food according to the number of pureed portions needed, remembering to include a little extra to make up for the loss of volume when pureeing. Review of the facility's policy titled, Diet Order System last revised 9/29/2022 revealed, All partners involved in meal service will check each tray against the diet card prior to delivery to the patient/resident. 1. Observation of the preparation of the puree meal and interview on 9/24/2025 at 11:45 am with Dietary [NAME] (DC) PP who was preparing the lunch meal revealed that 18 residents received a pureed diet. The Regional Registered Dietician (RRD) provided a copy of the menu and the recipe for Chicken and [NAME] Casserole and Broccoli. DC PP added a large pan of Chicken and [NAME] Casserole into the food processor, pureed the contents and checked for consistency. Interview with DC PP revealed that she added 18 spoonsful or more of the casserole to the recipe. She states density was checked with additions of chicken broth, alternating with processing until the desired consistency was reached. An interview on 9/24/2025 at 11:45 am with the RRD revealed that the menu recipe produced for the surveyor was generic and was configured for a serving size of 210. She stated that they reduced the number of servings to match the number of residents on puree consistency, which was a serving size to equal 18 residents plus a few extra portions. 2. Review of the electronic clinical record Face Sheet diagnoses for R10 included but were not limited to, hydronephrosis bilaterally, end stage renal disease, dependence on renal dialysis, anemia in chronic kidney disease, obstructive and reflux uropathy, malignant neoplasm of colon, secondary malignant neoplasm of lung, and anxiety disorder. Review of active physician orders revealed, a NAS (no added salt) diet with Special Instructions: No potatoes or bananas which was dated 8/15/2025. Review of the most recent Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed, Section C (Cognitive function) Brief Interview for Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment. Section O (Special treatments) was coded for dialysis. Review of the care plan last dated 9/21/2025 revealed: focus, goal and interventions included but not limited to 1. Potential for complications related to hemodialysis for Renal failure with intervention to consult with dietician for nutritional support. 2. Nutrition risk related to dialysis dependence and other diagnoses with intervention to provide diet as ordered, therapeutic diet liberalized renal diet as ordered/tolerated Interview on 9/23/2025 at 11:02 am with R10 revealed that he was not supposed to eat potatoes, bananas, or tomatoes because he is on a liberalized renal diet. He states he constantly gets potatoes. He states he was supposed to get large portions and thinks the staff does not read the meal slip/tickets. R10 provided photographs of multiple meal tickets representing food he states he received, which included potatoes, bananas and tomatoes. He states he does not receive large portions. Observation of breakfast tray on 9/24/25 revealed, one-half banana served on the meal tray to R10. Interview on 9/25/2025 at 3:00 pm with the RRD provided and verified the facility policy titled, Diet Order System last reviewed 9/29/2022 revealed, All partners involved in meal service will check each tray against the diet card prior to delivery to the patient/resident. The RRD revealed that dietary staff received education/training on checking meal slip tickets to ensure meals are plated correctly according to the diet ordered. She revealed it was the responsibility of all staff to make sure that food served is what was ordered.

Based on staff interviews, record review, and review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property the facility failed to report an injury of unknown origin for one of four residents (R) (R5) reviewed for accidents. Findings include:Review of the facility's policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, reviewed 11/15/2024, revealed, Procedures 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state survey agency and the state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment, including injuries of an unknown person source and misappropriation of patient property, within 2 hours after the allegation is based involve abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury.Review of R5's Quarterly Minimum Data Set (MDS), dated [DATE], for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment.Review of clinical records for R5 revealed, diagnoses that included, but were not limited to, aphasia following cerebral infarction, chronic systolic heart failure, type 2 diabetes mellitus without complications, vascular dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression.Review of R5's progress note dated 8/6/2025 revealed, the resident sustained an injury on 8/5/2025 from an unwitnessed fall. Interview on 9/24/2025 at 3:25 pm with Licensed Practical Nurse (LPN) CC revealed that she was working when a staff member was walking the hall and observed the resident in his room lying on a fall mat. LPN CC revealed, she was called to the room where she observed discoloration to the resident's eye. She assessed him, notified the provider and family. Neuro checks were completed as well as a post fall assessment. She stated the fall was documented in the medical record and was discussed the next morning at the clinical meeting that they have every day. She stated all department heads were in attendance including the Director of Nursing (DON), she was unsure if the Administrator was in attendance but stated she normally was.Interview on 9/24/2025 at 3:34 pm with the DON revealed that all falls with injuries are discussed during morning clinical meetings. She confirmed she was aware of R5's injury he sustained from an unwitnessed fall on 8/5/2025. The DON revealed that he was assessed and the next day it was determined the resident should go to the emergency room due to swelling of the eye. The DON further revealed that R5 was admitted due to being on an anti-coagulant and for a high level of lactic acid.Interview on 9/24/2025 at 3:35 pm with the Administrator revealed she did not remember the resident falling and obtaining an injury. She confirmed that all unwitnessed falls with an injury should be reported to the state and that the resident's injury from 8/5/2025 was not reported to the state.

Based on observations, staff interviews, record review, and review of the facility policy titled Care Plans, the facility failed to develop and implement care plans for six of 51 residents (R) (R111, R109, R18, R5, R135, and R155). Specifically, the facility failed to implement the care plans for R111, R5, R135, and R155 related to fall mats, for R18 related to oxygen and for R5 related to diet. In addition, the facility failed to develop a care plan for R18 related to oxygen use. This failure had the potential for the residents not to receive treatment and/or care according to their needs.Findings include: A review of the facility's undated policy titled Care Plan, reviewed 9/18/2025 revealed 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing, and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. 1. Review of the electronic health records (EHR) for R111 revealed that diagnoses that included but were not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, unsteadiness on feet, and wedge compression fracture of fourth lumbar vertebra, subsequent encounter for fracture with routine healing. Review of the Quarterly Minimum Data Set (MDS) for R111 dated 9/16/2025 for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) of eight which indicated the resident's cognition was moderately impaired. Review of R111's care plan dated 12/27/2023 revealed a focus area for fall with an intervention that included fall mats at beside bed. Observations on 9/23/2025 at 1:33 pm and 4:05 pm revealed R111 lying in bed without fall mats placement on the right and left side of the bed. Further observation revealed that the two fall mats were folded and leaning against the wall instead of being positioned on each side of the resident bed. Observation on 9/24/2025 at 8 :12 am and 2:03 pm revealed, R111 lying in bed without fall mats placement on the right and left side of the bed. Further observation revealed that the two falls mats folded and leaning against the wall instead of being positioned on each side of the resident bed. During an observation and interview on 9/24/2025 at 10:29 am with the Director of Nursing (DON), the DON confirmed that R111 was a lying in bed without fall mats placement on right and left side of the bed. 2. Review of R109's EHR revealed diagnoses that included but not limited to chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and shortness of breath. Review of the admission MDS dated [DATE] for Section C (Cognitive Patterns) revealed a BIMS score of five which indicated severe cognitive impairment and Section O (Special Treatments, Procedures, and Programs) revealed, oxygen therapy was received. Review of R109's physician order form (POF) revealed an order for oxygen at 2 LPM (two liter per milliliter) via nasal cannula. Review of R109's care plan listed a Focus Area Oxygen Use 2L/NC secondary to cough, COPD, Chronic Respiratory Failure /Terminal Illness with an intervention that included oxygen saturation as ordered. During an observation of R109's room on 9/23/2025 at 10:19 am and 1:01 pm, R109 was observed receiving oxygen at a flow rate of four liters per minute (LPM) via (by way of) nasal cannula (NC) from the oxygen concentrator. Observation on 9/23/2025 at 4:30 pm was conducted with the Administrator, the Administrator confirmed that R109 was receiving oxygen at a flow rate of four liter instead of two liters without a humidifier water bottle attached. Interview on 9/25/2025 at 2:30 pm with the MDS revealed that her expectation were for the licensed nursing staff to follow the order and care plan for oxygen therapy. She revealed she was unaware that resident was receiving oxygen at four liters instead of two liters . Cross Reference F695 3. Review of R18's cute on chronic combined systolic (congestive) and diastolic (congestive) heart failure (Primary, Admission), acute respiratory disease, acute respiratory failure with hypercapnia, cerebral infarction, unspecified, chronic obstructive pulmonary disease. Review of R18's Quarterly MDS dated [DATE] for Section C (Cognitive Patterns) revealed a BIMS score of eight, which indicated moderate cognitive impairment, Section J (Health Conditions) revealed shortness of breath Review of R18's care plan with last reviewed/revised date of 9/11/2025 revealed that R18 was not care planned for the use of oxygen. Observation on 9/23/2025 at 11:15 am revealed, R18 was observed eating lunch and receiving oxygen was set on 4 LPM via NC. Observation on 9/24/2025 at 9:15 am revealed, R18 was observed lying in bed and receiving oxygen at 4 LPM via NC. Observation on 9/24/2025 at 4:55 pm revealed, R18 was observed in bed eating dinner and receiving oxygen at 4 LPM via NC. Interview on 9/25/2025 at 12:03 pm with Assistant Director of Nursing (ADON) LL confirmed that if a resident was on oxygen that they should have an order and be care planned for oxygen. ADON LL confirmed that R18 did not have a care plan for oxygen. 4. Review of the EHR for R5 revealed diagnoses that included but were not limited to, aphasia following cerebral infarction, chronic systolic heart failure, type 2 diabetes mellitus without complications, vascular dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression. Review of R5's Quarterly MDS dated [DATE] for Section C (Cognitive Patterns) revealed a BIMS score of 0 indicating severe cognitive impairment. Review of R5's physician order dated 9/26/2024 listed a dietary order for a regular diet, puree consistency. Review of a progress note dated 4/5/2025 revealed that R5 had a choking incident. The progress note revealed that R5 was given a snack of the wrong consistency compared to the physician's order. Review of R5's care plan dated 6/24/2022 revealed that R5 was at risk for falls related to limited mobility and weakness. Interventions included a fall mat to both sides of the bed with a start date of 7/1/2023. Further review of the care plan with start date of 6/24/2022 and revised date 8/27/2025 revealed that R5 is at nutrition and hydration risk related to multiple chronic conditions; history of cerebral infarction resulting in dysphagia and need for both pureed diet and enteral feedings to meet nutritional needs. An observation on 9/23/2025 at 10:21 am revealed one fall mat on the left side of R5's bed and not one on the right side. An observation on 9/23/2025 at 3:00 pm revealed one fall mat to the left side of R5's bed and not one on the right side. Observation on 9/24/2025 at 8:59 am revealed the fall mat on the left side of the bed was rolled up on the floor and no fall mat on the right side. Interview on 9/24/2025 at 2:00 pm with Certified Nurse Assistant (CNA) LL revealed that on 4/5/2025, it was her first time passing out snacks to residents. She stated there was a variety of choices and she asked the resident if he wanted a snack. She confirmed R5 received a peanut butter sandwich without knowing he was on a special puree diet. Interview and rounding on 9/24/2025 9:28 am with the Director of Nursing (DON) confirmed that R5 should have a fall mat on each side of the bed. She confirmed there was no mat on the right side of the bed and that the mat on the left side was rolled up. The DON revealed that it was her expectation that fall mats be placed for residents that required them. She reviewed the pictures the surveyor had taken the day prior that captured there was no fall mat on the right side of the bed. Although the DON was not employed at the facility during the time the resident choked she revealed, her expectations was that staff follow the care plan and it's interventions. 5. Review of EHR for R135 revealed diagnoses that included but were not limited to, unspecified sequelae of cerebral infarction, major depressive disorder, single episode, unspecified, muscle weakness, anxiety disorder, unspecified, vascular dementia, unspecified severity, with mood disturbance, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the Quarterly MDS assessment for R135 dated 8/21/2025 for Section C (Cognitive Patterns) revealed a BIMS score of 0 indicating severe cognitive impairment. A review of the care plan revealed that R135 was at risk for falls related to impaired mobility, incontinence, and medication regimen. Interventions included but not limited to a fall mat on both sides of the bed with a start date of 1/14/2022 Observation on 9/23/2025 at 10:13 am revealed the resident asleep in bed and his fall mats rolled up by the sink that was across from the resident's bed. Observation on 9/23/2025 at 2:40 pm revealed the resident in bed with the fall mats still rolled up next to the sink and not on side of the resident's bed. Observation on 9/24/2025 at 8:58 am revealed a fall mat by the right bed side of the resident's bed however there was no fall mat on the left side of the bed. Observation and rounding on 9/24/2025 at 9:28 am with the DON confirmed R135 had a fall mat to the right side of his bed but not one on his left side. Surveyor showed the DON a picture taken on 9/23/2025 that displayed the mats rolled up next to the resident's sink. She confirmed they should be on the floor when the resident was in bed. 6. Review of EHR for R155 revealed diagnoses that included but were not limited to amyotrophic lateral sclerosis, schizophrenia, unspecified, epilepsy, unspecified, not intractable, without status epilepticus, and type 2 diabetes mellitus without complications. Review of the Quarterly MDS assessment for R155 dated 7/21/2025 for Section C (Cognitive Patterns) revealed a BIMS score of three which indicated severe cognitive impairment. Review of the care plan dated 9/25/2019 revealed R155 was at risk for falls related to impaired mobility, fall history, and epilepsy. Interventions included but not limited to, fall mat to bed side. Observation on 9/23/2025 at 10:42 am revealed there was no fall mat next to R155's bed, however his roommate had a floor mat next to bed, but it was more centered between both beds. Observation on 9/23/2025 at 2:41 pm revealed there was no fall mat next to R155's bed, however his roommate had a floor mat next to his bed, but it was more centered between both beds. Observation on 9/24/2025 at 8:58 am revealed there was no fall mat next to R155's bed, however his roommate had a floor mat next to his bed, but it was more centered between both beds. Interview and rounding on 9/24/2025 at 9:28 am with the DON confirmed that the resident should have a fall mat next to his bed. She said staff were responsible for ensuring mats are placed correctly during rounds. Interview on 9/25/2025 at 2:35 pm with the MDS Coordinator revealed that care plans were developed and implemented to give the residents the best care. She stated that interventions for residents that were at risk for falls or have a history of falls included but were not limited to fall mats by the bedside. She confirmed the resident required fall mats by his bedside and was unaware they were not being utilized. The MDS Coordinator revealed it was her expectation that staff follow the care plan for the residents' safety.

Based on observations, staff interviews, and record review, the facility failed to ensure assistance devices were placed at bedside to prevent accidents for four of five residents (R), (R111, R5, R135, R155) reviewed for accidents. Specifically, the facility failed to ensure fall mats were placed at bedside for the residents who had a history of falls.Findings include: 1. Review of the electronic health records (EHR) for R111 revealed that diagnoses that included but were not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, unsteadiness on feet, and wedge compression fracture of fourth lumbar vertebra, subsequent encounter for fracture with routine healing. Review of the Quarterly Minimum Data Set (MDS) for R111 dated 9/16/2025 for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) of eight which indicated the resident's cognition was moderately impaired. Review of R111's care plan dated 12/27/2023 revealed a focus area for fall with an intervention that included fall mats at beside bed. Further review of R111's care plan with last reviewed/revised date of 9/12/2025 revealed, Patient/Resident at risk for fall related to general weakness-12/27/2023: 1/10/2024 observed sitting on floor (fall without injury), 1/10/2024 sitting on floor-no injury, 1/25/2024 witnessed sliding to floor with no injury-4/15/2024: unwitnessed fall with minor injury (pain to right hand), 5/27/2024 unwitnessed fall with minor injury. Observations on 9/23/2025 at 1:33 pm and 4:05 pm revealed R111 lying in bed without fall mats placement on right and left side of the bed. Further observation revealed that two fall mats were folded and leaning against the wall instead of positioned on each side of the resident bed. During an observation and interview on 9/24/2025 at 10:29 am with the Director of Nursing (DON), the DON confirmed that R111 was a lying in bed without fall mats placement on right and left side of the bed. Interview on 9/24/2025 at 10:34 am, the DON reported that her expectation were for staff to monitor for fall mats placement while in the residents' room. 2. Review of the EHR for R5 revealed diagnoses that included but were not limited to, aphasia following cerebral infarction, chronic systolic heart failure, type 2 diabetes mellitus without complications, vascular dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression. Review of R5's Quarterly MDS dated [DATE] for Section C (Cognitive Patterns) revealed a BIMS score of 0 indicating severe cognitive impairment. Review of R5's care plan dated 6/24/2022 revealed that R5 was at risk for falls related to limited mobility and weakness. Interventions included but not limited to, a fall mat to both sides of the bed with a start date of 7/1/2023. Further review of the care plan revealed, an unwitnessed fall without injury on 7/1/2023, an unwitnessed fall with laceration to left eyebrow on 8/5/2025, and an unwitnessed fall with hematoma to left eye brow (sent to ER for evaluation with admit on 8/6/2025). An observation on 9/23/2025 at 10:21 am revealed one fall mat on the left side of R5's bed and not one on the right side. An observation on 9/23/2025 at 3:00 pm revealed one fall mat to the left side of R5's bed and not one on the right side. Observation on 9/24/2025 at 8:59 am revealed the fall mat on the left side of the bed was rolled up on the floor and no fall mat on the right side. Interview and rounding on 9/24/2025 9:28 am with the DON confirmed that R5 should have a fall mat on each side of the bed. She confirmed there was no mat on the right side of the bed and that the mat on the left side was rolled up. The DON revealed it was her expectation that the fall mats be placed for residents that required them as it was a safety device that reduces the risk of injury in case of a fall. During this time, she reviewed the pictures the surveyor had taken the day prior that captured there was no fall mat on the right side of the bed. 3. Review of the EHR for R135 revealed diagnoses that included, but were not limited to, unspecified sequelae of cerebral infarction, major depressive disorder, single episode, unspecified, muscle weakness, anxiety disorder, unspecified, vascular dementia, unspecified severity, with mood disturbance, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of R135's Quarterly MDS dated [DATE] for Section C (Cognitive Patterns) revealed, a BIMS score of 0 which indicated severe cognitive impairment. A review of R135's care plan dated 6/26/2019 revealed that R135 was at risk for falls related to impaired mobility, incontinence, and medication regimen. Interventions included a fall mat to both sides of the bed with a start date of 1/14/2022. Further review of R135's care plan revealed, Resident is observed on the floor by the bed 6/3. Fall without injury 9/24/2021. Fall without injury 1/14/2022 and 5/14/2025: Unwitnessed fall without injury. Observation on 9/23/2025 at 10:13 am revealed R135 was asleep in bed with the fall mats rolled up next to the sink and not placed on both sides of the bed. Observation on 9/23/2025 at 2:40 pm revealed R135 lying in bed with the fall mats still rolled up next to the sink and not placed on both sides of the bed. Observation on 9/24/2025 at 8:58 am revealed a fall mat by the right bed side of the resident's bed but not on the left side. Observation and rounding on 9/24/2025 at 9:28 am with the DON confirmed that R135 had a fall mat to the right side of his bed but not on the left side. During this time the surveyor showed the DON a picture taken on 9/23/2025 that displayed the mats rolled up next to the resident's sink. The DON revealed it was her expectation that fall mats be placed for residents that required them as it was a safety device that reduces the risk of injury in case of a fall 4. Review of the EHR for R155 revealed, diagnoses that included but were not limited to amyotrophic lateral sclerosis, schizophrenia, unspecified, Epilepsy, unspecified, not intractable, without status epilepticus, and type 2 diabetes mellitus without complications. A review of R155's quarterly MDS assessment dated [DATE] for Section C (Cognitive Patterns) revealed a BIMS score of three which indicated severe cognitive impairment. A review of R155's care plan dated 9/25/2019 revealed R155 was at risk for falls related to impaired mobility, fall history, and epilepsy. Interventions included fall mat to bed side. Further review of R155's care plans dated 9/25/2019 revealed that the resident had a fall w/o (without) injury on 8/27/2020; a fall without injury on 5/1/2021; a fall without injury on 5/3/2021; an unwitnessed fall with injury to right side of forehead on 10/10/2023, a fall without injury on 5/1/2024, an unwitnessed fall without injury on 8/4/2024 and a controlled fall, without injury on 9/2/2025. Observation on 9/23/2025 at 10:42 am revealed there was no fall mat next to R155's bed, however his roommate had a floor mat next to bed, but it was more centered between both beds. Observation on 9/23/2025 at 2:41 pm revealed, there was no fall mat next to R155's bed, however his roommate had a floor mat next to his bed, but it was more centered between both beds. Observation on 9/24/2025 8:58 am revealed, there was no fall mat next to R155's bed, however his roommate had a floor mat next to his bed, but it was more centered between both beds. Interview and rounding on 9/24/2025 at 9:28 am with the DON confirmed that R155 should have a fall mat next to his bed. The DON revealed that staff were responsible for ensuring mats were placed correctly during rounds. The DON revealed that It was her expectation that fall mats be placed for residents that required them as it was a safety device that reduces the risk of injury in case of a fall.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure that one of 16 sampled residents (R) (R109) was administered oxygen (O2) therapy in accordance with the physician orders. This failure had the potential to place R109 at risk for medical complications, unmet needs, and a diminished quality of life.Findings include:Review of the facility's policy titled Oxygen Administration dated 8/2/2023 revealed, It is the policy of the facility to provide oxygen safely and accurately to appropriate patients/residents. Oxygen .Oxygen will be administered by licensed personnel only when ordered by the physician , PA (Physician Assistant) or NP (Nurse Practitioner). The physician order may be written PRN (as needed) for comfort/dyspnea or may specify the number of liters, method of administration and length of the time the oxygen is to be administered. (1). O2 humidifier bottles should be used on all patient/resident s receiving higher than 2 liters/minute of oxygen flow. Review of R109 's electronic health records (EHR) revealed the following diagnoses but not limited to chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, dependence on supplement oxygen, and shortness of breath.Review of R109's admission Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of five which indicated the resident's cognition was severely impaired, Section O (Special Treatments, Procedures, and Programs) revealed the resident received oxygen therapy. Review of R109's physician order form (POF) revealed an order for oxygen at 2 LPM (two liter per milliliter) via nasal cannula.Observation on 9/23/2025 at 10:19 am and 1:01 pm revealed R109 lying in bed receiving oxygen by oxygen concentrator and nasal cannula at a flow rate of four liters with no humidifier bottle attached.An observation was conducted with the Administrator on 9/23/2025 at 4:30 pm in R109's room, the Administrator confirmed that the resident was receiving oxygen at a flow rate of four liters instead of two liters without a humidifier bottle. She reported that her expectations for her licensed nursing staff were to monitor and ensure that the resident's oxygen flow rates were set per the physician orders. Cross Reference F656

Based on record review and staff interviews, the facility failed to ensure a snack provided to a resident was in accordance with that resident's prescribed diet for one of 18 residents (R) (R5) that resulted in choking. Findings include:Review of the medical records Face Sheet revealed R5 had diagnoses that included but not limited to dysphasia and aphasia following cerebral infarction, chronic systolic heart failure, type 2 diabetes mellitus without complications, vascular dementia, and depression.Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed, Section C (Cognitive Patterns) documented a code 0 that Brief Interview for Mental Status (BIMS) should not be conducted as resident is rarely/never understood.Review of R5's physician order dated 9/26/2024 revealed, a dietary order for a regular diet, puree consistency. Review of the care plan with start date 6/24/2022 and revised date 8/27/2025 revealed, R5 is at nutrition and hydration risk related to multiple chronic conditions; history of cerebral infarction resulting in dysphagia and need for both pureed diet and enteral feedings to meet nutritional needs.Review of a progress note dated 4/5/2025 revealed that R5 had a choking incident. The note documented that R5 was given a snack of the wrong consistency compared to the physician's order. Interview on 9/24/2025 at 11:25 am with Corporate Dietician Consultant revealed that nurses and CNA's pass out snacks. She stated there are puree consistency snacks available such as pudding, apple sauce, and ice cream. She stated staff have a diet list on each floor that lists physician ordered diets. She confirmed that she was going to start posting that list on the snack carts. She stated this will make diet orders accessible to staff which will prevent staff from giving out the wrong type of snack and eliminate choking.Interview on 9/24/2025 at 2:00 pm with Certified Nurse Assistant (CNA) LL revealed that she was employed at the facility beginning March 2025. She stated she received education during orientation on resident diets. She confirmed 4/5/2025 was her first time passing out snacks to residents. She stated there was a variety of choices and asked the resident if he wanted a snack. She stated he received a peanut butter sandwich without knowing he was on a special puree diet. She stated he was choking, so she turned him on his side, and he was able to cough up the food. She stated she was educated after the incident by the night shift nurse on giving the correct snacks, but no other education was provided.

Based on observation, record review, the facility failed to implement the care plan for weekly skin inspections for two residents (R)(R9 and R12) and failed to develop care plan interventions for routine weekly skin assessments for residents (R1, R3, R8 and R11) who were at risk for skin breakdown from a sample of eight residents with pressure ulcers. On May 20, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Nurse Consultant and the Area [NAME] President were informed of the Immediate Jeopardy on May 20, 2025, at 2:49 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on December 24, 2024. The survey team validated the implementation of the removal plan through observations, staff interviews, and review of resident records. The immediacy of IJ was removed on May 23, 2025. Findings include: Review of the facility policy and procedure titled Care Plans with a revision date of 7/23/2023 revealed the following policy statement: It is the policy of the health care center for each resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Instrument Manual and the resident choice. The policy also noted the comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practical physical, mental and psychosocial needs that are identified in the comprehensive assessment. It further noted care plans will be updated by nurses, Case Mix Directors, or any other interdisciplinary team member so that the care plan will reflect the resident's needs at any given moment. 1. R1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: end stage renal disease, dependence on renal dialysis, neuropathy, pressure ulcer sacral region Stage 4, chronic ischemic heart disease, iron deficiency anemia, diabetes, peripheral vascular angioplasty and morbid obesity. Review of the Braden Scale (a tool used to assess a resident's risk of developing a pressure ulcer) form dated 4/15/2025 revealed the resident had a pressure ulcer risk score of 15 indicating the resident was at risk for skin breakdown. Review of the resident's care plan with a review/revision date of 8/30/2024 revealed the resident was at risk for skin breakdown related to physical limitations and disease process with a goal the resident's skin would remain intact until next review. Interventions for nursing staff included keep skin clean and dry as possible, pressure relieving device to bed, provide incontinence care and report any signs of skin breakdown (sore, tender, red, or broken areas). Although the resident had a care plan in place for being at risk for skin breakdown, there were no interventions in place to perform routine weekly skin assessments to identify skin breakdown timely per facility policy. Review of the Skin Notes in the resident's electronic record revealed that no weekly skin assessments were done for the month of January 2025, skin assessments were done three out of four weeks in February 2025, and although the resident was in the hospital from [DATE] to 3/25/2025, there was no documentation a skin assessment was performed on 3/25/2025 when she returned from the hospital. Further review of the record revealed there were no skin assessments in April 2025 until 4/16/2025 when a staff identified a Stage II to the right thigh and a re-opened Stage IV to the sacrum. 2. R3 (closed record) was admitted to the facility on [DATE] with the following but not limited to diagnoses: malignant neoplasm of the prostate, multiple myeloma, iron deficiency anemia, moderate protein calorie malnutrition, polyneuropathy, paraplegia, Stage IV pressure ulcers. Review of the resident's 12/31/2024 Quarterly Minimum Data Set revealed the resident's Brief Interview of Mental Status (BIMS) score was a 4 indicating severe cognitive impairment, required partial/moderate assistance with bed mobility, non-ambulatory, had three Stage III and two Stage IV pressure ulcers that were present on admit. The resident had a Braden Scale assessment completed on 9/25/2024 that indicated the resident had a pressure ulcer risk score of 9 indicating the resident was at very high risk for developing pressure ulcers. Review of the resident's care plan with a reviewed/revised date of 10/1/2024 revealed the resident was at risk for skin breakdown related to resident has multiple pressure ulcers with interventions to keep skin clean and dry as possible, minimize skin exposure to moisture, pressure relieving device to bed, provide incontinence care and report any signs of skin breakdown (sore, tender, red, or broken areas). Although the resident had a care plan in place for being at risk for skin breakdown, there were no interventions in place to perform routine weekly skin assessments to identify skin breakdown timely per facility policy. Review of the Skin Notes in the resident's electronic record revealed that weekly skin assessments were only done on 12/21/2024 and 1/18/2025. 3. R8 was admitted to the facility on [DATE] with the following but not limited to diagnoses: muscle weakness, heart failure, pulmonary hypertension, bullous pemphigoid, acute kidney failure, iron deficiency anemia, gout and diarrhea. Review of the resident's 3/21/2025 Significant Change MDS revealed he had BIMS score of 15 indicating he was cognitively intact and was at risk of developing pressure ulcers. Review of the Braden Scale form dated 2/8/2025 revealed the resident had a pressure ulcer risk score of 16 indicating the resident was at risk for skin breakdown. Review of the resident's 2/4/2025 care plan revealed the resident was at risk for impaired skin integrity with an approach to see skin risk analysis for interventions. During an interview with the DHS on 4/22/2025 at 3:07 pm, when asked to clarify the intervention to see skin risk analysis for interventions, she stated that was the Braden Scale. However, review of the Braden scale revealed there were no interventions in that assessment. Although the resident was at risk of developing pressure ulcers, the resident had one skin assessment on 3/22/2025 and there were no skin assessments in April 2025 until 4/16/2025 when the staff identified an unstageable pressure ulcer to the left heel. Review of the Wound Management Detail Report dated 4/17/2025 documented the date the wound to the left heel was identified as 4/17/2025. It further noted the resident had an unstageable pressure ulcer to the left heel measuring 2.5 cm x 5 cm with eschar noted, light serous drainage, no odor noted, and edges attached. 4. R9 was admitted to the facility on [DATE] with the following but not limited to diagnoses: anemia, chronic kidney disease, contractures to the right hand, left hand and left elbow, unspecified dementia with anxiety, heart failure, chronic obstructive pulmonary disease and abnormal posture. Review of the Braden Scale form dated 4/16/25 revealed the resident had a pressure ulcer risk score of 12 indicating the resident was at high risk for skin breakdown. Review of the 3/30/2025 Quarterly MDS revealed the resident had severely impaired cognition, was dependent on staff for activities of daily living (ADL) and bed mobility and was at risk of developing pressure ulcers. Review of the resident's care plan revealed the resident was at risk for additional pressure ulcers related to disease process, incontinence, impaired mobility and admitted with pressure ulcer to the sacrum. There was an approach for nursing staff to conduct systematic skin inspection weekly and report signs of further breakdown. Review of the Skin Notes in the Electronic Health Record revealed skin assessments were done 1/16/2025, 1/30/2025, 2/13/2025 and 2/27/2025. There were no skin assessments documented as done in March 2025 and none in April 2025 until 4/16/2025 during the facility wide skin sweep when staff identified an unstageable pressure ulcer to the resident's left elbow. Review of the 4/17/2025 Nursing Notes revealed documentation that as of 4/16/2025 nurse performing skin assessment to gather information and observed concern to the left elbow. Cleansed and dressing applied. Provider made aware. The 4/18/2025 Nursing Note documented the resident had an unstageable to the left elbow measuring 1.5 cm x 0.8 cm with slough noted. 5. R11 was admitted to the facility on [DATE] with the following but not limited to diagnoses: cognitive communication deficit, abnormal posture, anemia, muscle weakness, severe protein calorie malnutrition, intellectual disabilities and unspecified dementia. Review of the Braden Scale form dated 3/7/2025 revealed the resident had a pressure ulcer risk score of 14 indicating the resident was at moderate risk for skin breakdown. Review of the 3/25/2025 Annual MDS revealed the resident had cognitive impairment, dependent on staff for activities of daily living, dependent for bed mobility, at risk for developing pressure ulcers and had one Stage III pressure ulcer present on admit. Review of the resident's care plan revealed the resident had impaired skin integrity which noted an open area to the coccyx. There was an approach to see skin risk analysis for interventions, report any signs of skin breakdown (sore, tender, red, or broken areas). Review of the Skin Notes in the EHR revealed weekly skin assessments had not been done in March 2025 and April 2025 until 4/16/2025 during a facility wide skin sweep and identified a Stage III pressure ulcer to the resident's coccyx. However, review of the EHR revealed the resident has had this pressure ulcer since 9/17/2024. Review of the 9/17/2024 Wound Observation History form indicated the resident had a Stage III to the coccyx that measured 0.7 cm x 0.7 cm x 0.3 cm with granulation tissue. There was also a 4/14/2025 progress note from the wound care NP who noted the Stage III pressure ulcer to the coccyx continued to improve. It further noted the wound measured 0.6 cm x 0.6 cm x 0.2 cm with 5% yellow necrotic tissue, 50% granulation tissue and 45% intact. The plan was to continue current treatment of calcium alginate with silver 6. R12 was admitted to the facility on [DATE] with the following but not limited to diagnoses: chronic obstructive pulmonary disease, contracture left and right knee, cognitive communication deficit, abnormal posture, polyneuropathy, morbid obesity, stress incontinence, and iron deficiency anemia. Review of the Braden Scale form dated 4/15/2025 revealed the resident had a pressure ulcer risk score of 13 indicating the resident was at moderate risk for skin breakdown. Review of the 3/21/2025 Quarterly MDS revealed the resident had severely impaired cognitive skills, she was dependent on staff for ADL's, and at risk for developing pressure ulcers. Review of the resident's 10/23/2021 care plan revealed the resident was at risk for pressure ulcers related to disease process, incontinence and impaired mobility with an approach to conduct a systematic skin inspection (weekly, daily, etc). Pay particular attention to the bony prominences. Review of the weekly Skin Notes revealed a skin assessment was done 2/8/2025 and no skin assessments were done in March 2025 and April 2025 until 4/16/25 during a facility wide skin sweep when two unstageable pressure ulcers were identified to the sacrum and left knee. Review of the 4/17/2025 Wound Management Report revealed a 1.3 cm x 1.0 cm unstageable sacral wound with slough noted to the wound bed, attached reddened edges and a 9 cm x 3 cm unstageable left knee pressure ulcer with black necrotic tissue present. During a post survey interview with the Administrator on 6/24/2025 at 5:24 pm it was stated that any nurse could complete or update a care plan. It was reported that the care plans identified as missing for the residents was an oversight. She explained that nursing staff educated about being able to create and revise care plans during their orientation. She also reported that residents with wounds are followed in the Patients At Risk (PAR) meetings and care plans are reviewed at that time as well. Cross Refer to F686

Based on observations, record review and staff interviews, and review of facility policy titled Documentation of Skin and Wound Care, the facility failed to perform consistent weekly skin assessments for residents at high risk for skin breakdown in order to identify breakdown timely for six residents (R) (R1, R3, R8, R9, R11 and R12) and failed to perform treatments as ordered by the physician and/or recommended by the Wound Care Nurse Practitioner for three residents (R3, R11 and R12) of seven residents reviewed for pressure ulcers. The total sample size was 27. On May 20, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Nurse Consultant and the Area [NAME] President were informed of the Immediate Jeopardy on May 20, 2025, at 2:49 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on December 24, 2024. The survey team validated the implementation of the removal plan through observations, staff interviews, and review of resident records. The immediacy of IJ was removed on May 23, 2025. Findings include: Review of the facility policy and procedure titled Documentation of Skin and Wound Care (revised 6/14/24), revealed the following Policy Statement: It is the policy of the Healthcare center to complete documentation that reflects the current resident status as related to skin/wound care. Documentation will provide current and timely documentation on resident's condition related to skin/wound care, accurate information on resident's status as it pertains to skin/wound care, record care rendered and interventions in place and provide a detailed history of the wound assessments that have occurred in the healthcare center. The procedure noted documentation regarding wound observations and care should be completed on pressure ulcers weekly and as needed, per clinical judgement. Daily documentation of treatments is done by signing the ETAR that the dressing was completed. Weekly documentation of treatments will be completed on Wound Manager in the Electronic Health Record (EHR) and Focus Observation to include Skin observation. Further review of the policy revealed as an integral part of the pressure ulcer prevention program, an audit of all residents will be completed on admission and readmission, prior to any discharge or transfer and a minimum of every week. It further noted the Director of Health Service (DHS) or RN supervisor will develop a schedule of when each resident is to have the skin audit completed by the assigned charge nurse each week. This procedure is in addition to the responsibility of each partner to notify the Skin Integrity Coordinator (SIC) or designee when an area of altered skin integrity is identified. Wound assessment and documentation are completed weekly and when there is a significant change using the Documentation of Wound Observation and Assessment form. Wound assessments are completed weekly by the SIC RN. During an interview with the Regional Nurse Consultant OOOOOO on 4/17/2025 at 9:45 am, he stated the staff conducted a facility wide skin sweep on all the residents due to concerns identified with R1 on 4/16/2025. He provided a list of residents with new wounds found from the skin sweep on 4/16/2025. The list identified five residents with previously unidentified wounds. Three residents (R8, R9 and R12) were identified with unstageable pressure ulcers, one resident (R11) was identified with a Stage III pressure ulcer and one resident (R27) had a Stage I pressure ulcer. 1. R1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: end stage renal disease, dependence on renal dialysis, neuropathy, pressure ulcer sacral region Stage 4, chronic ischemic heart disease, iron deficiency anemia, diabetes, peripheral vascular angioplasty and morbid obesity. Review of the resident's Quarterly Minimum Data Set, dated [DATE] revealed she had Brief Interview for Mental Status (BIMS) score of 15 indicating she was cognitively intact, required partial to moderate assistance with hygiene and bathing, independent with bed mobility, she was non-ambulatory and had one Stage IV present on admit. Review of the Braden Scale (a tool used to assess a resident's risk of developing a pressure ulcer) form dated 4/15/2025 revealed the resident had a pressure ulcer risk score of 15 indicating the resident was at risk for skin breakdown. Review of the 1/15/2025 wound care provider Progress Note indicated the resident had Stage IV pressure ulcer to the sacrum since 6/7/2023. This progress note further indicated the sacral ulcer appeared to be healed at that time. Review of the Skin Notes in the resident's electronic record revealed that no weekly skin assessments were done for the month of January 2025, skin assessments were done three out of four weeks in February 2025, and although the resident was in the hospital from [DATE] to 3/25/2025, there was no documentation a skin assessment was performed on 3/25/2025 when she returned from the hospital. Further review of the record revealed there were no skin assessments in April 2025 until 4/16/2025 when a staff identified a Stage II to the right thigh and a re-opened Stage IV to the sacrum. During an interview with the resident on 4/16/2025 at 9:10 am, she complained of her bottom hurting. She also stated that she had complained of her bottom hurting to her daughter the other day and made her look at it but she did not know if she saw anything. During an observation of wound care on 4/16/2025 at 11:45 am with the Nurse Practitioner (NP), DHS and the Skin Integrity Nurse FFF, the resident had dressing to the sacrum and right thigh dated 4/15/25. The resident's right thigh was a Stage II that measured 1.5 centimeters (cm) x 1.4 cm x 0.1 cm. The sacrum measured 1.5 cm x 1.2 cm x 0.3 cm. The NP stated at that time the sacrum was a Stage III and the right thigh was a Stage II. During an interview with Licensed Practical Nurse Unit Manager IIII on 4/16/2025 at 10:35 am, she stated the resident does complain of her bottom hurting, so the other day she did a skin assessment on the resident and did not see any open areas, only old scar tissue. She stated they went ahead and placed a dressing on it to provide some cushion. During an interview with the Regional Nurse Consultant OOOOOO on 4/16/2025 at 4:15 pm, he stated he was only able to find skin assessments for February 2025. He stated since the surveyor was looking at the resident and after the areas were found on the resident on 4/16/2025, they looked at the resident's documentation and knew they had a problem. He stated they knew they had a problem with wounds but not to this extent. He further stated as of 4/16/2025 they started doing a 100% skin sweep on all the residents that would be completed that night and have started educating the staff. 2. R3 (closed record) was admitted to the facility on [DATE] with the following but not limited to diagnoses: malignant neoplasm of the prostate, multiple myeloma, iron deficiency anemia, moderate protein calorie malnutrition, polyneuropathy, paraplegia, Stage IV pressure ulcers. Review of the resident's 12/31/2024 Quarterly Minimum Data Set revealed the resident's BIMS score was a 4 indicating severe cognitive impairment, required partial/moderate assistance with bed mobility, non-ambulatory, had three Stage III and two Stage IV pressure ulcers that were present on admission. The resident had a Braden Scale assessment completed on 9/25/2024 that indicated the resident had a pressure ulcer risk score of 9 indicating the resident was at very high risk for developing pressure ulcers. Review of the physician's orders revealed the following wound care order with a start date of 12/3/2024 and end date of 2/7/2025 to pack lower back at 10 O'clock- 12 O' Clock with Opticell AG, cover wound bed with calcium alginate, finish with adhesive foam dressing once a day on Monday, Wednesday and Friday. Review of the January 2025 Medication Administration Record revealed the following missing treatments to the lower back on 1/17/2025, 1/20/2025, 1/24/25 and 1/27/2025 as indicated with no initials. Review of the Skin Notes in the resident's electronic record revealed that weekly skin assessments were only done on 12/21/2024 and 1/18/2025. 3. R8 was admitted to the facility on [DATE] with the following but not limited to diagnoses: muscle weakness, heart failure, pulmonary hypertension, bullous pemphigoid, acute kidney failure, iron deficiency anemia, gout and diarrhea. Review of the resident's 3/21/2025 Significant Change MDS revealed he had BIMS score of 15 indicating he was cognitively intact and was at risk of developing pressure ulcers. Review of the Braden Scale form dated 2/8/2025 revealed the resident had a pressure ulcer risk score of 16 indicating the resident was at risk for skin breakdown. Although the resident was at risk of developing pressure ulcers, the resident had one skin assessment on 3/22/2025 and there were no skin assessments in April 2025 until 4/16/2025 when the staff identified an unstageable pressure ulcer to the left heel. Review of the 4/17/2025 Nursing note indicated on 4/16/2025, nurse performing skin assessment and noted area of concern to resident's left heel. Wound care made aware and Hospice representative, dressing applied and heel boot in place. Review of the Wound Management Detail Report dated 4/17/2025 documented the date the wound to the left heel was identified as 4/17/2025. It further noted the resident had an unstageable pressure ulcer to the left heel measuring 2.5 cm x 5 cm with eschar noted, light serous drainage, no odor noted, and edges attached. Although the unstageable pressure ulcer was initially identified on 4/16/2025, a physician's order for treatment was not obtained until 4/18/2025 to cleanse the left heel with wound cleanser, apt dry, apply Betadine-soaked gauze and dry 4x4 gauze and protective dressing every Monday, Wednesday and Friday. Review of the April 2025 Medication Administration Record (MAR) revealed the treatment to the left heel was not started until 4/18/2025. The resident was evaluated by the wound care NP on 4/21/2025 who noted the resident had an unstageable pressure ulcer to the left heel that measured 8 cm x 8 cm with 100% black necrotic tissue. During an observation of the resident's left heel on 4/23/2025 at 11:18 am with the DHS and Skin Integrity RN FFF, the resident had an unstageable pressure ulcer to the left heel. The wound had approximately 60% black eschar and 40% pink granulation. 4. R9 was admitted to the facility on [DATE] with the following but not limited to diagnoses: anemia, chronic kidney disease, contractures to the right hand, left hand and left elbow, unspecified dementia with anxiety, heart failure, chronic obstructive pulmonary disease and abnormal posture. Review of the Braden Scale form dated 4/16/2025 revealed the resident had a pressure ulcer risk score of 12 indicating the resident was at high risk for skin breakdown. Further review of the record revealed the 4/16/2025 Braden Scale was the only Braden Scale done in 2025 and there were no Braden Scale assessments completed in 2024. Review of the 3/30/2025 Quarterly MDS revealed the resident had severely impaired cognition, was dependent on staff for activities of daily living (ADL) and bed mobility and was at risk of developing pressure ulcers. Review of the Skin Notes in the Electronic Health Record revealed skin assessments were done 1/16/2025, 1/30/2025, 2/13/2025 and 2/27/2025. There were no skin assessments documented as done in March 2025 and none in April 2025 until 4/16/2025 during the facility wide skin sweep when staff identified an unstageable pressure ulcer to the resident's left elbow. Review of the 4/17/2025 Nursing Notes revealed that as of 4/16/2025 there was documentation of nurse performing skin assessment to gather information and observed concern to the left elbow. Cleansed and dressing applied. Provider made aware. The 4/18/2025 Nursing Note documented the resident had an unstageable to the left elbow measuring 1.5 cm x 0.8 cm with slough noted. Review of the 4/2025 MAR revealed treatment was started on 4/16/2025 with cleansing the left elbow with normal saline, pat dry, apply calcium alginate and Medihoney with 4x4 gauze and cover with dressing every Tuesday, Thursday and Saturday. The resident was evaluated by the wound care NP on 4/21/2025 who noted the left elbow was a recurrent Stage IV pressure wound that as of 4/21/2025 the area was scabbed with no drainage and no open area. The area measured 2 cm x 2 cm. The NP noted the plan was to use Skin Prep and bordered foam dressing. Review of the Physician's orders revealed a new order on 4/22/2025 to cleanse the left elbow with normal saline, pat dry and apply Skin Prep every Tuesday, Thursday and Saturday. During an observation on 4/23/2025 at 11:02 am with the DHS and the Skin Integrity RN FFF, the resident was observed with two small, scabbed areas to the left elbow. 5. R11 was admitted to the facility on [DATE] with the following but not limited to diagnoses: cognitive communication deficit, abnormal posture, anemia, muscle weakness, severe protein calorie malnutrition, intellectual disabilities and unspecified dementia. Review of the Braden Scale form dated 3/7/2025 revealed the resident had a pressure ulcer risk score of 14 indicating the resident was at moderate risk for skin breakdown. Review of the 3/25/2025 Annual MDS revealed the resident had cognitive impairment, dependent on staff for activities of daily living, dependent for bed mobility, at risk for developing pressure ulcers and had one Stage III pressure ulcer present on admit. Review of the Skin Notes in the EHR revealed weekly skin assessments had not been done in March 2025 and April 2025 until 4/16/2025 during a facility wide skin sweep and identified a Stage III pressure ulcer to the resident's coccyx. During an observation of the resident on 4/23/2025 at 10:25 am with the DHS and the Skin Integrity RN FFF, the resident was observed to have a Stage III to the coccyx with 100% pink granulation tissue. However, review of the EHR revealed the resident has had this pressure ulcer since 9/17/2024. Review of the 9/17/2024 Wound Observation History form indicated the resident had a Stage III to the coccyx that measured 0.7 cm x 0.7 cm x 0.3 cm with granulation tissue. There was also a 4/14/2025 progress note from the wound care NP who noted the Stage III pressure ulcer to the coccyx continued to improve. It further noted the wound measured 0.6 cm x 0.6 cm x 0.2 cm with 5% yellow necrotic tissue, 50% granulation tissue and 45% intact. The plan was to continue current treatment of calcium alginate with silver. Review of the Physician's Orders revealed there was an order dated 10/28/2024 through 3/4/2025 to cleanse the sacral area(coccyx) with sterile normal saline, pat dry, pack wound with iodoform and cover with adhesive dressing every Monday, Wednesday and Friday. However, review of the MARs for March 2025 and April 2025, there was no documentation the treatment had been done as ordered until 4/18/2025 when a physician's order was obtained to cleanse the coccyx with normal saline, apply purachol and 4x4 gauze covered with adhesive dressing every Monday, Wednesday and Friday. During an interview and review of the EHR with the DHS on 4/23/2025 at 3:45 pm, she confirmed the resident was in the hospital from [DATE]-[DATE]. When the resident returned to the facility on 3/7/2025, the wound care orders were not restarted, and wound care was not done from 3/7/2025 through 4/17/2025. After they did the facility skin sweep on 4/16/2025 and identified the resident's Stage III pressure ulcer, physician orders were obtained for treatment on 4/16/2025. 6. R12 was admitted to the facility on [DATE] with the following but not limited to diagnoses: chronic obstructive pulmonary disease, contracture left and right knee, cognitive communication deficit, abnormal posture, polyneuropathy, morbid obesity, stress incontinence, and iron deficiency anemia. Review of the Braden Scale form dated 4/15/2025 revealed the resident had a pressure ulcer risk score of 13 indicating the resident was at moderate risk for skin breakdown. Review of the 3/21/2025 Quarterly MDS revealed the resident had severely impaired cognitive skills, she was dependent on staff for ADL's, and at risk for developing pressure ulcers. Review of the weekly Skin Notes revealed a skin assessment was done 2/8/2025 and no skin assessments were done in March 2025 and April 2025 until 4/16/2025 during a facility wide skin sweep when two unstageable pressure ulcers were identified to the sacrum and left knee. Review of the 4/17/2025 Wound Management Report revealed a 1.3 cm x 1.0 cm unstageable sacral wound with slough noted to the wound bed, attached reddened edges and a 9 cm x 3 cm unstageable left knee pressure ulcer with black necrotic tissue present. The wound care NP noted on 4/14/2025 a new unstageable pressure ulcer to the left knee measuring 3 cm x 3 cm x 1 cm with 100% black necrotic tissue. The NP noted a primary dressing of Betadine and a dry protective dressing three times a week. The 4/18/2025 Nursing Progress Note documented a 1.3 cm x 1.0 cm unstageable sacral wound with slough noted to wound bed and a 9 cm x 3 cm left knee pressure ulcer with black necrotic tissue. The 4/21/2025 wound care NP progress note documented the pressure ulcer to the sacrum as unstageable, measuring 1.2 cm x 1.2 cm x 1.0 cm with 100% yellow necrotic tissue with orders to apply honey, dry protective dressing three times a week. Review of the April 2025 MAR revealed a 4/14/2025 physician's order to cleanse wound to left knee with wound cleanser, paint wound with Betadine to wound bed and secure with dry protective dressing every Monday, Wednesday and Friday. However, further review of the April 2025 MAR indicated the wound care was only provided on 4/21/2025 and 4/25/2025. During an interview with the DHS on 4/29/2025 at 12:15 pm, she stated the nurses on the floor are responsible for doing the weekly skin assessments on all of the residents. Each unit has a schedule to go by and if new areas are identified they are reported to the wound nurse. During an interview with Unit Manager DDDD on 4/30/2025 at 12:40 pm, she stated the charge nurses were responsible for doing the weekly focused skin assessments on everybody each week and they have a schedule to go by. During an interview with the Administrator and the DHS on 5/6/2025 at 9:45 am, they stated from August 2024 to April 2025 they have had a total five treatment nurses. Stated there was one treatment nurse until a Registered Nurse was hired on 3/26/2025 and a third nurse was hired on 5/7/2025. They stated that at one time there was only one treatment nurse, and it was hard for them to document on wounds, such as weekly documentation and there were holes in the MAR's. Stated residents with wounds get a weekly Braden scale and those residents who don't have wounds get quarterly Braden scales, but they were not being done. When asked who was responsible for monitoring the skin integrity program, they stated the wounds would be discussed in weekly meetings. During an interview with Unit Manager IIII on 5/7/2025 at 10:15 am, she stated the charge nurses were responsible for doing the weekly skin assessments, but they were not doing them. Stated she did not know why they were not doing them. She stated those nurses have since resigned. When surveyor asked if she reported this to management, she stated that everybody knew about it. During an interview with the Wound Care NP on 5/20/2025 at 9:37 am, she stated the biggest issue was keeping a consistent wound care nurse. She stated that RN YY was good about calling her anytime and would give RN YY recommendations at that time until she could see the resident during her next visit which is weekly. Stated when she visits, she gives orders for the resident's wounds and leaves a copy of the order to both of the Skin Integrity Nurses and the DHS. She also confirmed that necrotic tissue does not develop overnight.

Based on record review, staff interviews and review of the Administrator Job Description and the Director of Health Services Position Description, administration failed to ensure staff were performing weekly skin assessments and wound treatments as ordered and failed to provide oversight and monitoring of the skin integrity program. This deficient practice impacted six residents (R) (R1, R3, R8, R9, R11 and R12) of 29 sampled residents. On May 20, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Nurse Consultant and the Area [NAME] President were informed of the Immediate Jeopardy (IJ) on May 20, 2025, at 2:49 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on December 24, 2024. The survey team validated the implementation of the removal plan through observations, staff interviews, and review of resident records. The immediacy of IJ was removed on May 23, 2025. Findings include: Review of the facility Administrator Position Description revealed: Directs the day-to-day functions of the nursing center in accordance with federal, state, and local regulations that govern long-term care centers, and as may be directed by the Area [NAME] President, to provide appropriate care for our patients/residents. Key responsibilities: -Current knowledge of state and federal laws governing the operation of nursing facilities. -Knowledge of licensing and payment programs, general business practices, nursing practice, psychology of resident care, personal care and social services, therapeutic and supportive long term care and services, and environmental health and safety relevant to nursing facility operations. -Ability to apply standards of professional practice to operations of nursing facility and to establish criteria to assure that care provided meets established standards of quality. -Ability to develop and implement administrative policies and procedures that reflect the center's philosophy and mission in compliance with federal and state laws and regulations. -Carries out all duties in accord with the center's mission and philosophy. Review of the Director of Health Services Position Description revealed: Job purpose to plan, organizes, develops and directs the overall operation of our Nursing Services Department in accordance with current federal, state, and local regulations governing our nursing center, and as may be directed by the Administrator and the Medical Director, to provide appropriate care. Key Responsibilities: -Maintain knowledge of documentation procedures including appropriate use of forms, timelines, and Medicare documentation etc. -Maintain working knowledge of current licensure standards and the survey process. -Perform other related duties as necessary and as directed by supervisor. The facility failed to provide effective oversight and monitoring of the Skin Management Program. Specifically, failed to ensure weekly skin assessments were routinely completed by licensed nurses on residents who were at risk of altered skin integrity and treatment orders were documented and completed as ordered. 1. Administration failed to ensure the implementation of the plan of care for weekly skin inspections for two residents (R9 and R12),and failed to develop interventions for routine weekly skin assessments for residents (R1, R3, R8 and R11) who were at risk for skin breakdown. Cross refer to F656. 2. Administration failed to ensure licensed nursing staff performed routine weekly skin assessments to identify skin breakdown timely for six residents (R1, R3, R8, R9, R11 and R12) at risk for skin breakdown, and failed to document treatment orders carried out for three residents (R3, R11 and R12). Cross Refer to F686. 3. Administration failed to ensure an effective Quality Assurance and Performance Improvement process was utilized to identify concerns related to the identification, care and management of the Wound Management System. There was no indication a Performance Improvement Plan (PIP) was developed as recommended by the Regional Nurse Consultant on 2/12/25 after he identified problems with the Skin Management Program. Cross Refer to F867 During an interview with the Administrator and the DHS on 5/6/2025 at 9:45 am, they stated from August 2024 to April 2025 they have had a total five treatment nurses. It was stated that at one time there was only one treatment nurse and it was hard for them to document on wounds. It was reported that wounds were discussed in weekly meetings.

Based on staff interviews, record review and review of the Quality Assurance and Performance Improvement policy, the facility failed to have a Quality Assurance and Performance Improvement committee that effectively provided oversight and monitoring to ensure staff were performing weekly skin assessments to ensure timely identification and treatment of pressure ulcers. On May 20, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Nurse Consultant and the Area [NAME] President were informed of the Immediate Jeopardy on May 20, 2025, at 2:49 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on December 24, 2024. The survey team validated the implementation of the removal plan through observations, staff interviews, and review of resident records. The immediacy of IJ was removed on May 23, 2025. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement Policy (QAPI) with a revision date of 12/1/2017 documented the following: The purpose of QAPI program at (Facility Name) is to continually take a proactive approach to assure and improve the way we provide care and engage with our patients, partners, and other stakeholders so that we may fully realize our vision, mission, and commitment to caring pledge. Process: All (Facility Name) partners and contracted staff are responsible for the quality of care and services within their respective departments and are expected to participate in the (Facility Name) QAPI Program. Each center must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care, quality of life, and resident choice. It is the expectation of the (Facility Name) QAPI program that each location will follow the established QAPI process to guide and direct the operations of that location. The executive leadership of (Facility Name) sets the expectation and provides the resources for implementation. Each SNF establishes a QAPI committee which has overall responsibility to develop and modify their respective QAPI plan, review information, and set priorities for performance improvement projects (PIP). Performance Improvement Projects: As part of its QAPI program, each (Facility Name) develops, implements, and evaluates PIP's. PIP's must include at least annually a project that focuses on high risk, high volume or problem-prone areas for improvement identified through the data collection and analysis based on: Feedback and input from stakeholders, Data/metrics reported monthly from all departments, Adverse event monitoring and investigation/analysis. The center must set priorities for PIP's based on the results of quality monitoring that consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care. Review of the Quality Assessment and Assurance/QAPI Committee Meetings and the corresponding Agenda Items for 1/14/25, 3/11/25 revealed there was no indication the QAPI committee identified the staff's failure to perform weekly skin assessments to ensure timely identification and treatment of pressure ulcers. During an interview with the Regional Nurse Consultant on 5/7/25 at 10:00 am, he stated on 2/11/25 he completed an Annual Risk checklist which identified problems with wound care. He recommended the facility do a Performance Improvement Plan (PIP) and put a plan in place. Stated he did not know why the facility decided not to do a PIP. If a facility decides not to do a PIP then the DHS will do a system checklist monthly that includes audits of all residents with wounds. He stated these were not done. During a post survey interview with the Administrator on 6/24/2025 at 5:24 pm who acknowledged that the facility did not implement a Performance Improvement Plan (PIP) until April after the survey team entered the facility. She explained that she felt they were working on correcting issues through staff education, morning clinical meetings, and Patient At Risk (PAR) meetings. However, some things were missed due to the some of the ongoing changes in leadership. Cross Refer to F656, F686 and F835

Based on observation, staff interviews, and review of the job description titled Position Description Dietary Manager, the facility failed to ensure the kitchen had a Certified Dietary Manager to oversee the duties and responsibilities of the kitchen staff; and failed to ensure the Dietitian assumed responsibility and accountable for the Dietary Services Department. The facility has 184 of 203 resident that receive oral meals. Findings include: Review of the facility Position Description Dietitian Job Purpose: Responsible for assuming professional responsibility and accountability for the Dietary Services Department in; the provision of nourishing, palatable, well-balanced diets to meet the daily nutritional and special dietary needs of each resident. Key Responsibilities: 12. Conducts regular meal observations, record reviews, and resident interviews for adherence to prescribed diet orders and nutrition interventions. 13. Conducts quality assurance functions that include regular compliance rounds of the Dietary Department's food preparation and storage areas for adherence to regulator guidelines. 14. Directs staff in improving the quality of foods served and the dining experience. Review of the facility Position Description Dietary Manager: Job Purpose: Plans, organizes, develops, and directs the overall operation of the Dietary Department in accordance with current federal, state and local regulations governing the center and as directed by the Administrator. Responsible for maintaining the Dietary Department in a clean, safe, and sanitary manner and prove nutritionally adequal meals in accordance with regulatory guidelines. Key Responsibilities: 8. Maintains the proper storage, preparation, distribution and serving of food under sanitary conditions in accordance with regulatory guidelines. 10. Follows procedures for serving partner meals to comply with company policies and procedures. 11. Supervises proper procedures for cleaning all kitchen equipment to include but not limited do carts, tables, counters, ice machine, buckets, blender, mixer, mat slicer, freezer, refrigerator, stove, oven steamer, garbage disposal, dish machine, coffee/tee maker, and steam table. 12. Supervises the operation of all major equipment to include but not limited to the dish machine, garbage disposal, blender, mixer steamer, meat slicer, fry, steamer, oven and coffee/tee maker. An observation on 5/1/2025 at 11:26 am, upon entrance into the kitchen, observed and met with Dietary Supervisor/Cook as there was no Certified Dietary Manager (CDM) available. An observation on 5/13/2025 at 2:09 pm, observed a Certified Dietary Manager (CDM) from an affiliated facility overseeing the duties and responsibilities of the kitchen. Review of the separation notice revealed the former CDM last day was 3/31/2025. Review of the List of Key Personnel provided by the facility revealed that the facility has a Registered Dietitian AA, Dietary Manager DDD and a Dietary Supervisor BB. However, the Dietary Manager DDD was responsible for other duties in the facility. Review of the kitchen staff dated 5/14/2025 that was provided by the facility revealed no CDM on the staff list. An interview on 5/15/2025 at 4:13 pm, Registered Dietitian AA revealed she was working with the former CDM about the cleanliness of the kitchen which was a concern. Registered Dietitian AA reported that she did help the dietary supervisor as much as possible. An interview on 5/19/2025 at 12:34 pm Dietary Supervisor BB revealed that the former CDM was the person to make cleaning schedules and duty assignments for each person. Dietary Supervisor BB acknowledged that she had not made any schedules. Further reporting that the kitchen staff were winging it meaning if they saw something that needed to be cleaned, they cleaned it. There were no assigned names for the kitchen duties. An interview with the Administrator on 5/19/2025 at 3:38 pm, revealed the former Certified Dietary Manager's (CDM) last workday was 3/31/2025.

Based on observations and staff interviews the facility failed to ensure that the ice machine was free from black and pink substances; failed to ensure the dishwasher maintained proper water temperature; failed to follow manufactures recommendations regarding sanitation of pots and pans in the three compartment sink; failed to ensure food on steam table maintained food temperature; failed to ensure opened food items were properly dated, labeled, and stored; failed to ensure cleanliness of the kitchen floors; failed to ensure a no touch trash can was near the sink and failed to ensure clean dishes were stored on a clean surface. This deficient practice had the potential to increase the spread of food borne illness for 184 of 203 residents that received an oral diet. Findings include: Observation 5/1/2025 at 11:26 am, revealed there is no touchless trash can near the sink. The staff were observed using a 50-gallon trash with a lid and several staff seen sliding the lid over with a paper towel or dropping the used paper towel in a narrow opening. Observation on 5/1/2025 at 11:28 observed on the stainless counter next to the coffee pot and a plastic container, two rolls of plastic trash bag and a can of uncapped stainless stain cleaner on the stainless stain counter next to the meat and vegetable sink. Observation on 5/1/2025 at 11:33 am, observed the inside of the ice machine inside on a white plastic chute black substance on the right and on the left side of the chute is a pinkish slime substance. The ice bin was full of ice and the ice door chute was open to air. The outside of the ice bin had debris and needed cleaning. Observation on 5/1/2025 at 11:35 am, of Supervisor [NAME] BB wiping the ice machine chute with a white towel and the cloth having a visible black and pinkish substance from the ice machine. An observation on 5/1/2025 at 11:37 am, observed in the dishwasher area breakfast dishes in the sink. On the floor on the right as standing facing the dishwasher area. There is a white wet blanket on the floor. There is also another white wet blanket with black substances on it. And on the left side of the floor near the drain on the floor is another white wet blanket. The floor in this area has food debris. In the rinse sink prior to the dishwasher there are multiple food covers and small glasses from the breakfast meal. On the wall above the water sprayer there is black substance on the wall. The kitchen floor has multiple areas throughout the kitchen with food particles, dirt and dried spills. An observation on 5/1/2025 at 11:51 am, observed on near the steam table a pile of stacked white plates. On the top plate, there is dried food particles. An observation on 5/1/2025 at 11:53 am, observed in storage room the floor bin has the scoop without a bag on top with scattered floor on the lid of the bin. The cornmeal bin and sugar bin have the scoops inside of the bin. An observation of Dietary Aide (DA) EE on 5/1/2025 at 2:19 pm, revealed him at the three compartment sink washing pots and pans. The first sink had soap and water below the water line, there was no rinse water in the second sink, and there was no sanitizer solution in the third sink. Each sink had instructional posters for operational use of each sink which included the title label of each sink and a measurement line drawing of the water level (to show the water filled line for each sink). The first sink was labeled wash sink and displayed waterline. The second sink was labeled rinse sink and displayed the waterline level. The display for the third sink (sanitizer step) indicated to merge items in the water for at least 30 seconds to allow complete sanitizing. DA EE was observed rinsing the pot under running water using the water faucet and missing the sanitizer step. During an observation and interview on 5/1/2025 at 2:23 pm with Dietary Supervisor the dish washer revealed the wash cycle hot water temperature was 117 degrees F and the rinse temperature was 142 degrees F. It was reported that the dishwasher had chlorine for sanitation. An observation on 5/1/2025 at 2:31 pm, observed the dishwasher pre-rinse sink sprayer, being used and water is sprayed on the ceiling, running on the floor onto the white dirty blanket under the sink. There is black substance on the wall behind the water knobs. An observation on 5/3/2025 at 11:20 am, observed the three-compartment sink with cookware below water line with pots in the sink. The first sink with soap and water below the water line, there is no rinse water in the second sink; and there is no sanitizer solution in the third sink. DA EE was observed rinsing the pot under a running water using the water faucet and missing the sanitizer step. He was observed drying a pan with cloth towel instead of allowing the pan to air dry. An observation on 5/3/2025 at 11:51 am, observed with Dietary Aide EE in the walk-in refrigerator. There was a package of turkey breast slices wrapped in clear plastic, a five-pound bag of cheddar wrapped in clear plastic, and a bag of liquid egg that did not have an open date. There was also cornbread wrapped in clear plastic, and it did not have a preparation date or a use by date. During an observation on 5/3/2025 at 12:02 pm, [NAME] DD obtained food temperatures from the steam table and the following items had a holding temperature below 135 degrees Fahrenheit (F): green beans 119.2 degrees F, onion rings 105.5 degrees F, and cheeseburger 113.5 degrees F. An observation on 5/5/2025 at 12:43 pm, observed with the Territory Representative for (named company) the high temperature dishwasher which was modified temporarily to a chlorine sanitizer on 4/21/2025. The first cycle of dishes washed reveal the wash water temperature was 128 degrees F and the rinse cycle 165 degrees F. The second cycle of dishes washed the water temperature was 120 degrees F and rinse cycle was 145 degrees F. The third cycle of dishes washed the wash water was 115 degrees F and rinse cycle was 138 degrees F. The fourth cycle of dishes washed the water temperature was 118 degrees F and rinse cycle was 130 degrees F. The fifth cycle of dishes washed the wash temperature was 115 degrees F and rinse cycle was 145 degrees F. An observation on 5/5/2025 at 12:57 pm, with the (named company) Territory Representative the first sink of the three-compartment sink with a pot and a pan in the first sink water. The Territory Representative obtained water temperatures for the sink and the water temperature was 106 degrees F and was below the recommended 110 degrees F. During an interview on 5/7/2025 at 1:55 pm, with Central Supplies staff it was revealed that he has never ordered the cleaning solution for the ice machine and that the Maintenance Director may be the one who orders the solution to clean the ice machine. An interview on 5/7/2025 at 2:16 pm, with the Maintenance Director revealed that to his knowledge the ice machine has never been sanitized using the cleaning solution because the facility has never had the cleaning solution. Lastly, it was reported that ice machine was purchased August 2023. A telephone interview on 5/5/2025 at 11:52 am with Territory Representative revealed that the dishwasher needs to be replaced because it is the smallest dishwasher. He continued to say that on 4/21/2025 that he came to the facility and temporarily converted the high temperature dishwasher to a chlorine sanitizer until the facility could get their hot water issue resolved. The hot water after continuous cycling water, the water temperatures is 130-135 degrees F. The chlorine wash is 120 F. During a subsequence interview at 1:04 pm, the Territory Representative revealed that the facility must get the hot water issues resolved before the high temperature dishwasher can be used as a regular high temperature dishwasher. An interview on 5/15/2025 at 11:43 am, Dietary Aide III revealed the dishwasher has had problems and that sometimes they can wash five loads and other days they can barely wash three loads. It was reported that hot water is taken away when the laundry department is washing the residents' laundry, and the kitchen then has to wait for the water to heat again. An interview on 5/19/2025 at 1:00 pm, Dietary Aide NNN revealed that the sprayer for the dishwasher area was always leaking water and blankets were on the floor. An interview on 5/15/2025 at 10:39 am, with Dietary Aide EE revealed that the 3 Compartment Sink in the first sink is the wash sink with water and soap, the second sink is the rinse water, and the third sink is for sanitizing. Dietary EE reported that line on the outside of the sink is for the water level in the sinks. It was further reported that the second sink is the rinse sink and when the sink is empty, he just rinses the pots from the faucet because he is close to getting off work. He reported the third sink's (sanitizer) purpose is to keep the bacteria off the dishes the pots are supposed to air dry. Dietary Aide EE denied using the cloth to dry a flat pan. During an interview with the Dietary Supervisor on 5/19/2025 at 12:34 pm he revealed his responsibilities are to make staffing assignments, ensure the kitchen is cleaned, palatability of food, and to ensure resident food is delivered on time. He continued to state that the dietary aides are to make sure that they put dates on the opened food items. The Dietary Supervisor reported that it could be lack of education or lack of knowledge as to why there was no dates placed on the food items. It was also confirmed that the scoops should be bagged when not in use and stored in a scoop holder on the wall. During an interview on 5/19/2025 at 3:38 pm, the Administrator revealed that the ice machine has been contracted out for services for 90 days and then the kitchen staff will clean twice a week. The contracted company will educate the Maintenance Director on how to perform the maintenance for the ice machine. The kitchen staff are to make sure the water line is met and that all three sinks are properly filled when cleaning cookware in the three-compartment sink. The Administrator further confirmed that no scoops should be stored in the dry goods bins. It was reported that any opened food items are to be dated and those that are not dated must be discarded. The dirty kitchen floors should be mopped, and the Administrator did not have an answer for why this was not done. It was further reported that dietary staff should not have been using the 55-gallown trashcan and blankets should not have been placed on the floor when the dish sprayer was not working appropriately.

Based on record review, and the facility policy Grievances: Healthcare Centers, the facility failed to ensure the grievances from resident council meetings were addressed with resolutions for four of seven months reviewed. Findings include Review of the facility policy Grievances: Healthcare Center Policy Statement: The Administrator of each healthcare center serves as its grievance official and is responsible for the following: overseeing the grievance proves; receiving and tracking grievances through to the conclusion; leading necessary investigations; maintaining confidentiality of all information associated with grievances (for example, the identity of the patient for those grievances submitted anonymously); issuing written grievance decisions to the person who filed the grievance (if known); and coordinating with state and federal agencies as necessary in light specific allegations. Procedures: 1. If the patient or family member requires assistance with writing the grievance, the staff person receiving the information will assist with completing the appropriated section of the Grievance/Complaint Form: Healthcare Centers. 2. The Administrator will be responsible for overseeing the grievance process: The Administrator or designee will track the grievance on the Greivance/Complaint Log Form: Healthcare Centers. This will provide a central place for all grievances. 5. The Grievance/Complaint should be resolved withing three business days. 1. Review of the Patient/Resident Council Minutes/Report Form dated 11/18/2024 revealed no tea, late meals; form dated 1/20/2025 multiple issues with meals to include not being able to eat in dining room on weekends due to time and timing of evening meals; form dated 2/17/2025 revealed no coffee in the building; form dated 3/17/2025 revealed kitchen coffee pot is broken and food is still cold. There was no evidence that resolutions to grievances were put in place or addressed. An interview on 5/22/2025 at 10:59 am, with the Activity Director who revealed that she writes residents' complaints voiced during the resident council meeting and the concerns are then given to the department head related to the concern. It was further reported that there is a food committee with dietary, but the Activity Director acknowledged that she does not follow back up with the residents related to follow up on the grievances that they have filed. An interview on 5/22/2025 at 11:13 am, with Social Worker, Bachelor of Social Work (BSW) who acknowledged that the Activity Director would bring the grievances to the morning meetings and the grievances were discussed and addressed to the department head of those concerns. Social Worker BSW reported that he was not a part of the process for getting resolutions or addressing the concerns. An interview on 5/22/2025 at 11:17 am, Social Worker, Master of Social Work (MSW) revealed that she had never reviewed any grievances from the Patient/Resident Council Minutes/Report Form because the forms were not given to her but moving forward, she will begin to keep a record of them. An interview on 5/22/2025 at 3:38 pm, with the Administrator revealed that staff should be educated on completing a grievance form and anyone (staff) in the facility can write a grievance. The Social worker is to get the forms, then the form goes to the department head that related to the concerns.

Based on observations, staff interview, and record review, the facility failed to ensure that resident meals were served in a timely manner. This deficient practice had the potential to affect 184 of 203 residents that received an oral diet. Findings include: The following was observed during kitchen visits: 1. On 5/1/2025 at 11:37 am, the dishwasher area had breakfast dishes in the sink. 2. On 5/3/2025 at 11:21 am, five carts of dirty breakfast dishes at entry of the dishwasher door waiting to be place in the dishwasher. 3. On 5/5/2025 at 11:52 am, observed a backlog of breakfast dishes waiting to wash. Observation on 5/5/2025 at 2:38 pm, of Licensed Practical Nurse (LPN) OOOO on 600 Hall assisting with the delivery of the lunch meal trays. An interview on 5/5/2025 at 2:55 pm with R14 revealed that his dinner is always late with dinner arriving between 6:30 pm to 8 pm. Observation of lunch trays being delivered to 600 hall on 5/13/2025 at 2:01 pm revealed the lunch was being served in Styrofoam containers. CNA UUUU confirmed that the meal trays had just been delivered for lunch. Observation of 500 hall revealed lunch meal trays being delivered on 5/15/2025 at 1:35 pm. Review of posted mealtimes for residents revealed breakfast is served at 7:00 am, lunch is served at 11:15 am, and supper is served at 4:30 pm. During an in interview with the Dietary Supervisor on 5/19/2025 at 12:34 pm revealed his responsibility is staffing assignment, ensuring that the kitchen is cleaned, making sure food is palatable, and making sure residents' meals are on time. Dietary Supervisor reported that the facility has purchased an additional 121 dinner plates. However, meals have been late because of the dishwasher and plates being wet for the next meal.

Based on resident interviews and staff interviews, the facility failed to ensure that three residents (R) (R14, R28, R29) of six residents who wanted to vote were assisted with obtaining absentee ballots or was registered to vote in the November 2024 election. Findings include 1. Review of the medical record revealed Resident 14 was admitted to the facility with the following diagnoses that include but are not limited to absence of right and left leg above the knee, malignant neoplasm of the prostate and generalized weakness and a Brief Interview Mental Status score (BIMS) of 14 which indicated intact cognition. An interview on 5/19/2025 at 2:37 pm with R14 revealed he wanted to vote in November 2024 election and needed help to renew his state identification card and no one assisted him. 2. Review of the medical record revealed R28 was admitted to the facility with the following diagnoses that include but are not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, atherosclerotic heart disease of native coronary artery and seasonal allergic rhinitis and BIMS score was 15 indicating intact cognition. An interview on 5/19/2025 at 3:00 pm, with R28 revealed that she has her identification to vote, but no one assisted her nor provided her an absentee ballot to vote. She reported that she wanted to vote and would have voted if she had assistance. 3. Review of the medical record revealed R29 was admitted to the facility with the following diagnoses that include but are not limited to syncope, gastro-esophageal reflux, epilepticus, anxiety disorder and hypoglycemia. Interview on 5/19/2025 at 2:58 pm, R29 revealed that he is a registered voter but did not receive an absentee ballot to vote. He continued to state that he wanted to vote. A telephone interview on 5/19/2025 at 1:12 pm, with the County voter registers revealed that the facility can reference the informative links on the county's voter's registers and elections web page to assist with voter enrollment requirements and verify if residents are a registered vote. An interview on 5/19/2025 at 3:32 pm, the Social Worker Master of Social Work (MSW) revealed she will do a survey with residents who have a BIMS greater than 10 to see if they want to vote. She continued to state that she will follow up to make sure residents have a valid state identification card if needed. She further reported that she was not employed in the facility during November 2024 election. An interview on 5/22/2025 at 11:13 am, Social Worker Bachelor of Social Work (BSW) revealed that a group of voter registrars had come to the facility for residents who wanted to vote but he did not assist or follow up on nor did he know which residents wanted to vote in the November 2024 election.

Based on record review and staff interviews, the facility failed to ensure the physician was notified of abnormal vital signs for one resident (R)(R5) and failed to notify the responsible party of diagnostic test results and impaired skin for R17 of 29 sampled residents. Findings include: Review of the policy provided by the facility titled Changes in a Resident's Condition, with a revision date of 8/18/23 noted the following policy: In case of an accident or sudden adverse change in a resident's condition or adjustment, a center will immediately take actions appropriate to the specific circumstances to meet the resident's needs, including notification of the resident's authorized representative or legal surrogate and the resident's physician. R5 was admitted to the facility on [DATE] with the following but not limited to diagnoses: atherosclerotic heart disease, hypertension, unsteadiness on feet, atrial fibrillation, abdominal aortic aneurysm, difficulty walking, hypotension, iron deficiency anemia and muscle weakness. Review of the 11/20/2024 Physical Therapy Treatment Encounter Note revealed the resident's blood pressure (BP) was assessed while in the supine position and was documented as 103/48 millimeters of mercury (mmHg). When the resident was transferred from supine to the sitting position the BP was 68/46 mmHg. The resident was returned to the supine position to perform therapeutic exercises. The 11/21/2024 Physical Therapy Treatment Encounter Note documented the resident was in bed and supine BP was 115/53 mmHg, heart rate 50, the sitting BP was 88/57 mmHg, and the heart rate was 52. The documentation further noted when the resident stood, staff was unable to get a BP, just stated Low and resident partially passed out. After three minutes in supine position the BP was 138/61 mmHg. The resident was then transferred to the wheelchair was unable to get a BP and the resident completely passed out. The resident was placed back in the bed and BP was 107/58 mmHg. The nurse was informed of all the BP's. The Certified Medication Aide (CMA) reported the resident had his BP medication this morning. The Physical Therapist asked if the physician could be contacted for parameters for BP and medication regimen. Review of the 11/21/2024 Occupational Therapy Treatment Encounter Note documented the resident's BP in supine position was 115/53 mmHg. The resident's BP sitting was 88/57 mmHg. The resident's standing BP was Lo and resident became faint. The therapist lowered the resident to the bed and returned to supine position. Resident's BP in supine was 92/46 and then approximately three minutes later the BP was 138/68. The resident was then assisted with transfer to the wheelchair. The resident passed out in the wheelchair and was unable to tolerate sitting. The resident was returned to supine with bilateral lower extremities elevated and was alert and oriented immediately after laying back down. Nurse notified of orthostatic hypotension. Review of the clinical record revealed there was no documentation the physician or the Nurse Practitioner (NP) was notified of the low BP until 11/25/2024. Review of the 11/25/24 Nursing Progress Note revealed new orders were obtained from the NP to discontinue the atenolol (blood pressure medication), monitor BP twice a day for five days then daily. During an interview with the Administrator on 4/16/2025 at 4:00 pm, she confirmed staff did not notify the NP of the resident's low blood pressure until 11/25/24. Review of the medical records revealed R17 was admitted with the following diagnoses that include but not limited to dementia, type 2 diabetes mellitus, gastrostomy status, abnormal posture, and hypertension. Review of the progress notes dated 4/18/2025 through 5/15/2025 revealed entry dated 4/28/2025 that R17 had a diagnostic procedure for verification placement of gastrostomy. There was no evidence that the responsible party was notified. Review of the diagnostic test dated 4/28/2025 revealed gastrostomy tube tip in stomach. An interview on 5/14/2025 at 10:11 am, the family member revealed visiting R17 on 5/7/2025 saw vomit on her gown and had the nurse to assess the resident. Family member reported being told that R17 was going to have a diagnostic test and the family member would be called with the results. The family member further reported seeing a pink dressing on R17's lower right leg and denied being made aware of any skin issue on R17's leg. R17's family member reported no followup communication related to being informed of the diagnostic test results or the reason for the dressing on R17's leg. An observation on 5/15/2025 at 2:06 pm with Registered Nurse (RN) YY skin integrity nurse, RN FFFFF skin integrity nurse and Certified Nursing Assistant (CNA) ZZ who provided a body audit for R17. This observation confirmed that there is a pink dressing without a date on the right leg. An interview on 5/15/2025 at 3:02 pm, RN YY skin integrity nurse revealed that the wound on the right lower leg was new, and she was unaware of the wound before today's observation. RN YY further reported that the person who placed the dressing on the opened area should have gotten orders.

Based on record review, staff interview, and review of policy titled Procedure: Indwelling Urinary Catheter the facility failed to obtain a physician's order to continue an indwelling catheter for one resident (R) (R3) who was admitted from the hospital with an indwelling urinary catheter from a sample of 29 residents. Findings include: Review a procedure provided by the facility titled Procedure: Indwelling Urinary Catheter dated 2019 revealed under the section titled Procedure step 2 was to verify orders. R3 was admitted to the facility on [DATE] with the following but not limited diagnoses: malignant neoplasm of prostate, Stage IV pressure ulcer, multiple myeloma not achieving remission, paraplegia and colostomy. Review of the 9/24/2024 admission orders from the hospital and all orders up to 2/7/2025 lacked a physician's order for an indwelling urinary catheter. Review of the 9/24/2024 admission Nursing Progress Note indicated the resident arrived to the facility from (Hospital Name) with a Foley catheter intact. The 10/8/2024 Nursing Progress note documented a 24 French Foley catheter was removed with 250 cubic centimeters (cc) of urine in bag. Inserted a new 24 French Foley catheter using sterile technique. Review of the 12/31/2024 Quarterly Minimum Data Set revealed the resident had the presence of an indwelling catheter. During an interview with Unit Manager DDDD on 4/30/2025 at 12:40 pm, she confirmed R3 had a Foley catheter. During an interview with Regional Nurse Consultant OOOOOO on 5/21/25 at 12:35 pm, he confirmed there was not a physician's order for the Foley catheter for R3.

Based on observation, resident interview and policy Nutritional Screening and Assessments/Food Preferences, the facility failed to ensure food preference was honored for one resident (R14) of three sample residents. Findings include Review of the policy titled, Nutritional Screening and Assessments/Food Preferences (revised date of 3/28/2024): Procedure: 4. Patient/resident food preferences and choices will be honored within reason according to the patient/resident's diet order and menu selections available. Review medical record revealed R14 had a Minimum Data Set (MDS) Quarterly assessment dated [DATE] which indicated R14 had a Brief Interview Mental Status (BMIS) score of 14 which indicated intact cognition. Review of the Diet Review/Food & Beverage Preference List revealed R14 has a dislike for broccoli. An observation and interview on 5/5/2025 at 2:55 pm, of R14's lunch meal tray had the following food items: rice, broccoli, pear slices, carrots, dinner roll, fruit, and a glass of water. R14 revealed that he is never asked what he wants off the menu and they always serve him things that he does not like such as the broccoli. An interview on 5/22/2025 at 3:38 pm, the Administrator revealed that the plan is to print the menu and have the residents to let us know what they want to eat.

Based on record review, staff interviews, review of the Facility Assessment, and review of the facility's Position Description for the job title of Licensed Practical Nurse (LPN) Charge Nurse the facility failed to ensure that a staff person hired as a licensed nurse and assigned nursing duties in the facility had the required qualifications to provide nursing care on four of four wings of the facility (wings one through four). On January 30, 2020 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Health Services, Corporate Nurse Consultant, and Clinical Competency Coordinator were informed of the Immediate Jeopardy on January 30, 2020 at 3:45 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on November 25, 2019. The Immediate Jeopardy is outlined as follows: Staff Person AA was hired on November 25, 2019 as a Licensed Practical Nurse (LPN). However, a review of her personnel file revealed that the practical nurse license contained within the file was for a single state, Florida nursing license. The non-Georgia license was not identified prior to hire by Human Resources (HR) staff. After surveyor inquiry on January 22, 2020, further investigation revealed that Staff Person AA did not have a valid nursing license to function as an LPN in any state and her identity was unknown. The Florida practical nurse license that Staff Person AA presented as her own, belonged to someone else. Review of Staff Person AA's work schedule and assignments revealed that she worked as an LPN on all wings of the facility from November 26, 2019 through January 21, 2020. Review of clinical records revealed that she provided nursing duties, that she was not licensed to provide, that included but were not limited to: medication administration via multiple routes, pain assessments, behavior monitoring, finger stick blood sugar checks, oxygen administration, indwelling urinary catheter care, [MEDICAL TREATMENT] assessments, change in condition assessments, peripherally inserted central catheter (PICC) line flushes, and gastrostomy tube care including administration of nutritional supplements, water flushes and medications through the gastrostomy tube. Further review of clinical records and the nursing care that Staff Person AA provided revealed that she failed to ensure that a PICC line was flushed as ordered for Resident (R)#17, administered a dose of [MEDICATION NAME] medication three hours early for R#21, administered blood pressure medications outside of the Physician ordered parameters for R#22, failed to obtain a dressing change for a perma catheter for R#23, administered a dose of insulin two hours late for R#26, failed to follow up with the Physician or Nurse Practitioner for a high blood sugar reading for R#29, and failed to adequately assess a change in condition for R#34. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.35(c), Competent Nursing Staff (F726), Scope/Severity: L; 483.70, Administration (F835), Scope/Severity: L; 483.70(d), Governing Body (F837), Scope/Severity: L; and 483.70(f), Staff Qualifications (F839), Scope/Severity: L. At the time of the exit on January 30, 2020, the Immediate Jeopardy remained ongoing. Findings include: A review of the Facility Assessment for the resident population from November 2018 through November 2019 revealed that the facility had a high frequency of moderate acuity level residents (relative to benchmark). The facility assessment also included that the facility was sufficient in overall staffing and staff competencies for the resident acuity. The facility had a Position Description for the job title of Licensed Practical Nurse (LPN) Charge Nurse. The job purpose was to direct nursing care for the residents and supervise the day-to-day nursing activities performed by assigned staff. The minimum education required was a nursing degree from an accredited college or university or a graduate from an accredited/approved LPN program. The minimum licensure/certification required by law included a current and unrestricted LPN licensure in the state of practice. However, the facility failed to ensure that Staff Person AA was licensed and competent to provide nursing care to the facility assessed resident population by accurately and thoroughly reviewing and verifying her nursing license and identity, prior to her hire date as a licensed practical nurse on 11/25/19. Staff Person AA was hired on 11/25/19 as an LPN. However, a review of her personnel file revealed that the nursing license contained in the file was for a single state, Florida nursing license. The non-Georgia license was not identified by HR staff. After surveyor inquiry, further investigation revealed that Staff Person AA had no valid license to function as an LPN in any state and her true identity was unknown. After surveyor inquiry on 1/22/2020, Staff Person AA did not return to the facility but sent a poorly readable document to the facility in an attempt to validate that she had a compact nursing license to practice nursing in Florida and Georgia. However, a search online to validate the document revealed that it was falsified and that she had never even heard of this facility. The Florida practical nurse license that Staff Person AA presented as her own, belonged to someone else. In addition, the forms contained within the personnel file contained more than one last name, three different dates of birth, and two different social security numbers. During a telephone interview on 1/23/2020 at 2:32 p.m., a search of the social security numbers by Regulatory Specialist EE with the Florida Department of Health, Division of Medical Quality Assurance, revealed that neither one of the social security numbers included in Staff Person AA's personnel file matched the social security number associated with the practical nurse license she presented as her own. During a subsequent interview on 1/23/2020 at 2:45 p.m. with Regulatory Specialist EE, revealed that he called the individual listed as the nurse on file for the Florida nursing license number that Staff Person AA presented as her own. Regulatory specialist EE stated that the individual stated that she had not applied for work at the nursing facility. During an interview on 1/27/2020 at 3:45 p.m. HR staff person DD confirmed that she met with Staff Person AA immediately following her interview on 11/14/19 to complete the new hire packet of forms. HR staff DD recalled that during Staff Person AA's interview (that Staff Person AA had with nursing staff), the Staffing Coordinator came into HR Staff DD's office and they looked up Staff Person AA's nursing license online and printed off a copy. Staff Person AA had stated she had a compact license (a license to practice in multiple states). HR Staff Person DD stated that the wording of single state on the copy of the license had been overlooked in error. In addition to the concern of an unlicensed person providing care to residents as an LPN, a review of Staff Person AA's schedule and assignments from 11/26/19 through 1/21/2020, and a review of 23 sampled residents she provided nursing services to, the following concerns were identified: 1. Record review revealed R#17 was admitted to the facility with [DIAGNOSES REDACTED]. R#17 had a 11/30/19 physician's orders [REDACTED]. Review of the 11/25/19 through 12/25/19 Medications Administration History revealed that unlicensed Staff Person AA administered the IV [MEDICATION NAME] through the resident's peripherally inserted central catheter (PICC) on 12/1/19 at 5:00 p.m. Record review revealed a physician's orders [REDACTED]. Review of the 11/25/19 through 12/25/19 Medications Administration History revealed that unlicensed Staff Person AA administered [MEDICATION NAME] flush on 11/29/19 and on 12/1/19. Further review revealed Staff Person AA did not administer the 12/3/19 5:00 p.m. dose as ordered. Staff Person AA documented the [MEDICATION NAME] was already given in the a.m. despite having an order to flush at 5:00 a.m. and 5:00 p.m. 2. Record review revealed R#21 was admitted to the facility with [DIAGNOSES REDACTED]. R#21 had a physician's orders [REDACTED]. The [MEDICATION NAME] was scheduled to be administered at 12:00 a.m., 6:00 a.m., 12:00 p.m. and at 6:00 p.m. Review of the 11/25/19 through 12/25/19 Medication Administration History revealed Staff Person AA administered the medication three hours and seven minutes early on 12/11/19 at 9:07 a.m. Staff Person AA documented the medication was administered late because the 7 p.m. nurse did not give medication because the resident was asleep. Staff Person AA then administered the medication three hours later at 12:00 p.m. on 12/11/19. Further review revealed Staff Person AA administered the medication three hours early on 12/19/19 at 9:00 p.m. instead of the scheduled time of 12:00 a.m. Staff Person AA then administered the medication at 4:00 a.m. on 12/19/19 instead of the scheduled time of 6:00 a.m. During an interview with LPN BB on 1/30/2020 at 3:15 p.m., she stated that she did not know why Staff Person AA gave the [MEDICATION NAME] early. Further interview with LPN BB revealed that Staff Person AA had made an additional medication error on 1/22/2020. Review of the Medication Discrepancy/Adverse Reaction Report Form, Description of Event, dated 1/22/2020, noted [MEDICATION NAME] was given at 11:00 p.m. The medication had been changed on 1/17/2020 to twice daily (9:00 a.m. and 5:00 p.m.) from every six hours. LPN BB stated that the oncoming nurse saw the medication error and reported it to her. 3. Record review revealed R#22 was admitted with [DIAGNOSES REDACTED]. Record review revealed that R#22 had a physician's orders [REDACTED].#22 had a systolic blood pressure (bp) was less than 120. Review of the 11/25/19 through 1/21/2020 Medication Administration History revealed the following systolic blood pressures that were less than 120 (when the carvedilol should not have been administered but was administered by Staff Person AA): on 11/26/19 at 5:00 p.m. bp 101/60, 11/29/19 at 5:00 p.m. bp - 108/63, 12/1/19 at 5:00 p.m. bp - 110/67, 12/3/19 at 8:00 a.m. and 5:00 p.m. bp - 109/67 and 117/64 respectively, 12/4/19 at 5:00 p.m. bp - 110/68, 12/11/19 at 8:00 a.m. bp - 118/62, 12/15/19 at 8:00 a.m. and 5:00 p.m. bp - 109/65 and 95/55 respectively, 1/6/2020 at 8:00 a.m. and 5:00 p.m. bp - 116/75 and 110/65 respectively, and 1/10/2020 at 8:00 a.m. bp - 95/58. Record review revealed that R#22 had a physician's orders [REDACTED]. Review of the 11/25/19 through 12/25/19 and the 12/25/19 through 1/21/2020 Medication Administration History revealed the following systolic blood pressures that less were than 120 (when the [MEDICATION NAME] should not have been administered but was administered by Staff Person AA): on 11/29/19 at 3:00 p.m. and 9:00 p.m. bp - 108/63 and 102/60 respectively, 12/1/19 at 3:00 p.m. bp - 110/61, 12/3/19 at 9:00 a.m. bp - 109/67, 12/4/19 at 9:00 a.m. and 3:00 p.m. bp - 108/68 and 110/68 respectively, 12/11/19 at 9:00 a.m. bp -118/62, 12/15/19 at 9:00 a.m. and 3:00 p.m. bp - 109/65 and 95/55 respectively, 12/19/19 at 9:00 p.m. bp - 108/65. Record review revealed that R#22 a physician's orders [REDACTED]. Review of the 11/25/19 through 1/21/2020 Medication Administration History revealed the following systolic blood pressures less than 120 (when the [MEDICATION NAME] should not have been administered but was administered by Staff Person AA): on 11/29/19 at 3:00 p.m. and 9:00 p.m. bp - 108/63 and 102/60 respectively, 12/1/19 at 3:00 p.m. bp -110/67, 12/3/19 at 9:00 a.m. bp - 109/67, 12/4/19 at 9:00 a.m. and 3:00 p.m. bp - 108/68 and 110/68 respectively, 12/11/19 at 9:00 a.m. bp - 118/62, 12/15/19 at 9:00 a.m. bp - 109/65, 12/18/19 at 9:00 p.m. bp - 119/68, 12/19/19 at 9:00 p.m. bp -108/65, 1/6/2020 at 9:00 a.m. bp -116/75, 1/10/2020 at 9:00 a.m. bp - 95/58 and 1/20/20 at 9:00 p.m. bp - 108/72. Record review revealed that R#22 had a physician's orders [REDACTED]. Review of the 11/25/19 through 12/25/19 Medication Administration History revealed the following systolic blood pressures less than 120 (when the [MEDICATION NAME] should not have been administered but was administered by Staff Person AA): on 12/3/19 bp - 109/67, 12/4/19 bp - 108/68 and 12/15/19 bp -109/65. Record review of the 11/25/19 through 12/25/19 Medication Administration History revealed on 12/19/19 at 1:00 p.m., R#22 had an abnormal low blood pressure of 70/55. There was no evidence of documentation that unlicensed Staff Person AA notified the Physician of this low blood pressure. The blood pressure was rechecked at 2:38 p.m. and the blood pressure remained low at 85/64 with no evidence of documentation that the Physician was ever notified. Further record review revealed that R#22 had a physician's orders [REDACTED]. Review of the 11/25/19 through 12/25/19 Medication Administration History revealed on 11/27/19 during the day shift, unlicensed Staff Person AA documented the resident's oxygen was not administered and documented that the resident's blood pressure was 90/56. Interview on 1/30/2020 at 3:00 p.m., with the DHS revealed she could not give an explanation as why the oxygen was not administered. 4. Record review revealed that R#34 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Progress Note for R#34 dated 1/4/2020 at 6:23 p.m. documented by Staff Person AA revealed the following, Resident alert x 3, resident stayed in bed all day. I took resident's blood sugar and it gave a low reading. The battery was running low, so I change the battery. I took another reading and it was much better than the last reading I had taken before. Resident had no major C/O (complaints) today will continue to monitor the resident. Review of the fingerstick blood sugars taken on 1/4/2020 revealed blood sugars were taken at 7:02 a.m. blood sugar - 132, 11:28 a.m. blood sugar - 66 and at 3:55 p.m. blood sugar - 249. (sic) Review of the clinical record revealed there was no way to determine if the glucometer gave a reading of LOW (meaning the blood sugar was too low for the device to read) or if the battery was low. There was no documentation of what the blood sugar result was when Staff Person AA checked the blood sugar or when she rechecked the blood sugar. Interview on 1/30/2020 at 3:00 p.m., with the DHS revealed she could not provide an explanation of what Staff Person AA documented on 1/4/2020. Record review revealed that R#34 had a Physician order [REDACTED]. Review of the 1/1/2020 through 1/28/2020 Medications Administration History revealed on 1/13/2020 at 5:00 p.m. that without a physician's orders [REDACTED]. Further review revealed that there were no parameters in the physician's orders [REDACTED]. Further review of the record for R#34 revealed a Progress Note dated 1/9/2020 at 7:31 p.m. written by Staff Person AA which documented the following: Resident alert x4 resident had an episode of being nonresponsive. Resident VS (vital signs) were stable, and he was checked every 30 min (minutes). Resident eventually started talking, resident was looking for attention and he received it. Resident will continue to be monitored. (sic) There was no evidence of documentation of how long the resident had been unresponsive on 1/9/2020. There was also no evidence the Physician was notified of the residents change in condition. Interview on 1/30/2020 at 3:15 p.m., with LPN BB revealed she remembered being involved in the assessment of R#34 and remembered the resident being arousable and was in no distress. 5. Record review revealed that R#23 was admitted to the facility with [DIAGNOSES REDACTED]. Record review revealed that R#23 had a physician's orders [REDACTED]. Monitor for redness and fever. Review of the 11/25/19 through 12/25/19 Medications Administration History revealed that on 12/11/19 the resident's dressing was due to be changed. Unlicensed Staff Person AA documented that it was not done and noted the dressing had to be changed by a Registered Nurse (RN) although Staff Person documented on 12/4/19 that she had changed the dressing. There was no evidence of documentation in the clinical record that unlicensed Staff Person AA notified an RN to change the dressing on 12/11/19. Review of a facility document titled, Nursing Management of Infusion Therapy, Georgia: Role of the RN&LPN revealed an LPN was qualified to provide site care/dressing change (Peripheral, Midline, PICC, [MEDICAL CONDITION]). 6. Record review revealed that R#29 was admitted to the facility with [DIAGNOSES REDACTED]. Record review revealed that R#29 had a physician's orders [REDACTED]. Review of the 12/1/19 through 12/31/19 Medications Administration History revealed the unlicensed Staff Person AA documented on 12/22/19 at 5:00 p.m. a blood sugar reading of High (indicating R#29's blood sugar was too high for the glucometer to register). There was no evidence of documentation that Staff Person AA rechecked the blood sugar or notified the Physician or the NP of the resident's High reading. There was also no evidence of documentation that Staff Person AA continued to monitor R#29's blood sugar or the resident for signs and symptoms of continued [MEDICAL CONDITION]. Interview on 1/30/2020 at 3:00 p.m., with the DHS confirmed there was no evidence of documentation that Staff Person AA called the Physician or the NP.

Based on interviews, record review, personnel file review, and review of the facility's job description for the Administrator the facility's Administration failed to effectively monitor the verification of staff identity and failed to verify valid nursing licensure for one of 60 Licensed Practical Nurses (LPN) (for Staff Person AA) reviewed for license verification. On January 30, 2020 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Health Services, Corporate Nurse Consultant, and Clinical Competency Coordinator were informed of the Immediate Jeopardy on January 30, 2020 at 3:45 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on November 25, 2019. The Immediate Jeopardy is outlined as follows: Staff Person AA was hired on November 25, 2019 as a Licensed Practical Nurse (LPN). However, a review of her personnel file revealed that the practical nurse license contained within the file was for a single state, Florida nursing license. The non-Georgia license was not identified prior to hire by Human Resources (HR) staff. After surveyor inquiry on January 22, 2020, further investigation revealed that Staff Person AA did not have a valid nursing license to function as an LPN in any state and her identity was unknown. The Florida practical nurse license that Staff Person AA presented as her own, belonged to someone else. Review of Staff Person AA's work schedule and assignments revealed that she worked as an LPN on all wings of the facility from November 26, 2019 through January 21, 2020. Review of clinical records revealed that she provided nursing duties, that she was not licensed to provide, that included but were not limited to: medication administration via multiple routes, pain assessments, behavior monitoring, finger stick blood sugar checks, oxygen administration, indwelling urinary catheter care, [MEDICAL TREATMENT] assessments, change in condition assessments, peripherally inserted central catheter (PICC) line flushes, and gastrostomy tube care including administration of nutritional supplements, water flushes and medications through the gastrostomy tube. Further review of clinical records and the nursing care that Staff Person AA provided revealed that she failed to ensure that a PICC line was flushed as ordered for Resident (R)#17, administered a dose of [MEDICATION NAME] medication three hours early for R#21, administered blood pressure medications outside of the Physician ordered parameters for R#22, failed to obtain a dressing change for a perma catheter for R#23, administered a dose of insulin two hours late for R#26, failed to follow up with the Physician or Nurse Practitioner for a high blood sugar reading for R#29, and failed to adequately assess a change in condition for R#34. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.35(c), Competent Nursing Staff (F726), Scope/Severity: L; 483.70, Administration (F835), Scope/Severity: L; 483.70(d), Governing Body (F837), Scope/Severity: L; and 483.70(f), Staff Qualifications (F839), Scope/Severity: L. At the time of the exit on January 30, 2020, the Immediate Jeopardy remained ongoing. Findings include: The facility had a Position Description for the Administrator. The position description included that the purpose of the job of the Administrator was to direct the day-to-day functions of the nursing center in accordance with federal, state, and local regulations that govern long-term care centers and to provide appropriate care for residents. Key responsibilities included the ability to apply standards of professional practice to operations of the facility and establish criteria to assure that care provided meets established standards of quality. During an interview on 1/23/2020 at 9:50 a.m., the Administrator revealed that when hiring new nursing staff for the facility, Human Resources Staff Person DD completed all of the leg work and the potential new hire was interviewed by the Director of Health Services (DHS). Afterward, the Administrator determined pay and made sure the leg work was completed and approved the newly hired person. However, the Administrator failed to ensure that the identity and nursing license of Staff Person AA was accurately reviewed and verified prior to Staff Person AA's approval and hire date on 11/25/19. Record review revealed that Staff Person AA was hired on 11/25/19 as an LPN. However, a review of her personnel file revealed that the nursing license contained in the file was for a single state, Florida nursing license. The non-Georgia license was not identified by Human Resource (HR) staff. After surveyor inquiry, further investigation revealed that Staff Person AA did not have a valid license to function as an LPN in any state and her true identity was unknown. The Florida practical nurse license that Staff Person AA presented as her own, belonged to someone else. In addition, the forms contained within the personnel file for Staff Person AA contained more than one last name, three different dates of birth, and two different social security numbers. During an interview on 1/22/2020 at 5:00 p.m. the Administrator stated he was not aware that Staff Person AA did not have a valid Georgia nursing license and that he could not justify her being hired. During a telephone interview on 1/23/2020 at 2:32 p.m., with Regulatory Specialist EE with the Florida Department of Health, Division of Medical Quality Assurance, revealed that a search of the social security numbers that had been provided by Staff Person AA revealed that neither one of the social security numbers matched the social security number associated with the practical nurse license that Staff Person AA presented as her own. During a subsequent interview on 1/23/2020 at 2:45 p.m. with Regulatory Specialist EE, revealed that he called the individual listed as the nurse on file for the Florida nursing license number that Staff Person AA presented as her own. Regulatory Specialist EE revealed that individual stated that she had not applied for work at this nursing facility and that she had never even heard of this nursing facility. Cross refer to F726

Based on record review, interviews, licensure review, personnel file review, and review of the facility policy titled, Non-Corporate New Hire Process the facility failed to ensure that a staff person hired as a licensed nurse had the required licensure to provide nursing care to residents on four of four wings of the facility (wings one through four). On January 30, 2020 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Health Services, Corporate Nurse Consultant, and Clinical Competency Coordinator were informed of the Immediate Jeopardy on January 30, 2020 at 3:45 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on November 25, 2019. The Immediate Jeopardy is outlined as follows: Staff Person AA was hired on November 25, 2019 as a Licensed Practical Nurse (LPN). However, a review of her personnel file revealed that the practical nurse license contained within the file was for a single state, Florida nursing license. The non-Georgia license was not identified prior to hire by Human Resources (HR) staff. After surveyor inquiry on January 22, 2020, further investigation revealed that Staff Person AA did not have a valid nursing license to function as an LPN in any state and her identity was unknown. The Florida practical nurse license that Staff Person AA presented as her own, belonged to someone else. Review of Staff Person AA's work schedule and assignments revealed that she worked as an LPN on all wings of the facility from November 26, 2019 through January 21, 2020. Review of clinical records revealed that she provided nursing duties, that she was not licensed to provide, that included but were not limited to: medication administration via multiple routes, pain assessments, behavior monitoring, finger stick blood sugar checks, oxygen administration, indwelling urinary catheter care, [MEDICAL TREATMENT] assessments, change in condition assessments, peripherally inserted central catheter (PICC) line flushes, and gastrostomy tube care including administration of nutritional supplements, water flushes and medications through the gastrostomy tube. Further review of clinical records and the nursing care that Staff Person AA provided revealed that she failed to ensure that a PICC line was flushed as ordered for Resident (R)#17, administered a dose of [MEDICATION NAME] medication three hours early for R#21, administered blood pressure medications outside of the Physician ordered parameters for R#22, failed to obtain a dressing change for a perma catheter for R#23, administered a dose of insulin two hours late for R#26, failed to follow up with the Physician or Nurse Practitioner for a high blood sugar reading for R#29, and failed to adequately assess a change in condition for R#34. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.35(c), Competent Nursing Staff (F726), Scope/Severity: L; 483.70, Administration (F835), Scope/Severity: L; 483.70(d), Governing Body (F837), Scope/Severity: L; and 483.70(f), Staff Qualifications (F839), Scope/Severity: L. At the time of the exit on January 30, 2020, the Immediate Jeopardy remained ongoing. Findings include: The facility had a Non-Corporate New Hire Process policy. The policy included that the hiring manager will meet with the candidate to complete pre-employment screening paperwork. The paperwork listed in the policy included licensure and/or certification verification if applicable. The Licensure/Certification section of the policy documented that verification of licensure is mandatory prior to hire. During an interview on 1/23/2020 at 9:50 a.m., the Administrator stated that when hiring new nursing staff for the facility, Human Resources Staff Person DD completed all the leg work (paperwork) and the potential new hire was interviewed by the Director of Health Services. Afterward, the Administrator determined pay and made sure the leg work was completed and approved the newly hired person. However, the facility failed to ensure that the identity and licensure of Staff Person AA was accurately and thoroughly reviewed and verified, prior to her hire date as an LPN on 11/25/19. During an interview on 1/22/2020 at 5:00 p.m. the Administrator stated he was not aware that Staff Person AA did not have a valid Georgia nursing license and that he could not justify her being hired. Staff Person AA was hired on 11/25/19 as an LPN. However, a review of her personnel file revealed that the nursing license contained in the file was for a single state, Florida nursing license. The non-Georgia license was not identified by HR staff. After surveyor inquiry, further investigation revealed that Staff Person AA had no valid license to function as an LPN in any state and her true identity was unknown. After surveyor inquiry on 1/22/2020, Staff Person AA did not return to the facility but sent a poorly readable document to the facility in an attempt to validate that she had a compact nursing license to practice nursing in Florida and Georgia. However, a search online revealed the Florida practical nurse license that Staff Person AA presented as her own, belonged to someone else. During a telephone interview on 1/23/2020 at 2:32 p.m., a search of the social security numbers by Regulatory Specialist EE with the Florida Department of Health, Division of Medical Quality Assurance, revealed that neither one of the social security numbers included in Staff Person AA's personnel file matched the social security number associated with the practical nurse license she presented as her own. Cross refer to F726

Based on record review, staff interviews, and review of the facility policy titled, Care Plans the facility failed to develop a person-centered care plan with appropriate interventions related to falls for one severely cognitively impaired resident of six residents (R#3) reviewed for care plans. Actual harm was identified when R#3 fell on [DATE], 11/26/19, 12/5/19, and 12/14/19. Each fall resulted in R#3 having a dislocated left hip that required surgical intervention. Findings include: A review of the facility policy titled, Care Plans with an effective date of 12/31/1996, last reviewed 1/13/2020 documented, in pertinent part, the following for the Admission Comprehensive Plan of Care: 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan should describe the following: The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 4. The care plan will contain 4 components: Problem, Goal, Approaches and Role of Accountability. Problems should be written as actual problems or conditions, potential problems or conditions, at risk for problems or conditions, or may address patient/resident limitations, maintenance level or improvement possibilities, and resident discharge goals. Problem statement to be stated to the extent possible, in functional or behavioral terms (i.e. how is the condition a problem for the patient/resident: how does the condition limit or jeopardize the patient/resident's ability to complete tasks or daily life or affect the resident's ability to complete tasks of daily life or affect the patient/resident's well-being). Goal: The goal is an expected outcome the patient/residents should achieve by implementing specific interventions. All goals should be realistic and attainable considering the patient/resident's current clinical status. 1. Record review revealed that R#3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Review of the 11/11/19 Admission Minimum Data Set (MDS) assessment revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of 3, indicating the resident was severely cognitively impaired. This assessment also revealed that R#3 required extensive assistance of one-person physical assistance for bed mobility, required extensive two plus person physical assistance with transfers and that R#3 had a history of [REDACTED]. The Care Area Assessment (CAA) Summary triggered Cognitive loss/Dementia and Falls with the option for these to be included in the resident's care plans. Record review revealed that R#3 had a care plan with a problem start date of 11/4/19 for being at risk for falls related to disease process, impaired cognition, incontinence and impaired mobility. Diagnosis: [REDACTED]. The care plan included the following approaches: Goal: Patient/Resident will not sustain injury related to falling through the next 30 days. Approach start date 11/4/19: Cue for safety awareness Keep environment safe Place call light within reach. Approach start date 11/28/19: Fall 11/27, Resident stated he got up without assistance and fell and got back in bed. Will encourage resident to call for assistance. Approach start date 12/11/19: Skilled OT/PT (Occupational Therapy/Physical Therapy) services. Approach start date 12/14/19: Encourage to use call light for assistance Hourly rounding to encourage safety. Review of a 11/4/19 at 3:34 p.m. Progress Note documented: Resident (R#3) had a fall in the bathroom directly following his admission. The Event Report dated 11/4/19 at 4:52 p.m. noted witnessed fall with injuries. The resident's mental status was noted as confused. Review of a Progress Note dated 11/12/19 at 1:03 a.m., documented the following: staff was summoned to room to find the resident on his buttocks at the foot of the bed. Review of the 11/12/19 Patient at Risk (PAR) Note documented the resident had a fall early morning. Safety measures put in place and would continue to monitor for three weeks. However, there was no indication the resident's fall on 11/4/19 was discussed. Interview on 1/15/2020 at 3:50 p.m., with Licensed Practical Nurse (LPN) CC who documented the 11/12/19 PAR note revealed that safety measures put in place meant she was referring to the interventions that were already in the resident's care plan. Record review revealed that R#3 went to a scheduled Orthopedic appointment on 11/14/19 where it was determined that his right hip was fine, but his left hip was broken, and he had to be sent from the Orthopedic surgeon's office to an acute care hospital. Review of a radiology report dated 11/14/19 documented that the resident's right hemiarthroplasty was intact with good alignment, but the femoral neck of the resident's left hip was fractured. The Physician documented the resident appeared to have had falls while at the nursing home and the left hip would need to be fixed with a left hip hemiarthroplasty. Review of the 11/18/19 hospital Discharge Summary documented R#3 had been readmitted to the hospital on [DATE] for a left [MEDICAL CONDITION] and was status [REDACTED]. R#3 returned to the facility on [DATE]. Review of the care plan for R#3 revealed the care plan was revised to reflect the left hip arthroplasty with interventions for skilled Occupational therapy and Physical therapy which the resident had already been receiving since 11/4/19 and for a knee immobilizer to both legs at all times except while doing therapy. There were no interventions in place to address the resident's increased risk for falls after a new left [MEDICAL CONDITION]. Review of the 11/19/19 PAR Note for R#3 documented the following, in pertinent part: Interdisciplinary Team (IDT) met and reviewed R#3 due to the resident being readmitted to the facility on [DATE]. The resident had a left hip replacement. Resident will be monitored for four weeks. Review revealed there was no evidence of documentation that the IDT discussed the resident's falls or re-evaluated the current care planned interventions to determine their effectiveness. There was also no evidence of documentation that the IDT team discussed the resident being at increased risk for falls due to having a new left hip replacement. 2. Review of the Progress Notes dated 11/19/19, 11/20/19, 11/22/19, 11/23/19 and 11/24/19 documented that R#3 was trying to remove knee immobilizers and trying to get out of bed. Review of an Event Report dated 11/27/19 at 2:33 a.m., documented the resident (R#3) had an unwitnessed fall with left hip protruding. It further documented the resident expressed excruciating pain to the left hip and the left hip had abnormal alignment. The resident was transported to the hospital Interview on 1/9/2020 at 12:15 p.m., with the DHS revealed that on 11/26/19 R#3 stated he got up without assistance, fell and got back to bed. Review of the care plan for R#3 revealed an intervention was added to the care plan on 11/28/19 documenting the resident had a fall on 11/27/19 when he stated that he got up without assistance, fell and got back in bed. The intervention added was to encourage resident to call for assistance, although the resident was cognitively impaired. Review of the PAR Note dated 11/26/19 documented, in pertinent part, the Interdisciplinary Team (IDT) team met and discussed R#3 due to the resident's readmission on 11/4/19. Resident has safety measures put in place due to fall. Will continue on occurrence monitoring times three weeks. However, there was no evidence of documentation the IDT re-evaluated the safety measures that were already in place to determine if they were appropriate and/or effective for R#3 who was severely cognitively impaired and already had two falls in the facility that resulted in the resident having to have surgical intervention. (sic) Review of the 12/3/19 hospital Discharge Summary documented that the resident had a left hip dislocation requiring a revision (surgical intervention) of [MEDICAL CONDITION] endoprosthesis reduction of the dislocated left [MEDICAL CONDITION] endoprosthesis. R#3 was discharged back to the facility on [DATE]. 3. Review of the Progress Note for R#3 dated 12/5/19 at 2:54 a.m., documented the following: upon making rounds, resident noted to have gotten himself out of the bed. The resident was noted in between the a/c (air conditioning) unit and the bed with body positioned on the floor. Review of the 12/5/19 SBAR (Situation, Background, Assessment, Recommendation) documented the resident (R#3) was laying in supine position in bed with noted frowning facial expressions. It also documented the resident complained of pain to left hip. The Physician was notified, and the resident was sent to the emergency room . Review of the 12/6/19 hospital Operative Note for R#3 revealed the resident had a left hip [MEDICAL CONDITION] dislocation with disassociation of components which required a revision of left hip [MEDICAL CONDITION] hemiarthroplasty. R#3 returned to the facility on [DATE]. Review of the resident's care plan revealed the only new intervention for R#3's fall was for the resident to receive skilled OT/PT services (which was added on 12/11/19) which the resident had been receiving since 11/4/19. There were no interventions to address the resident getting up by himself or why he was attempting to get up. 4. Review of the Progress Note for R#3 dated 12/14/19 at 3:12 p.m. revealed that at approximately 10:15 a.m., the resident was noted lying on the floor, appeared to be coming from the bathroom. Resident denies any pain, no bruise or abrasion noted at this time. The Physician was notified with no new orders given. Review of the care plan revealed an intervention on 12/14/19 to encourage the resident to use the call light for assistance and hourly rounding to ensure safety. Record review revealed that there was already an intervention in place to encourage R#3 to call for assistance since 11/28/19 which was not effective for a resident with impaired cognition. Review of the 12/15/19 SBAR for R#3 revealed documentation that the family came to visit the resident and were concerned that the resident may have dislocated his left hip again after his fall on 12/14/19 and requested he be sent out for evaluation. Review of the 12/26/19 hospital Discharge Summary revealed a repeat dislocation of the left hip prosthesis with [MEDICAL CONDITION] greater trochanter. Further review revealed the resident underwent [REDACTED]. The resident was discharged back to the facility on [DATE] and at the family's request was sent to back to the acute care hospital on [DATE]. R#3 did not return to this facility. Interview with LPN GG on 1/10/2020 at 2:45 p.m., revealed when a resident had a fall, the nurse who did the SBAR or the nurse assigned to the resident will implement interventions. LPN GG stated they had not been reviewing the BIMS scores when considering care plan interventions for R#3. Cross refer to F 689

Based on record review, staff interviews, and review of the facility policy and procedure titled, Occurrences the facility failed to provide adequate supervision, failed to identify the root cause of multiple falls, and failed to evaluate the effectiveness of their current interventions to prevent future falls for one of six residents (R#3) who had a history of [REDACTED]. Actual harm was identified when R#3 fell on [DATE], 11/26/19, 12/5/19, and 12/14/19. Each fall resulted in R#3 having a dislocated left hip that required surgical intervention. Findings include: Review of the facility policy and procedure titled, Occurrences with a revision date of 5/4/16 revealed the following in the policy statement: Appropriate, realistic interventions will be implemented in accordance to their plan of care. The following was noted under the section titled Occurrence Documentation 2. Clinical record occurrence documentation will include: Addition of care plan interventions in effort to decrease the risk of additional occurrences. The following was noted in the section titled Investigation and Follow-up: 2. Communication between all parties is essential for identifying the events and circumstances that resulted in the occurrence and for identifying interventions that limit the risk of the occurrence. 6. Director of Health Services will be responsible to review each occurrence for thorough investigation, documenting the investigation in the patient/resident care software occurrence report and appropriate care plan interventions are put in place to decrease risk for repeated occurrences. Monthly Occurrence Logs: 2. The log is to be reviewed by the Director of Health Services and/or designee at the end of each month. The log is reviewed at QA/PI (Quality Assurance and Process Improvement) Committee and documented in the minutes. 1. Record review revealed that R#3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Review of the 11/11/19 Admission Minimum Data Set assessment revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of 3, indicating the resident was severely cognitively impaired. This assessment revealed that the Functional Status for R#3 was as follows: R#3 required extensive assistance of one-person physical assistance for bed mobility and for use of the toilet, required extensive assistance of two plus person physical assistance with transfers. Section G0300 for Balance During Transition and Walking: Moving from seated to standing: R#3 was assessed to be unsteady only able to stabilize with human assistance. Walking, turning around, moving on and off toilet did not occur. For surface to surface transfers R#3 was assessed to be unsteady and only able to stabilize with human assistance. Section G0400 Functional Limitation in Range of Motion: R#3 was assessed as having impairment to one side of his lower extremities. R#3 was admitted with a history of falls with fracture prior to admission to the facility and had one fall with injury since admission. Record review revealed the facility completed fall risk assessments on 11/4/19, 11/18/19, 12/3/19, and on 12/11/19 which determined R#3 was at a high risk for falls. Review of the 11/4/19 at 3:34 p.m. Progress Note documented, in pertinent part: Resident (R#3) had a fall in the bathroom directly following his admission. Resident has a bruise to his left forearm and upper arm upon admission. Resident now has multiple skin tears to his left arm following his fall. Resident has a dressing to his left hand, steri- strips to his left forearm and left upper arm. Review of a Situation, Background, Assessment, Recommendation (SBAR) form dated 11/4/19 documented the resident had just arrived from the hospital when he got out of bed unassisted and walked to the bathroom. The Certified Nursing Assistant (CNA) noted the resident as he came through the bathroom door into the adjoining room and fell to the floor. There were multiple skin tears to his left hand and arm. The SBAR documented interventions put in place was a bed alarm and to monitor. Review of the Event Report dated 11/4/19 at 4:52 p.m., documented: witnessed fall with injuries. The resident's mental status was noted as confused. Review of an SBAR dated 11/11/19 documented that R#3 was on the foot of the bed positioned on his buttocks. The Physician was notified on 11/11/19 at 11:40 p.m. and would continue to monitor. Review of the Event Report dated 11/12/19 at 1:09 a.m., documented that the resident stated he got out of the bed and stumbled to the floor with no injuries noted. The Event Report further documented under the Interventions section that immediate measures taken as none of the above. The outcome of interventions documented that the interventions were effective and reinforced the resident to call for all assistance out of bed even though the resident was severely cognitively impaired. Pain observation revealed that the resident did not have any pain. The close date of the Event Report was 11/28/19 at 5:11 p.m. Review of a Progress Note dated 11/14/19 at 11:32 a.m., staff documented: the resident departed facility in stable condition (resident to scheduled Orthopedic surgeon appointment). No c/o (complaints of) pain or discomfort noted or reported at that time. The writer (Licensed Practical Nurse) received a phone call from the transportation director, who went with the resident to his follow up appointment. The writer also spoke with the nurse in the office (Orthopedic surgeon's office) who informed the writer that R#3's right hip was looking good, yet he had broken the left hip and would be directly admitted to the hospital. (sic). Review of the 11/14/19 Progress Note from the Orthopedic surgeon revealed R#3 complained of left hip pain. The physical exam revealed left hip pain with logroll and heel strike. (sic) Review of the radiology report dated 11/14/19 documented that the resident's right hemiarthroplasty was intact with good alignment. Left hip femoral neck fracture. The Physician documented the resident appeared to have had falls while at the nursing home and the left hip would need to be fixed with a left hip hemiarthroplasty. Review of the 11/18/19 hospital Discharge Summary documented the resident had been readmitted to the hospital on [DATE] for a left [MEDICAL CONDITION] and was status [REDACTED]. R#3 returned to the facility on [DATE]. 2. Review of the Progress Notes dated 11/19/19, 11/20/19, 11/22/19, 11/23/19 and 11/24/19 documented that R#3 was trying to remove knee immobilizers and trying to get out of bed. Review of a Progress Note for R#3 dated 11/26/19 at 7:48 p.m., documented the following: the resident (R#3) was alert and oriented with complaint of painful left hip. Surgical staples are intact although the left leg is inverted. The resident was transported to the hospital. Review of an SBAR dated 11/26/19 documented the Situation (change in condition, symptoms, or signs observed and evaluated) are: [MEDICAL CONDITION] to left hip surgical site. Things that make the condition or symptom worse are: not calling for all out of bed assistance. Things that make the condition or symptom better are: calling for assistance. The condition, symptom, or sign has occurred before: yes. treatment for [REDACTED]. Review of the Section titled Appearance documented: Summoned to room and resident to have left leg inverted with [MEDICAL CONDITION] noted to left hip. (sic) Review of a Patient at Risk (PAR) Note dated 11/26/19 documented, in pertinent part, the IDT (Interdisciplinary Team) met and discussed resident (R#3) due to readmission on 11/4/19. Resident has safety measures put in place due to fall. Will continue on occurrence monitoring times three weeks. However, there was no evidence the IDT re-evaluated the safety measures that were already in place for R#3 to determine if they were effective. Review of the Event Report dated 11/27/19 at 2:33 a.m., documented the resident had an unwitnessed fall with left hip protruding. It further documented the resident expressed excruciating pain to the left hip and the left hip had abnormal alignment. Interview on 1/9/2020 at 12:15 p.m., with the Director of Health Services (DHS) revealed that on 11/26/19 R#3 stated he got up without assistance, fell and got back to bed. Review of the 12/3/19 hospital Discharge Summary documented that R#3 had a left hip dislocation requiring a revision of [MEDICAL CONDITION] endoprosthesis reduction of the dislocated left [MEDICAL CONDITION] endoprosthesis. R#3 was discharged back to the facility on [DATE]. 3. Review of a Physical Therapy Plan of Care note dated 12/4/19 documented the following: R#3 was receiving Physical Therapy and that his rehab potential was poor. R#3 has the physical ability to recover; however, due to dementia carry over is questionable. Review of the Progress Note for R#3 dated 12/5/19 at 2:54 a.m., documented the following: upon making rounds, resident noted to have gotten himself out of the bed. The resident was noted in between the a/c (air conditioning) unit and the bed with body positioned on the floor. Review of the 12/5/19 SBAR documented the resident (R#3) was laying in supine position in bed with noted frowning facial expressions. It also noted the resident complained of pain to left hip. The Physician was notified, and the resident was sent to the emergency room . Review of the 12/6/19 hospital Operative Note for R#3 revealed the resident had a left hip [MEDICAL CONDITION] dislocation with disassociation of components which required a revision left hip [MEDICAL CONDITION] hemiarthroplasty. R#3 returned to the facility on [DATE]. 4. Review of a Physical Therapy Plan of Care dated 12/11/19 documented the following: Patient (R#3) consented to readjustment of bilateral knee immobilizers and abductor pillow; however, resident shook head stating that he does not want to get up. Per nurse, resident was on 1:1 supervision last night (12/10/19) and already tried to take off hip abductor pillow. Further review revealed that the therapist spoke to the nurse, charge nurse, and DHS regarding the need for constant 1:1 supervision with patient to prevent repeated falls and reinjuring bilateral hips. Review of a 12/13/19 at 3:02 a.m. Progress Note for R#3 documented: the resident had gotten out of bed and was in the bathroom sitting on the toilet by the time staff got there. The bed alarm was intact which alerted staff the resident was moving. Review of the Progress Note for R#3 dated 12/14/19 at 3:12 p.m. revealed that at approximately 10:15 a.m., the resident was noted lying on the floor, appeared to be coming from the bathroom. Resident denies any pain, no bruise or abrasion noted at this time. The Physician was notified with no new orders given. Review of a 12/15/19 SBAR for R#3 revealed documentation that the family came to visit the resident and were concerned that the resident may have dislocated his left hip again after his fall on 12/14/19 and requested he be sent out for evaluation. The resident was sent to the ER. Review of a 12/26/19 hospital Discharge Summary revealed that R#3 had been admitted to the hospital on [DATE] and the Discharge Summary documented the following: R#3 had a repeat dislocation of the left hip prosthesis with a [MEDICAL CONDITION] greater trochanter. Further review revealed the resident had to have surgery which included an open reduction of the dislocated hip [MEDICAL CONDITION] endoprosthesis on 12/16/19 and a left hip revision/replacement on 12/23/19. The resident was discharged back to the facility on [DATE]. Review of a Progress Note dated 12/27/19 at 1:33 a.m. documented: Family requested for resident to be sent back to the hospital. Resident sent per family request. Record review revealed R#3 was sent to the emergency room . Further record review revealed that when R#3 was discharged from the hospital but he did not return to this facility but was admitted to a different Long Term Care facility. Interview on 1/9/2020 at 12:15 p.m., with the DHS revealed R#3 was discussed in PAR every week but interventions were not written down on the PAR log form. The DHS stated the PAR form was not a formal paper. The DHS also stated the facility did not have a specific policy and procedure for the fall prevention program, but that they just use best practice. During an interview with Physical Therapist (PT) FF on 1/14/2020 at 1:45 p.m. and 1/15/2020 at 1:52 p.m., revealed that when she evaluated R#3 on 12/11/19 the resident's cognition was so bad he could not remember to use hip precautions. PT FF also stated during the evaluation on 12/11/19 she knew the resident had almost fallen the previous night and had fallen about four times previously. PT FF stated she had made the comment to herself I think he needs to be on 1:1 (monitoring) right now, something needs to be done. PT FF stated she talked to the charge nurse, unit manager and the DHS about placing R#3 on 1:1 supervision. She stated nursing decided to place the resident on 1:1 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts since his falls were during those shifts. PT FF stated ideally, she would have liked for R#3 to have around the clock 1:1 supervision but it was up to nursing to determine how much and when R#3 needed 1:1 supervision. Interview on 1/14/2020 at 1:45 p.m., with the DHS revealed R#3 was placed on 1:1 supervision on 12/10/19, 12/11/19 and 12/12/19 (for the 3:00 p.m. to 11:00 p.m. and the 11:00 p.m. to 7:00 a.m. shifts) due to the resident being agitated. On 12/13/19, R#3 was no longer agitated so the IDT team decided to discontinue the resident's 1:1 supervision.

Based on record review, staff and family member interviews, and review of the facility policy's titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property and No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property the facility failed to ensure that two of ten residents (R) (R#2 and R#3) were free from sexual abuse and the facility failed to provide protection for two of ten residents (R#2 and R#3), in the Memory Support Unit (MSU) from continued sexual abuse. On (MONTH) 8, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on (MONTH) 8, 2019 at 4:55 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 10, 2019. The Immediate Jeopardy is outlined as follows: Resident (R) #1 was observed by staff from (MONTH) 10, 2019 through (MONTH) 20, 2019 repeatedly behaving in a sexually abusive manner toward cognitively impaired vulnerable residents in the Memory Support Unit (MSU). R#1 was observed on (MONTH) 10, 2019 feeling the private area of R#3, a female resident, in the common day room. On (MONTH) 12, 2019, R#1 was observed rubbing R#2's leg and had his hand inside her shirt rubbing her breast. On (MONTH) 12, 2019, R#1 pulled out his penis while standing in front of R#3, who was sitting in the common day room, and started masturbating. On (MONTH) 15, 2019, R#1 was observed putting his hand down R#2's shirt touching her breast while she was asleep. He also had his hands in between R#3's inner thighs rubbing various body parts on the resident, attempted to put R#3's hand down his pants, and was trying to hug and kiss the resident. On 9/15/19, R#1 was also observed fondling himself and was masturbating in the common day room in front of other residents. On 9/19/19 R#1 was observed inappropriately touching R#3. On (MONTH) 20, 2019, R#1 was observed showing inappropriate behavior by feeling on R#3. All of the incidents occurred in the common day room in the MSU. After R#1 was first observed being sexually abusive toward the female residents on (MONTH) 10, 2019, and multiple observations thereafter of R#1 being sexually abusive toward residents (specifically R#2 and R#3) and two observations of R#1 publicly masturbating in front of residents in the common day room, there were no protective measures put in place to protect R#2, R#3, or any of the other residents that resided in the MSU, from R#1's sexually abusive behavior. Although the first observation of sexually abusive behavior toward residents occurred on (MONTH) 10, 2019, the facility failed to investigate the sexually abusive behavior and did not report the abuse to the State Survey Agency until (MONTH) 4, 2019, after surveyor inquiry. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J; 42 C.F.R. 483.12(b)(1)-(4), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J; 42 C.F.R 483.12(c)(1)(4), Reporting of Alleged Violations (F609), Scope/Severity: J; 42 C.F.R. 483.12(c)(2)-(4), Investigate/Prevent/Correct Alleged Violations (F610), Scope/Severity: J; 42 C.F.R. 483.21(b)(2)(i)-(iii), Care Plan Timing and Revision (F657), Scope/Severity: J; 42 C.F.R 483.70, Administration (F835), Scope/Severity: [NAME] Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J; 42 C.F.R. 483.12(b)(1)-(4), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J; 42 C.F.R 483.12(c)(1)(4), Reporting of Alleged Violations (F609), Scope/Severity: J; 42 C.F.R. 483.12(c)(2)-(4), Investigate/Prevent/Correct Alleged Violations (F610), Scope/Severity: [NAME] At the time of exit on (MONTH) 18, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted, therefore; the Immediate Jeopardy remains ongoing. Findings include: Review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, and Misappropriation of Property version 5 last reviewed 9/20/19 dated, documented the definition of sexual abuse is non-consensual sexual contact of any type with a patient. Review of the facility policy titled, No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property last reviewed 1/8/19, documented the following procedure: During an active investigation of patient abuse, neglect, exploitation, mistreatment, or misappropriation of patient property, when there is substantial evidence that such has occurred, the provider should take all reasonable efforts to protect the affected patient(s) from harm. Record review revealed that R#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 9/5/19, for R#1 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating that the resident was moderately cognitively impaired. The resident was also assessed as having wandering behavior that occurred four to six days, but less than daily. The resident required minimal assistance from staff and only required supervision for locomotion on and off the unit. Record review revealed that R#2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 8/16/19, for R#2 revealed a Brief Interview for Mental Status score of 99 indicating that R#2 was severely cognitively and required extensive assistance with transfers, required limited assistance with locomotion in room and supervision with locomotion in corridor. Record review revealed that R#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual MDS assessment, dated 9/29/19, for R#3 documented that the BIMS score for R#3 was two, indicating that R#3 was severely cognitively impaired and that the resident was independent with transfers and ambulation. Review of the Resident Progress Notes for R#1 documented the following: 1. 9/10/19 at 4:16 p.m. the resident (R#1) was seen by writer feeling on a female resident's (R#3) private area, the resident became belligerent when stopping him. (sic) 2. 9/12/19 at 4:15 p.m. the resident (R#1) was noted rubbing on R#2's leg and had his hand inside of her shirt rubbing on her right breast in the TV room. The resident was asked to stop and that it was inappropriate to do this in public without the other resident's consent. The resident started to curse and say that he was not doing anything to anyone. Will continue to monitor resident for changes. 3. 9/12/19 at 4:20 p.m., reported by Certified Nursing Assistant (CNA), to Licensed Practical Nurse (LPN) II, that resident (R#1) pulled penis out of pants standing in front of female resident (R#3) and started masturbating. Resident was asked to put his private parts back in his pants and not do this because it is inappropriate. Resident again got upset stating that he was not doing anything, and we are telling a damn lie on him. Resident redirected back to his room without incident. Will continue to monitor for changes and report as noted. 4. 9/12/19 at 4:30 p.m. Writer spoke with pharmacist in reference to resident's behavior and if there was a medication that will help in this situation because redirection is not being successful. Pharmacist suggested medication regimen. Writer will consult with MD (Physician) on recommendation. 5. 9/15/19 at 9:12 p.m., starting this morning this resident (R#1) has required close supervision in the common area of MSU. He has been observed putting his hand down other resident's (R#2) shirt, putting his hands between their (R#3) legs, rubbing various body parts of other residents (R#3), attempting to hug and kiss other residents (R#3), masturbating and fondling himself in the common area, trying to put other resident's (R#3) hands down his pants, he stands over other residents and does not consider/understand the personal space of others. Redirection required often and only partly successful. When redirected he becomes verbally and physically aggressive. Resident noted jumping up approaching and threatening to hit this nurse multiple times this shift. PRN (as needed) [MEDICATION NAME] administered and noted ineffective. As I (LPN EE) am entering this note he is attempting to touch another resident, staff is redirecting at this time. The DHS and his responsible party have been notified. 6. 9/16/19 at 4:06 p.m. Resident received a new order for Depo-[MEDICATION NAME] 150 mg (milligrams)/ml (milliliter) injection to be given every two weeks for libido and [MEDICATION NAME] 50 mg to start on next fill. 7. 9/19/19 at 6:16 p.m., during the latter part of the shift resident (R#1) was noted inappropriately touching another female resident (R#3). 8. 9/20/19 at 2:58 a.m., resident out of bed showing inappropriate behavior by feeling on female resident (R#3), cursing staff when redirecting him. Resident told writer he will knock her Goddamn brains out when trying to stop him from feeling and touching female residents. He stated he can do whatever he wants to. Resident was given prn [MEDICATION NAME] with very little results. Will continue to monitor. Review of the 9/1/19 through 10/1/19 Medication Administration Records (MARS) documents that the first date that R#1 received the Depo-[MEDICATION NAME] 150mg/ml injection was 9/17/19. Interview on 10/2/19 at 9:25 a.m. with CNA BB revealed that about two weeks ago she saw R#1 sit down beside R#3. He grabbed her hand and she moved it, he touched her hand again then touched her breast. She then hit him and then he touched her thigh. She stated the nurse helped separate the two residents. Interview on 10/2/19 at 9:40 a.m., with CNA CC revealed that a couple of weeks ago R#1 touched R#3 on her breast in the dayroom. CNA CC stated when R#1 first arrived to the facility he touched R#3 two to three times by trying to touch her breasts and in between her legs, she even slapped him once. CNA CC stated for some reason he (R#1) was focused on R#3. CNA CC stated when R#1 first got to the facility he would mess with R#3 (try to touch R#3 in an inappropriate manner) and staff a lot. CNA CC stated he (R#1) would also pull his penis out in the day room and they would have to remove him from the day room and take him to his room. CNA CC stated if she was a resident and he was doing that, it would make her feel dirty. CNA CC stated R#1 would become angry and get loud when they (staff) would redirect him. Interview on 10/2/19 at 9:50 a.m., with the Licensed Practical Nurse (LPN) Unit Manager DD revealed that R#1 had inappropriate touching to R#2 around 9/12/19 but she could not remember the exact date. LPN Unit Manager DD stated R#1 rubbed R#2's leg and had his hand inside her shirt. It (sexually inappropriate behavior) was reported to her and then she reported it to the DHS that same day or the next day during the morning meeting. LPN Unit Manager DD stated she called the doctor and then the pharmacist to see if there was anything, they could give him for his increased libido and medicine was ordered on [DATE]. LPN Unit Manager DD then stated that on 9/15/18 LPN EE reported to her (LPN Unit Manager DD) that R#1 was touching another resident, and thought it was R#3. It was also reported to the DHS of the R#1's inappropriate touching, masturbating and fondling himself in the day room. Interview on 10/8/19 at 3:20 p.m., with LPN EE revealed that she worked from 7:00 a.m.- 11:00 p.m. on 9/15/19 and that she observed R#1 with his hand down R#2's shirt on top of her breast while she was asleep in the day room and his hands were between her inner thighs. R#1 was also rubbing her arm, leg and had his hand on her back. LPN EE stated that R#1 was also was attempting to hug and kiss R#3 and she (R#3) would tell R#1 No don't do that. R#1 then started masturbating in the TV room while he was sitting in a chair but LPN EE could not remember who was sitting next to him. LPN EE further stated that on that day R#1 also tried to put R#3's hand down his pants and she would remove her hand. LPN EE stated every time they would try to redirect R#1 he would get agitated and would run up to her threatening to hit her. LPN EE stated she called the DHS that day (9/15/19 at 10:22 a.m.) and called the Unit Manager at 10:29 a.m. LPN EE stated the DHS told her they already knew about the behavior and the Unit Manager was calling the doctor. LPN EE stated that Unit Manager DD told her she called the doctor on Friday to get an order for [REDACTED]. LPN EE stated the next day on 9/16/19 at the morning meeting with all department heads (which included the Administrator, the DHS, and the Unit Managers), LPN EE reported to them exactly what happened on 9/15/19 and what was documented in the progress notes. LPN EE stated that during the morning meeting, they pulled the note up on the computer and read it. LPN EE then stated that the Administrator and the DHS stated that they thought R#1's behavior was related to his dementia. LPN EE stated she thought they talked about placing R#1 on 1:1 monitoring but when she worked in the Memory Support Unit (MSU) on 9/29/19 R#1 was not on 1:1 monitoring. Interview on 10/2/19 at 1:00 p.m., with the DHS revealed that she was notified on 9/15/19 by LPN EE that R#1 had his hand down R#2's shirt. The DHS stated she instructed LPN EE that R#1 was to be monitored by her and the CNAs and that R#1 was not to be left alone with other residents. The DHS also stated it was discussed in the 9/16/19 morning meeting, and they reached out to the pharmacy and then got orders. The DHS stated she was not aware of the incidents that occurred on 9/10/19, 9/12/19 or the behaviors after 9/15/19. The DHS stated this was not reported to the State Survey Agency because they felt as if the resident's behavior was not intentionally abusing anyone due to his dementia. Subsequent interview on 10/3/19 at 9:30 a.m., with the DHS revealed that the DHS confirmed she was not notified of R#1's behavior until 9/15/19. The DHS stated close monitoring of R#1 was done to protect the other residents even though he was still able to have access to the other residents. The DHS stated actual 1:1 monitoring was not done; just close observation and that extra staff was not called in to help monitor R#1. The DHS further stated 1:1 observation was started on 10/2/19. She stated the Physician was notified of the behavior on 9/16/19 when staff called and got an order for [REDACTED].>Interview on 10/2/19 at 3:45 p.m. with the Administrator revealed that the sexual abuse was not reported to State Survey Agency because the information that was given to him was not the same information that was in the nurse's notes. The Administrator stated he had the impression that staff was able to intervene before R#1 actually touched the residents. The Administrator stated he should have read the documentation, but he did not until today (10/2/19). Interview on 10/3/19 at 11:25 a.m., with LPN FF revealed that a few days after R#1 was admitted to the facility he started feeling on the ladies. LPN FF stated R#1 would like to sit next to R#3 and would touch her leg. LPN FF stated when she would make R#1 sit in another chair that was not next to R#3, he would become belligerent and tell LPN FF that he would knock her GD head off and act like he was going to hit her. LPN FF stated the first day R#1 touched R#3 she reported it to Unit Manager DD who said to tell the DHS. The DHS told LPN FF she would take care of it and that the DHS told Unit Manager DD to get an order for [REDACTED]. Interview on 10/3/19 at 1:10 p.m., with CNA GG revealed that CNA GG never seen R#1 touch other residents inappropriately but heard he was touchy, feely. CNA GG stated that she has never been instructed to do close monitoring of R#1. CNA GG stated R#1 does get agitated when you redirect him from going in other resident's room and can get loud and snatches his arm away. During a subsequent interview with CNA GG on 10/7/19 at 12:45 p.m. CNA GG revealed that she was in the shower room supervising R#1 bathe himself when he started touching himself and masturbating. R#1 then asked for her and the other CNA to participate and then R#1 asked them to bend over. CNA GG stated she reported it to the nurse. CNA GG stated she reported this to LPN FF. Interview on 10/3/19 at 1:40 p.m., with CNA HH revealed that a few weeks ago she saw R#1 sit next to R#3 and put his hand down her shirt touching her breast. R#3 removed his hand from her shirt and looked like she was mad. CNA HH stated she redirected R#1 back to his room and he started cursing at her. CNA HH stated she has never been instructed to monitor R#1 closely and that 1:1 monitoring was started yesterday (10/2/19). Interview on 10/4/19 at 12:00 p.m., with LPN II revealed that on 9/12/19, R#1 had his hand down R#2's shirt with his hand on her breast. LPN II stated that later that day he (R#1) was masturbating in front R#3. LPN II stated that was just R#1s behavior. On both occasions LPN II separated the residents and R#1 would get angry. LPN II stated she could not remember when she reported the behavior to the Unit Manager, but she did remember reporting the resident pulling his penis out. LPN II stated they did not do 1:1 monitoring but they watched R#1 closely anyway and there was not any extra staff sent to do 1:1 monitoring. Interview on 10/4/19 at 3:05 p.m., with CNA JJ revealed that approximately two weeks ago R#1 came to the TV room around 3:00 p.m. and was touching R#3's arm. CNA JJ stated the nurse had told them that earlier that day he tried to touch the therapist. CNA JJ stated then later that day she saw R#1 sitting next to R#2 with his hand up her sleeve to her breast rubbing her breast. CNA JJ stated that she ran over there with another CNA to remove R#1 and he became mad, irate, and cussing telling them to mind their own business. CNA JJ stated R#2 was just sitting there with no reaction. CNA JJ further stated that R#1 did this everyday all day and he would also touch the CNA's breasts and rub up on their legs. CNA JJ also stated one day a lady who would visit and sing for the residents was singing in the TV room when R#1 started rubbing on her. CNA JJ stated they had to remove him several times from touching the visitor and R#1 would become very mad telling them he would knock their GD head off. CNA JJ stated the visitor just stopped singing, got her stuff and left. CNA JJ stated the nurses knew about it because they saw it happen. Telephone interview on 10/8/19 at 11:15 a.m., with the Family of R#2 revealed that several weeks ago she saw a white male wandering around in the TV room (Day Room) and she saw him rubbing the inner thighs of R#3. She further stated she saw the nurses running to catch him telling R#1 Get your hands of R#3. Family of R#2 stated he (R#1) wouldn't stop and they had to ask him three or four times to get him to stop. Family of R#2 stated he became upset and was yelling but she didn't know what R#1 was saying. Family of R#2 stated she thought to herself, I hope he doesn't do that to my mom and that she could not believe what she saw. Family of R#2 stated the Unit Manager spoke to her in person about two to three days after R#1 had touched R#3, to tell her that R#1 had touched her mother on her breasts while she was asleep in her room. Interview on 10/8/19 at 2:45 p.m., with Registered Nurse (RN) KK revealed that R#1's sexual behavior was discussed at five different morning meetings (which are attended by the Administrator, the DHS, and the Unit Managers) and that it (the sexually abusive behavior of R#1) was brought up multiple times. In addition, RN KK stated that on one of the 24-hour reports, LPN EE wrote R#1 was touching and grabbing R#3's breasts and in between her legs and that he was masturbating in front of the residents. RN KK stated that they all failed these residents and she hopes this never happens again. Interview on 10/16/19 at 10:35 a.m., with the Medical Director (MD) revealed that he was informed last week of the incidents and they had an impromptu Quality Assurance meeting discussing the events. The MD stated that although the residents involved were not his residents, he went and assessed them, and they did not seem to have any increased stress from the incidents. The MD stated he would expect the nurses to notify him if this happened to his residents. Telephone interview on 10/16/19 at 4:20 p.m., with Physician LL revealed that he is in touch with the staff almost every day. Physician LL stated that he remembers the staff reporting R#1's sexual behavior and he told them that if it was just one time, to just monitor him and start behavior management. Physician LL stated he honestly could not remember if the staff contacted him every time regarding R#1's sexual behavior without looking at the record but he knows they contacted him a good bit. Physician LL stated that he did not want to start the Depo-[MEDICATION NAME], for R#1, if the behavior was just a one-time occurrence. Physician LL further stated that the behaviors then happened rather quickly, and he needed to do something because there were mostly females in the unit and just a few males. Although R#1 displayed sexually abusive behaviors towards R#2 and R#3, and other residents in the MSU Day Room, from 9/10/19 through 9/20/19 and had masturbated twice in the common day room, there was no documentation the Physician was notified of the inappropriate sexually abusive behaviors until 9/16/19 when an order was obtained for Depo-[MEDICATION NAME] and [MEDICATION NAME], medications used to treat the [MEDICAL CONDITION]. Further review of the medical record revealed there was not any evidence that the Physician was notified of the continued sexual abuse towards R#3 on 9/19/19 and 9/20/19. Review of the medical record for R#3 revealed the resident's responsible party was not notified of the 9/10/19 incident until 10/7/19. The 10/11/19 Progress Notes documents the resident's responsible party was called to give an update on the investigation in reference to the resident being common day area on or around 9/10/19 through 9/21/19, when another resident was displaying inappropriate sexual behaviors. Although staff stated R#1 was closely monitored, he continued to have access to R#2, R#3, and other residents residing on the MSU, allowing R#1 to continue to put his hands down female resident's shirts touching their breasts, putting his hands in between their legs and also masturbating and fondling himself in front of other residents in the common day room. The staff failed to immediately report the sexual abuse to the Administrator, failed to conduct an investigation, failed to immediately report the sexual abuse to the State Survey Agency, and failed to protect residents from continued sexual abuse.

Based on record review, staff and family interviews, and review of the facility policies titled, Abuse Prevention and Reporting, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property and Abuse Identification the facility failed to implement the protection, reporting and investigation components of their abuse policy when two of 10 residents (R) (R#2 and R#3) in the Memory Support Unit (MSU) were repeatedly sexually abused by R#1. On (MONTH) 8, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on (MONTH) 8, 2019 at 4:55 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 10, 2019. The Immediate Jeopardy is outlined as follows: Resident (R) #1 was observed by staff from (MONTH) 10, 2019 through (MONTH) 20, 2019 repeatedly behaving in a sexually abusive manner toward cognitively impaired vulnerable residents in the Memory Support Unit (MSU). R#1 was observed on (MONTH) 10, 2019 feeling the private area of R#3, a female resident, in the common day room. On (MONTH) 12, 2019, R#1 was observed rubbing R#2's leg and had his hand inside her shirt rubbing her breast. On (MONTH) 12, 2019, R#1 pulled out his penis while standing in front of R#3, who was sitting in the common day room, and started masturbating. On (MONTH) 15, 2019, R#1 was observed putting his hand down R#2's shirt touching her breast while she was asleep. He also had his hands in between R#3's inner thighs rubbing various body parts on the resident, attempted to put R#3's hand down his pants, and was trying to hug and kiss the resident. On 9/15/19, R#1 was also observed fondling himself and was masturbating in the common day room in front of other residents. On 9/19/19 R#1 was observed inappropriately touching R#3. On (MONTH) 20, 2019, R#1 was observed showing inappropriate behavior by feeling on R#3. All of the incidents occurred in the common day room in the MSU. After R#1 was first observed being sexually abusive toward the female residents on (MONTH) 10, 2019, and multiple observations thereafter of R#1 being sexually abusive toward residents (specifically R#2 and R#3) and two observations of R#1 publicly masturbating in front of residents in the common day room, there were no protective measures put in place to protect R#2, R#3, or any of the other residents that resided in the MSU, from R#1's sexually abusive behavior. Although the first observation of sexually abusive behavior toward residents occurred on (MONTH) 10, 2019, the facility failed to investigate the sexually abusive behavior and did not report the abuse to the State Survey Agency until (MONTH) 4, 2019, after surveyor inquiry. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J; 42 C.F.R. 483.12(b)(1)-(4), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J; 42 C.F.R 483.12(c)(1)(4), Reporting of Alleged Violations (F609), Scope/Severity: J; 42 C.F.R. 483.12(c)(2)-(4), Investigate/Prevent/Correct Alleged Violations (F610), Scope/Severity: J; 42 C.F.R. 483.21(b)(2)(i)-(iii), Care Plan Timing and Revision (F657), Scope/Severity: J; 42 C.F.R 483.70, Administration (F835), Scope/Severity: [NAME] Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J; 42 C.F.R. 483.12(b)(1)-(4), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J; 42 C.F.R 483.12(c)(1)(4), Reporting of Alleged Violations (F609), Scope/Severity: J; 42 C.F.R. 483.12(c)(2)-(4), Investigate/Prevent/Correct Alleged Violations (F610), Scope/Severity: [NAME] At the time of exit on (MONTH) 18, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted, therefore; the Immediate Jeopardy remains ongoing. Findings include: Review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, with a revision date of 7/29/19, documented the following procedures: 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending Physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. The Ombudsman should also be notified as required by state law. The Administrator or designee should direct an investigation into the allegation or incident. 5. Follow specific state reporting form/web portals for the documenting reportable event. Unless state requirements specify otherwise, a written investigation report should be submitted to the state agency within five days of the incident. Review of the facility policy titled, No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property last reviewed 1/8/19, documented the following procedure: 2. During an active investigation of patient abuse, neglect, exploitation, mistreatment, or misappropriation of patient property, when there is substantial evidence that such has occurred, the provider should take all reasonable efforts to protect the affected patient(s) from harm. 4. The provider should take all reasonable measures to provide emotional support and reassurance to patients and their families or representatives following the reporting or discovery of suspected patient abuse, neglect, exploitation, mistreatment, or misappropriation of property and any follow-up care as needed. A review of the facility policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, documented the following procedure: The Administrator of the provider is responsible for assuring that an accurate and timely investigation is completed. Review of the facility policy titled, Abuse Identification documents the following: 2. Identification of patients/residents whose behavior is abusive to other patient's/residents. If a patient/resident is identified in one of the following categories, a thorough assessment should be completed to include any identified situations or factors that trigger abusive behavior. Patients/residents whose personal histories render them at risk for abusing others. Patients/resident who have displayed or attempted to display abusive behavior toward others. From this assessment, intervention strategies should be developed on the care plan or behavior management plant to prevent occurrences including monitoring for factors that trigger abusive behaviors for the patient/resident. The care plan including interventions should be evaluated on a regular basis and revised as necessary. 3. Identification of coverage and responsibility. Patients/residents in a Health Care Center should not be subjected to abuse or neglect by anyone (including but not limited to: staff, other patients/residents, consultants, volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals). Any person observing, hearing a complaint of, and/or identifying any signs and symptoms of abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, and misappropriation of patient property, or exploitation should report it to the Administrator as soon as possible. The Administrator will inform and designate other staff members to assist in the investigation as indicated. It is the responsibility of any department head receiving the complaint of alleged abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient/ resident property to inform the Administrator as soon as possible. Review of the facility policy titled, Abuse Prevention and Reporting documented the following procedure: 1. Anyone witnessing, suspecting or hearing an allegation of mental, physical, verbal or sexual abuse; neglect or exploitation of any resident will immediately report this to the Administrator whether the Administrator is on the premises or not. 2. The Administrator will immediately begin an investigation and implement measures necessary to assure the safety and protection of the residents from the actual or alleged perpetrator. Record review revealed that R#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 9/5/19, indicated the resident had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 9 indicating that R#1 was moderately cognitively impaired. The resident was also assessed as having wandering behavior that occurred four to six days, but less than daily. The resident required minimal assistance from staff and only required supervision for locomotion on and off the unit. R#2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 8/16/19, for R#2 revealed a Brief Interview for Mental Status score of 99 indicating that R#2 was severely cognitively impaired and required extensive assistance with transfers, required limited assistance with locomotion in room and supervision with locomotion in corridor. R#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual MDS assessment, dated 9/29/19, for R#3 documented that the BIMS score for R#3 was two, indicating that R#3 was severely cognitively impaired and that the resident was independent with transfers and ambulation. Review of the Resident Progress Notes for R#1 revealed that staff were aware and documented R#1's sexually abusive behavior on: 9/10/19, 9/12/19, 9/15/19, 9/19/19, and 9/20/19; however, further record review revealed that the incidents of sexual abuse were not reported to the State Survey Agency until 10/4/19, an investigation of the sexual abuse was not conducted until 10/4/19, and R#1 was not placed on 1:1 monitoring to protect other residents until 10/2/19. Interview on 10/3/19 at 9:30 a.m., with the Director of Health Services (DHS) confirmed she was not notified R#1's behavior until 9/15/19. The DHS stated close monitoring of R#1 was done to protect the other residents even though R#1 was still able to have access to the other residents. The DHS stated actual 1:1 monitoring was not done; just close observation and extra staff was not called in to help monitor the R#1. The DHS further stated 1:1 observation was started on 10/2/19. The DHS stated the Physician was notified of R#1's behavior on 9/16/19 when they got an order for [REDACTED].>Interview on 10/2/19 at 3:45 p.m. with the Administrator revealed that R#1's sexual abuse was not reported to State Survey Agency because the information that was given to him was not the same information that was in the nurse's notes. The Administrator stated he had the impression that staff was able to intervene before R#1 actually touched the residents. The Administrator stated he should have read the documentation, but he did not until today. Administrator further stated that after reading the documentation, that this was something that definitely should have been reported and investigated. Interview on 10/3/19 at 11:25 a.m., with LPN FF revealed that a few days after R#1 was admitted to the facility he started feeling on the ladies. She stated R#1 was not on a behavior management program, just medication. LPN FF stated R#1 now has 1:1 monitoring which started yesterday (10/2/19). LPN FF stated that extra staff was not sent to help monitor R#1 until yesterday. During an interview with the Family of R#2 on 10/17/19 at 12:10 p.m., revealed that she had only been informed once of her mother being touched inappropriately by a male resident. Although staff stated R#1 was closely monitored, he continued to have access to R#2 and R#3, since 9/10/19 which allowed R#1 to continue to put his hands down female resident's shirts touching their breasts, putting his hands in between their legs and also masturbating and fondling himself in the common day room. The staff failed to put measures in place to protect other residents, failed to immediately report the sexual abuse to the Administrator, failed to conduct an investigation and failed to immediately report the sexual abuse to the State Survey Agency according to the facility abuse policy. Cross refer to F600

Based on record review, staff interviews, and review of the facility policies titled, Abuse Prevention and Reporting and Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property the facility failed to immediately report an allegation of sexual abuse to the Administrator and the State Survey Agency for two of 10 residents (R#2 and R#3) in the Memory Support Unit that were sexually abused by R#1. On (MONTH) 8, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on (MONTH) 8, 2019 at 4:55 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 10, 2019. The Immediate Jeopardy is outlined as follows: Resident (R) #1 was observed by staff from (MONTH) 10, 2019 through (MONTH) 20, 2019 repeatedly behaving in a sexually abusive manner toward cognitively impaired vulnerable residents in the Memory Support Unit (MSU). R#1 was observed on (MONTH) 10, 2019 feeling the private area of R#3, a female resident, in the common day room. On (MONTH) 12, 2019, R#1 was observed rubbing R#2's leg and had his hand inside her shirt rubbing her breast. On (MONTH) 12, 2019, R#1 pulled out his penis while standing in front of R#3, who was sitting in the common day room, and started masturbating. On (MONTH) 15, 2019, R#1 was observed putting his hand down R#2's shirt touching her breast while she was asleep. He also had his hands in between R#3's inner thighs rubbing various body parts on the resident, attempted to put R#3's hand down his pants, and was trying to hug and kiss the resident. On 9/15/19, R#1 was also observed fondling himself and was masturbating in the common day room in front of other residents. On 9/19/19 R#1 was observed inappropriately touching R#3. On (MONTH) 20, 2019, R#1 was observed showing inappropriate behavior by feeling on R#3. All of the incidents occurred in the common day room in the MSU. After R#1 was first observed being sexually abusive toward the female residents on (MONTH) 10, 2019, and multiple observations thereafter of R#1 being sexually abusive toward residents (specifically R#2 and R#3) and two observations of R#1 publicly masturbating in front of residents in the common day room, there were no protective measures put in place to protect R#2, R#3, or any of the other residents that resided in the MSU, from R#1's sexually abusive behavior. Although the first observation of sexually abusive behavior toward residents occurred on (MONTH) 10, 2019, the facility failed to investigate the sexually abusive behavior and did not report the abuse to the State Survey Agency until (MONTH) 4, 2019, after surveyor inquiry. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J; 42 C.F.R. 483.12(b)(1)-(4), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J; 42 C.F.R 483.12(c)(1)(4), Reporting of Alleged Violations (F609), Scope/Severity: J; 42 C.F.R. 483.12(c)(2)-(4), Investigate/Prevent/Correct Alleged Violations (F610), Scope/Severity: J; 42 C.F.R. 483.21(b)(2)(i)-(iii), Care Plan Timing and Revision (F657), Scope/Severity: J; 42 C.F.R 483.70, Administration (F835), Scope/Severity: [NAME] Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J; 42 C.F.R. 483.12(b)(1)-(4), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J; 42 C.F.R 483.12(c)(1)(4), Reporting of Alleged Violations (F609), Scope/Severity: J; 42 C.F.R. 483.12(c)(2)-(4), Investigate/Prevent/Correct Alleged Violations (F610), Scope/Severity: [NAME] At the time of exit on (MONTH) 18, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted, therefore; the Immediate Jeopardy remains ongoing. Findings include: Review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property with a revision date of 4/26/2017 documented the following procedures: 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending Physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. The Ombudsman should also be notified as required by state law. The Administrator or designee should direct an investigation into the allegation or incident. Review of the facility policy titled, Abuse Prevention and Reporting issued (MONTH) 2012, documented the following procedure: 1. Anyone witnessing, suspecting or hearing an allegation of mental, physical, verbal or sexual abuse; neglect or exploitation of any resident will immediately report this to the Administrator whether the Administrator is on the premises or not. 2. The Administrator will immediately begin an investigation and implement measures necessary to assure the safety and protection of the residents from the actual or alleged perpetrator. Record review revealed that R#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 9/5/19, for R#1 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating that the resident was moderately cognitively impaired. The resident was also assessed as having wandering behavior that occurred four to six days, but less than daily. The resident required minimal assistance from staff and only required supervision for locomotion on and off the unit. Record review revealed that R#2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 8/16/19, for R#2 revealed a Brief Interview for Mental Status score of 99 indicating that R#2 was severely cognitively impaired and required extensive assistance with transfers, required limited assistance with locomotion in room and supervision with locomotion in corridor. Record review revealed that R#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual MDS assessment, dated 9/29/19, for R#3 documented that the BIMS score for R#3 was two, indicating that R#3 was severely cognitively impaired and that the resident was independent with transfers and ambulation. Review of the Resident Progress Notes for R#1 revealed that staff were aware and documented R#1's sexually abusive behavior on: 9/10/19, 9/12/19, 9/15/19, 9/19/19, and 9/20/19; however, further record review revealed that the incidents of sexual abuse were not reported to the State Survey Agency until 10/4/19, an investigation of the sexual abuse was not conducted until 10/4/19, and R#1 was not placed on 1:1 monitoring to protect other residents until 10/2/19. Interview on 10/2/19 at 9:50 a.m., with the Licensed Practical Nurse (LPN) Unit Manager DD revealed that it was reported to her that R#1 had inappropriate touching to R#2 around 9/12/19 but LPN Unit Manager DD could not remember the exact date. LPN Unit Manager DD stated R#1 rubbed R#2's leg and had his hand inside her shirt. LPN Unit Manager DD stated it was reported to her and then she reported it to the DHS that same day or the next day at morning meeting (which is attended by the Administrator, the DHS, and the Unit Managers). LPN Unit Manager DD stated she called the doctor and then the pharmacist to see if there was anything, they could give R#1 for his increased libido and a medicine was ordered on [DATE]. LPN Unit Manager DD then stated that on 9/15/18 LPN EE reported to her that R#1 was touching another resident, and thought it was R#3 and that it was also reported to the DHS of the R#1's inappropriate touching, masturbating and fondling himself in the day room. Interview on 10/2/19 at 1:00 p.m., with the DHS revealed that she was notified on 9/15/19 by Licensed Practical Nurse (LPN) EE that R#1 had his hand down R#2's shirt. The DHS stated this was not reported to the State Survey Agency because they felt as if the resident's behavior was not intentionally abusing anyone due to his dementia. Interview on 10/8/19 at 3:20 p.m., with LPN EE revealed that she worked from 7:00 a.m.- 11:00 p.m. on 9/15/19. She stated that she observed R#1 with his hand down R#2's shirt on top of her breast while she was asleep in the day room and his hands were between her inner thighs. R#1 was also rubbing R#2's arm, leg and had his hand on her back. LPN EE stated R#1 was also was attempting to hug and kiss R#3 and she would tell him No don't do that. R#1 then started masturbating in the TV room while he was sitting in a chair but LPN EE could not remember who was sitting next to him. LPN EE further stated that on 9/15/19 R#1 also tried to put R#3's hand down his pants and she would remove her hand. LPN EE stated every time they would try to redirect R#1 he would get agitated and would run up to her threatening to hit her. LPN EE stated she called the DHS that day on 9/15/19 at 10:22 a.m. and she called the Unit Manager that same day at 10:29 a.m. LPN EE stated that during the morning meeting on 9/16/19, (which is attended by the Administrator, the DHS, and the Unit Mangers), they pulled the 9/15/19 nurses note up on the computer and read it. (The 9/15/19 Nurses Note documents the following: Starting this morning this resident (R#1) has required close supervision in the common area of the MSU. He (R#1) has been observed putting his hand down other resident shirts, putting his hands between there legs, rubbing various body parts of other residents, attempting to hug and kiss other residetns. masturbating and fondling himself in the common area, trying to put other residents hands down his pants, he (R#1) stands over other residents and does not consider /understand the personal space of others. Redirection required often and only partly successful. When redirected he (R#1) becomes verbally and physically aggressive. Resident (R#1) noted jumping up approaching and threatening to hit this nurse multiple times this shift). LPN EE then stated that the Administrator and the DHS stated that they thought R#1's behavior was related to his dementia. During an interview with the DHS on 10/2/19 at 1:00 p.m., she stated she was notified on 9/15/19 by LPN EE that R#1 had his hand down R#2's shirt. She stated she instructed the nurse that R#1 was to be monitored by her and the CNAs and that R#1 was not to be left alone with other residents. The DHS also stated it was discussed in the 9/16/19 morning meeting, and they reached out to the pharmacy and got orders for R#1. The DHS stated she was not aware of the incidents that occurred on 9/10/19, 9/12/19 or the behaviors after 9/15/19. The DHS stated this was not reported to the State Survey Agency because they felt as if R#1's behavior was not intentionally abusing anyone due to his dementia. Interview on 10/2/19 at 3:45 p.m. with the Administrator revealed that the sexual abuse was not reported to State Survey Agency. The Administrator stated he should have read the documentation, but he did not until today. He further stated that after reading the documentation, that this was something that definitely should have been reported. Interview on 10/3/19 at 11:25 a.m., with LPN FF revealed that a few days after R#1 was admitted to the facility he started feeling on the ladies. LPN FF stated the first day R#1 touched R#3 she reported it to Unit Manager DD who said to tell the DHS. The DHS told her she would take care of it and that the DHS told Unit Manager DD to get an order for [REDACTED]. Interview on 10/4/19 at 12:00 p.m., with LPN II revealed that on 9/12/19 R#1 had his hand down R#2's shirt with his hand on her breast. LPN II stated then later day R#1 was masturbating in front R#3. LPN II stated that was just R#1s behavior. LPN II stated she could not remember when she reported the behavior to the Unit Manager, but she did remember reporting the resident pulling his penis out. Interview on 10/8/19 at 2:45 p.m., with Registered Nurse (RN) KK revealed that R#1's sexual behavior was discussed at five different morning meetings (which included the Administrator, the DHS, and the Unit Managers) and that it was brought up multiple times. RN KK further stated she felt like the DHS would have reported this, but the Administrator did not see the seriousness of this. Although the first observation of sexually abusive behavior toward residents occurred on 9/10/19 and continued through 9/20/19, the facility staff failed to immediately report the sexual abuse to the Administrator. Once the Administrator read the Progress Notes that documented R#1's sexually abusive behavior in the Morning Meeting on 9/16/19 he did not report the sexual abuse to the State Survey Agency until 10/4/19. Cross refer to F600

Based on record review, and review of the facility policies titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, and Abuse Prevention and Reporting the facility failed to conduct a timely investigation of an allegation of sexual abuse for two of 10 residents (R#2 and R#3) in the Memory Support Unit that were reviewed for sexual abuse. On (MONTH) 8, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on (MONTH) 8, 2019 at 4:55 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 10, 2019. The Immediate Jeopardy is outlined as follows: Resident (R) #1 was observed by staff from (MONTH) 10, 2019 through (MONTH) 20, 2019 repeatedly behaving in a sexually abusive manner toward cognitively impaired vulnerable residents in the Memory Support Unit (MSU). R#1 was observed on (MONTH) 10, 2019 feeling the private area of R#3, a female resident, in the common day room. On (MONTH) 12, 2019, R#1 was observed rubbing R#2's leg and had his hand inside her shirt rubbing her breast. On (MONTH) 12, 2019, R#1 pulled out his penis while standing in front of R#3, who was sitting in the common day room, and started masturbating. On (MONTH) 15, 2019, R#1 was observed putting his hand down R#2's shirt touching her breast while she was asleep. He also had his hands in between R#3's inner thighs rubbing various body parts on the resident, attempted to put R#3's hand down his pants, and was trying to hug and kiss the resident. On 9/15/19, R#1 was also observed fondling himself and was masturbating in the common day room in front of other residents. On 9/19/19 R#1 was observed inappropriately touching R#3. On (MONTH) 20, 2019, R#1 was observed showing inappropriate behavior by feeling on R#3. All of the incidents occurred in the common day room in the MSU. After R#1 was first observed being sexually abusive toward the female residents on (MONTH) 10, 2019, and multiple observations thereafter of R#1 being sexually abusive toward residents (specifically R#2 and R#3) and two observations of R#1 publicly masturbating in front of residents in the common day room, there were no protective measures put in place to protect R#2, R#3, or any of the other residents that resided in the MSU, from R#1's sexually abusive behavior. Although the first observation of sexually abusive behavior toward residents occurred on (MONTH) 10, 2019, the facility failed to investigate the sexually abusive behavior and did not report the abuse to the State Survey Agency until (MONTH) 4, 2019, after surveyor inquiry. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J; 42 C.F.R. 483.12(b)(1)-(4), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J; 42 C.F.R 483.12(c)(1)(4), Reporting of Alleged Violations (F609), Scope/Severity: J; 42 C.F.R. 483.12(c)(2)-(4), Investigate/Prevent/Correct Alleged Violations (F610), Scope/Severity: J; 42 C.F.R. 483.21(b)(2)(i)-(iii), Care Plan Timing and Revision (F657), Scope/Severity: J; 42 C.F.R 483.70, Administration (F835), Scope/Severity: [NAME] Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J; 42 C.F.R. 483.12(b)(1)-(4), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J; 42 C.F.R 483.12(c)(1)(4), Reporting of Alleged Violations (F609), Scope/Severity: J; 42 C.F.R. 483.12(c)(2)-(4), Investigate/Prevent/Correct Alleged Violations (F610), Scope/Severity: [NAME] At the time of exit on (MONTH) 18, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted, therefore; the Immediate Jeopardy remains ongoing. Findings include: A review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property documented the following procedures: 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. The Ombudsman should also be notified as required by state law. The Administrator or designee should direct an investigation into the allegation or incident. A review of the facility policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property documented the following procedure: The Administrator of the provider is responsible for assuring that an accurate and timely investigation is completed. Review of the facility policy titled, Abuse Prevention and Reporting documented the following procedure: 1. Anyone witnessing, suspecting or hearing an allegation of mental, physical, verbal or sexual abuse; neglect or exploitation of any resident will immediately report this to the Administrator whether the Administrator is on the premises or not. 2. The Administrator will immediately begin an investigation and implement measures necessary to assure the safety and protection of the residents from the actual or alleged perpetrator. Record review revealed that R#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 9/5/19, for R#1 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating that the resident was moderately cognitively impaired. The resident was also assessed as having wandering behavior that occurred four to six days, but less than daily. The resident required minimal assistance from staff and only required supervision for locomotion on and off the unit. Record review revealed that R#2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 8/16/19, for R#2 revealed a Brief Interview for Mental Status score of 99 indicating that R#2 was severely cognitively impaired and required extensive assistance with transfers, required limited assistance with locomotion in room and supervision with locomotion in corridor. Record review revealed that R#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual MDS assessment, dated 9/29/19, for R#3 documented that the BIMS score for R#3 was two, indicating that R#3 was severely cognitively impaired and that the resident was independent with transfers and ambulation. Review of the Resident Progress Notes for R#1 revealed that staff were aware and documented R#1's sexually abusive behavior on: 9/10/19, 9/12/19, 9/15/19, 9/19/19, and 9/20/19; however, further record review revealed that the incidents of sexual abuse were not reported to the State Survey Agency until 10/4/19, an investigation of the sexual abuse was not conducted until 10/4/19, and R#1 was not placed on 1:1 monitoring to protect other residents until 10/2/19. During an interview with Registered Nurse (RN) KK on 10/8/19 at 2:45 p.m., she stated that R#1's sexual behavior was discussed at five different morning meetings and that it was brought up multiple times. Interview on 10/2/19 at 3:45 p.m. with the Administrator revealed that he should have read the documentation regarding R#1's behavior, but he did not until today. The Administrator further stated that after reading the documentation (of the incidents that occurred with R#1), that this was something that definitely should have been investigated. Interview on 10/4/19 at 11:30 a.m. with the Administrator revealed that after reading F600 they decided to go ahead and do a self-report on R#1 as sexual abuse and that they were going to go ahead and start an investigation. Although the first observation of sexually abusive behavior toward residents occurred on 9/10/19 and continued through 9/20/19, the facility staff failed to immediately report the sexual abuse to the Administrator and did not start an investigation of the sexual abuse until 10/4/19. Cross refer to F600

Based on record review, staff interviews, and review of the facility policy titled, Care Plans the facility failed to revise the care plan to reflect the sexually abusive behaviors of R#1 toward two of 10 (R#2, R#3) residents who resided in the Memory Support Unit (MSU). On (MONTH) 8, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on (MONTH) 8, 2019 at 4:55 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 10, 2019. The Immediate Jeopardy is outlined as follows: Resident (R) #1 was observed by staff from (MONTH) 10, 2019 through (MONTH) 20, 2019 repeatedly behaving in a sexually abusive manner toward cognitively impaired vulnerable residents in the Memory Support Unit (MSU). R#1 was observed on (MONTH) 10, 2019 feeling the private area of R#3, a female resident, in the common day room. On (MONTH) 12, 2019, R#1 was observed rubbing R#2's leg and had his hand inside her shirt rubbing her breast. On (MONTH) 12, 2019, R#1 pulled out his penis while standing in front of R#3, who was sitting in the common day room, and started masturbating. On (MONTH) 15, 2019, R#1 was observed putting his hand down R#2's shirt touching her breast while she was asleep. He also had his hands in between R#3's inner thighs rubbing various body parts on the resident, attempted to put R#3's hand down his pants, and was trying to hug and kiss the resident. On 9/15/19, R#1 was also observed fondling himself and was masturbating in the common day room in front of other residents. On 9/19/19 R#1 was observed inappropriately touching R#3. On (MONTH) 20, 2019, R#1 was observed showing inappropriate behavior by feeling on R#3. All of the incidents occurred in the common day room in the MSU. After R#1 was first observed being sexually abusive toward the female residents on (MONTH) 10, 2019, and multiple observations thereafter of R#1 being sexually abusive toward residents (specifically R#2 and R#3) and two observations of R#1 publicly masturbating in front of residents in the common day room, there were no protective measures put in place to protect R#2, R#3, or any of the other residents that resided in the MSU, from R#1's sexually abusive behavior. Although the first observation of sexually abusive behavior toward residents occurred on (MONTH) 10, 2019, the facility failed to investigate the sexually abusive behavior and did not report the abuse to the State Survey Agency until (MONTH) 4, 2019, after surveyor inquiry. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J; 42 C.F.R. 483.12(b)(1)-(4), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J; 42 C.F.R 483.12(c)(1)(4), Reporting of Alleged Violations (F609), Scope/Severity: J; 42 C.F.R. 483.12(c)(2)-(4), Investigate/Prevent/Correct Alleged Violations (F610), Scope/Severity: J; 42 C.F.R. 483.21(b)(2)(i)-(iii), Care Plan Timing and Revision (F657), Scope/Severity: J; 42 C.F.R 483.70, Administration (F835), Scope/Severity: [NAME] Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J; 42 C.F.R. 483.12(b)(1)-(4), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J; 42 C.F.R 483.12(c)(1)(4), Reporting of Alleged Violations (F609), Scope/Severity: J; 42 C.F.R. 483.12(c)(2)-(4), Investigate/Prevent/Correct Alleged Violations (F610), Scope/Severity: [NAME] At the time of exit on (MONTH) 18, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted, therefore; the Immediate Jeopardy remains ongoing. Findings include: A review of the facility policy titled, Care Plans documented the following procedure for Care Plan Review and Update: 1. Comprehensive care plans should be reviewed not less than quarterly according to the Omnibus Budget Reconciliation Act (OBRA) MDS (Minimum Data Set) schedule, following the completion of the assessment. Care plan updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. 2. Discontinued problems, goals or approaches should be indicated directly on the care plan. A line should be drawn through the discontinued item. Updates to the care plans should be made with any changes in condition at the time the change in condition occurred. 3. All updates to care plans are to be dated and signed. The Master Care Plan will be electronically updated and printed following the completion of Comprehensive OBRA assessments. 4. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient's/resident's needs at any given moment. Record review revealed that R#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 9/5/19, for R#1 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating that the resident was moderately cognitively impaired. The resident was also assessed as having wandering behavior that occurred four to six days, but less than daily. The resident required minimal assistance from staff and only required supervision for locomotion on and off the unit. Review of the 8/27/19 care plan for the resident revealed the care plan was last reviewed/revised on 9/6/19 with the problem of presence of behavioral symptoms related to disease process, dementia with behaviors with the following behaviors listed: physically aggressive, verbally aggressive, wanders unsafely- exit seeking and banging on doors, sexually inappropriate- sexual advances towards staff and resists care. The care plan goal was, the patient will not harm themselves or others secondary to their behaviors through the next 30 days. The approaches were to: Administer and monitor the effectiveness and side effects of medications as ordered, assess for pain involvement with resident behaviors, intervene as needed to protect the rights and safety of others, approach in a calm manner, divert attention, remove from situation and take to another location as needed, and refer for symptom and mental health evaluation. Further record review revealed that R#1's care plan was not revised to reflect the sexually inappropriate behavior towards other residents that occurred from 9/10/19 through 9/20/19. Interview on 10/8/19 at 2:45 p.m., with Registered Nurse (RN) KK she stated that the MDS Department are not the only ones who can revise the care plan. RN KK stated usually the nurses on the hall will revise the care plan when there has been a change in the resident's condition. RN KK stated that R#1's behavior was discussed at five different morning meetings about his sexual behaviors, that his behavior was brought up multiple times. She stated the resident's care plan should have been revised. Interview on 10/4/19 at 9:45 a.m., with the Director of Health Services (DHS) revealed that anyone can revise the care plan when needed. The DHS further stated that the MDS department usually reviews the care plan during the Quarterly or Annual MDS, but they also discuss residents during the morning meeting and will revise care plans from the information obtained from the meeting. The DHS stated when she reviewed R#1's care plan, she saw he was care planned for sexually inappropriate behaviors towards staff, but she did not notice the care plan did not include the sexual behaviors towards residents. Cross refer to F600

Based on record review, staff interviews, and Review of the POS [REDACTED]#1) and failed to provide oversight and protection for two of 10 residents (R#2, R#3) who were subjected to repeated sexual abuse from R#1. On (MONTH) 8, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on (MONTH) 8, 2019 at 4:55 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 10, 2019. The Immediate Jeopardy is outlined as follows: Resident (R) #1 was observed by staff from (MONTH) 10, 2019 through (MONTH) 20, 2019 repeatedly behaving in a sexually abusive manner toward cognitively impaired vulnerable residents in the Memory Support Unit (MSU). R#1 was observed on (MONTH) 10, 2019 feeling the private area of R#3, a female resident, in the common day room. On (MONTH) 12, 2019, R#1 was observed rubbing R#2's leg and had his hand inside her shirt rubbing her breast. On (MONTH) 12, 2019, R#1 pulled out his penis while standing in front of R#3, who was sitting in the common day room, and started masturbating. On (MONTH) 15, 2019, R#1 was observed putting his hand down R#2's shirt touching her breast while she was asleep. He also had his hands in between R#3's inner thighs rubbing various body parts on the resident, attempted to put R#3's hand down his pants, and was trying to hug and kiss the resident. On 9/15/19, R#1 was also observed fondling himself and was masturbating in the common day room in front of other residents. On 9/19/19 R#1 was observed inappropriately touching R#3. On (MONTH) 20, 2019, R#1 was observed showing inappropriate behavior by feeling on R#3. All of the incidents occurred in the common day room in the MSU. After R#1 was first observed being sexually abusive toward the female residents on (MONTH) 10, 2019, and multiple observations thereafter of R#1 being sexually abusive toward residents (specifically R#2 and R#3) and two observations of R#1 publicly masturbating in front of residents in the common day room, there were no protective measures put in place to protect R#2, R#3, or any of the other residents that resided in the MSU, from R#1's sexually abusive behavior. Although the first observation of sexually abusive behavior toward residents occurred on (MONTH) 10, 2019, the facility failed to investigate the sexually abusive behavior and did not report the abuse to the State Survey Agency until (MONTH) 4, 2019, after surveyor inquiry. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J; 42 C.F.R. 483.12(b)(1)-(4), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J; 42 C.F.R 483.12(c)(1)(4), Reporting of Alleged Violations (F609), Scope/Severity: J; 42 C.F.R. 483.12(c)(2)-(4), Investigate/Prevent/Correct Alleged Violations (F610), Scope/Severity: J; 42 C.F.R. 483.21(b)(2)(i)-(iii), Care Plan Timing and Revision (F657), Scope/Severity: J; 42 C.F.R 483.70, Administration (F835), Scope/Severity: [NAME] Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J; 42 C.F.R. 483.12(b)(1)-(4), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J; 42 C.F.R 483.12(c)(1)(4), Reporting of Alleged Violations (F609), Scope/Severity: J; 42 C.F.R. 483.12(c)(2)-(4), Investigate/Prevent/Correct Alleged Violations (F610), Scope/Severity: [NAME] At the time of exit on (MONTH) 18, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted, therefore; the Immediate Jeopardy remains ongoing. Findings include: A review of the Administrator's Position Description revealed, in part, the following documentation: Job Purpose: Directs the day-to-day functions of the nursing center in accordance with federal, state, and local regulations that govern long-term care centers, and as may be directed by the Area Vice President, to provide appropriate care for our patients/residents. Key Responsibilities: 1. Current knowledge of state and federal laws governing the operation of nursing facilities. 2. Knowledge of licensing and payment programs, general business practices, nursing practice, psychology of resident care, personal care and social services, therapeutic and supportive long-term care and services, and environmental health and safety relevant to nursing facility operations. 7. Ability to develop and implement administrative policies and procedures that reflect the center's philosophy and mission in compliance with federal and state laws and regulations. 8. Demonstrates knowledge of and respect for the rights, dignity and individuality of each patient/resident in all interactions. During an interview with the Director of Health Services (DHS) on 10/2/19 at 1:00 p.m., she stated she was notified on 9/15/19 by the nurse that R#1 had his hand down R#2's shirt. The DHS stated she instructed the nurse that R#1 was to be monitored by her and the Certified Nursing Assistance (CNA's) and he (R#1) was not to be left alone with other residents. The DHS stated that the incidents that occurred with R#1on 9/15/19 were discussed in the 9/16/19 morning meeting. The DHS stated she was not aware of the inappropriate sexual behaviors on 9/10/19, 9/12/19, or the behaviors after 9/15/19. During an interview with the Administrator on 10/16/19 at 3:20 p.m. he stated he was made aware of R#1's sexually inappropriate behaviors on 9/16/19 at the morning meeting. The Administrator stated since the resident had not had these behaviors before, they felt it was a new behavior. The Administrator stated he had the understanding there were staff present during these behaviors and they were able to stop R#1 before he touched the residents. The Administrator stated that he, and the staff present in the morning meeting, were all in agreement it was a behavior and that they were treating the behavior. The Administrator stated there were no other actions taken at that point (9/16/19) and that he left it up to nursing to get an order for [REDACTED]. Cross refer to F600, F607, F609, F610 and F657

Based on clinical record review, National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules review, hospital Patient Transfer Form review, hospital Discharge Summary review, hospital Discharge Medication Reconciliation Report review, hospital history and physical examination [REDACTED]. The total survey sample was thirty-four (34) residents. Resident #109 had [DIAGNOSES REDACTED]. The 10/03/2014 hospital Patient Transfer Form referred nursing facility staff to the hospital Discharge Medication Reconciliation Report for a review of Resident #109's transfer medications, but there was no evidence of facility receipt, or follow-up, regarding this Report when Resident #109 was admitted on [DATE]. Evidence indicated that nursing staff obtained Resident #109's medication orders on 10/03/2014 without informing the physician of Resident #109's transfer medication orders (as documented on Resident #109's missing hospital Discharge Medication Reconciliation Report). On 10/22/2014, Resident #109 had [MEDICAL CONDITION] and was transferred to the hospital, where she had tonic-clonic [MEDICAL CONDITION] and a blood glucose of 682 milligrams/deciliter (mg/dL). She was documented to have "[DIAGNOSES REDACTED]", was administered [MEDICATION NAME] and Insulin drug therapies, and was admitted into the Intensive Care Unit (ICU). Resident #109's hospital Discharge Medication Reconciliation Report of 10/03/2014 was later obtained and revealed that during her previous hospital stay (before nursing facility transfer on 10/03/2014), she had received [MEDICATION NAME] for [MEDICAL CONDITION] and Humalog and [MEDICATION NAME] for Diabetes Mellitus. The facility's failure to clarify with the attending physician Resident #109's nursing facility admission medication orders, including medication therapy for [MEDICAL CONDITION] Disorder and Diabetes Mellitus, upon her 10/03/2014 transfer from the hospital and facility admission, resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator, Director of Health Services (DHS), and Nurse Consultant were informed of the immediate jeopardy on December 11, 2014 at 1:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on October 22, 2014, the date Resident #109 was transferred to the hospital for [MEDICAL CONDITION] activity after the facility's failure to confirm with the attending physician the resident's 10/03/2014 hospital transfer orders (including [MEDICATION NAME] anticonvulsant and Insulin drug therapies) upon the resident's 10/03/2014 transfer from the hospital to the facility. The immediate jeopardy continued through December 12, 2014, and was removed on December 13, 2014. The facility implemented a Credible Allegation of Jeopardy Removal related to the immediate jeopardy on December 12, 2014. During a 12/10/2014, 2:05 p.m. interview, the DHS acknowledged that on 10/03/2014, when Resident #109 was admitted to the facility and orders were obtained, licensed nursing staff did not use the hospital Discharge Medication Reconciliation Report, as indicated on the hospital Patient Transfer Form, for a review of the resident's medications. A Credible Allegation of Jeopardy Removal was received on December 12, 2014. Based on the corrective plans which had been developed and implemented by the facility via this Credible Allegation of Jeopardy Removal on December 12, 2014, the immediacy of the deficient practice was determined to have been removed on December 13, 2014. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued management level staff oversight of resident admission/readmission procedures to ensure the continuity of resident medication therapy. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary resident information, including resident medication therapy, at the time of resident admission/readmission, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about facility Policies and Procedures governing Admission Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including physicians' orders for resident drug therapy, were current and accurate. Findings include: Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules revealed that the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice, Section 2.3.2(e) - Standards Related to Licensed Practical Nurse/Vocational Nurse Responsibilities for Nursing Practice Implementation, specified that the nurse seeks clarification of orders when needed. Resident #109's 10/15/2014 Admission Minimum Data Set documented diagnoses, in Section I - Active Diagnoses, including, but not limited to, [MEDICAL CONDITIONS], Dementia, Anxiety Disorder, Diabetes Mellitus, and [MEDICAL CONDITION] Disorder. A hospital Patient Transfer Form for Resident #109 documented transfer to the nursing facility on 10/03/2014 from a hospital, and Resident #109's hospital Discharge Summary documented she had been an inpatient in the hospital from 09/22/2014 until her 10/03/2014 nursing facility transfer. Resident #109's nursing facility medical record contained handwritten medication orders of 10/03/2014 from the transferring hospital physician specifying that she receive [MEDICATION NAME] 400 milligrams (mgs) at bedtime, [MEDICATION NAME] 3 mgs at bedtime, [MEDICATION NAME] 1 mg every 4 hours as needed, and an [MEDICATION NAME] 9.5 mg/24 hour Patch every 24 hours. Resident #109's nursing facility admission Physician's Orders of 10/03/2013, signed by Licensed Practical Nurse (LPN) "AA", documented that upon nursing facility admission, physician's orders were obtained for [MEDICATION NAME], and [MEDICATION NAME] Patch (as recommended by the transferring hospital physician per the transfer medication orders above). However, despite Resident #109's 10/03/2014 nursing facility admission Physician's Orders documenting [DIAGNOSES REDACTED]. facility admission. Resident #109's hospital Discharge Summary referenced above documented that while in the hospital (prior to nursing facility transfer), Resident #109 had frequent [MEDICAL CONDITION] and received the anticonvulsant medication [MEDICATION NAME]. However, as referenced above, Resident #109's 10/03/2014 nursing facility admission Physician's Orders did not contain an order for [REDACTED]. During a 12/10/2014, 1:50 p.m. interview, LPN "AA" stated that when Resident #109 was admitted to the facility on [DATE], this nurse had the resident's hospital Discharge Summary, hospital Patient Transfer Form, and handwritten hospital physician's medication orders (all referenced above), but had no other transfer forms for Resident #109. LPN "AA" acknowledged, however, during a 12/11/2014, 10:45 a.m. interview, that even though she had Resident #109's hospital Discharge Summary (which referenced the resident's receipt of [MEDICATION NAME] drug therapy in the hospital), she did not actually read this Discharge Summary while transcribing Resident #109's admission Physician's Orders on 10/03/2014. Further review of Resident #109's 10/03/2014 hospital Patient Transfer Form referenced above revealed a notation instructing nursing staff to "see discharge med rec" regarding the resident's medication therapy. During an interview on 12/10/2014 at 1:30 p.m., Registered Nurse (RN) "CC" stated that when a resident was transferred to the nursing facility, the transferring facility would provide a list of medications on a Discharge Medication Reconciliation form (the "discharge med rec" form). As indicated in the 12/10/2014, 1:50 p.m. interview with LPN "AA" referenced above, LPN "AA" acknowledged that she had Resident #109's hospital Patient Transfer Form (which instructed to see the "discharge med rec", also know as the Discharge Medication Reconciliation form, regarding the resident's medications) when she transcribed Resident #109's admission Physician's Orders on 10/03/2014. However, review of Resident #109's medical record revealed no evidence of a Discharge Medication Reconciliation form (as referenced on the resident's Patient Transfer Form, and which listed the medication Resident #109 received while hospitalized ). During a 12/10/2014, 2:05 p.m. interview, the DHS stated that when Resident #109 was admitted on [DATE], the facility had the hospital physician's handwritten medication orders listing [MEDICATION NAME], and [MEDICATION NAME] Patch drug therapy (as above). The DHS acknowledged, however, that these handwritten hospital physician's medication orders received from the hospital were not Resident #109's Discharge Medication Reconciliation form referenced on the hospital Patient Transfer Form. The DHS further acknowledged, during a subsequent interview on 12/10/2014 at 3:30 p.m., that the hospital physician's handwritten medication orders were used by LPN "AA" as a Medication Reconciliation sheet when Resident #109 was admitted on [DATE]. On 12/10/2014, the DHS provided a copy of Resident #109's 10/03/2014 Discharge Medication Reconciliation Report. A facsimile-stamped date of 12/10/2014 was on the top of Resident #109's hospital Discharge Medication Reconciliation Report, thus indicating that this Report was provided to the nursing facility on 12/10/2014 (during this standard survey). Review of Resident #109's 10/03/2014 Discharge Medication Reconciliation Report revealed that while in the hospital, prior to her 10/03/2014 nursing facility admission, (in addition to [MEDICATION NAME], and [MEDICATION NAME] Patch medication therapy, which she received once admitted to the nursing facility) Resident #109 had hospital physicians' orders to receive the following medications: [REDACTED]. Additionally, Resident #109's 10/03/2014 hospital Discharge Medication Reconciliation Report indicated that while still at home, Resident #109 had received [MEDICATION NAME], 28 units subcutaneously twice a day with meals. Further review of Resident #109's hospital Discharge Medication Reconciliation Report referenced above revealed notations, in the Action Taken section, indicating the hospital physician recommended, upon the resident's 10/03/2014 discharge from the hospital, to "Continue for Home Use" the resident's medication therapy for [MEDICATION NAME], Humalog Insulin, [MEDICATION NAME], Carvedilol, [MEDICATION NAME], and Aspirin. However, as documented above, Resident #109's clinical record revealed no evidence to indicate that, upon the resident's 10/03/2014 transfer from the hospital to the nursing facility, the nursing facility received the resident's hospital Discharge Medication Reconciliation Report (which the resident's 10/03/2014 hospital Patient Transfer Form referenced regarding the resident's transfer medication therapy). There was no evidence of facility licensed nursing staff attempting to obtain Resident #109's Discharge Medication Reconciliation Report (in which the hospital physician recommended the continuation of the resident's [MEDICATION NAME], Humalog Insulin, [MEDICATION NAME], Carvedilol, [MEDICATION NAME], and Aspirin drug therapy), upon the resident's 10/03/2014 facility admission, during the process of reviewing the resident's medication therapy with her attending physician and obtaining the resident's nursing facility admission Physician's Orders of 10/03/2014. Record review revealed that nursing staff did not obtain physician's orders for Resident #109 regarding [MEDICATION NAME], Humalog Insulin, [MEDICATION NAME], Carvedilol, [MEDICATION NAME], and Aspirin upon her 10/03/2014 facility admission. Record review for Resident #109 then revealed a Nurse's Notes (NN) entry of 10/22/2014 at 10:30 a.m. which documented [MEDICAL CONDITION] activity. This NN documented that a check of Resident #109's medical chart revealed no order for [MEDICAL CONDITION] medication, and when contacted, the physician ordered the anticonvulsant [MEDICATION NAME] 100 mgs. However, 10/22/2014, 1:45 p.m. NN then documented that Resident #109 had several [MEDICAL CONDITION] that day, and that when notified, the physician ordered to transport the resident to the hospital emergency room . A hospital history and physical examination [REDACTED]. This H&P documented Resident #109's previous hospital stay, and that while in the hospital, Resident #109 had received [MEDICATION NAME], but documented that she had not been receiving [MEDICATION NAME] therapy since in the nursing facility. The H&P documented that Resident #109 had five [MEDICAL CONDITION] at the nursing facility, two (2) witnessed tonic-clonic [MEDICAL CONDITION] after hospital transfer, and that the resident's glucose level on 10/22/2014 was 682 mg/dL. (MayoClinic.org referenced blood glucose greater than 200 mg/dL as high). Resident #109's hospital H&P documented impressions including "[DIAGNOSES REDACTED]" with a history of [MEDICAL CONDITION] disorder, that [MEDICATION NAME] anticonvulsant therapy would be restarted, and that she would receive an insulin drip and would be admitted to the ICU. During an interview conducted on 12/10/2014 at 2:33 p.m. with the Administrator and the DHS, the DHS stated that, when a resident was transferred to the facility from a hospital, she would except any nurse to obtain referral medication orders from the hospital, and to clarify these orders with the resident's attending physician. Based on the above, Resident #109 had [DIAGNOSES REDACTED]. The hospital Patient Transfer Form instructed nursing facility staff to refer to the resident's hospital Discharge Medication Reconciliation Report regarding the resident's medication therapy; however, there was no evidence the nursing facility staff either received this Report, or inquired about this Report, upon Resident #109's transfer. Later acquisition of this Discharge Medication Reconciliation Report (on 12/10/2014) revealed that Resident #109 had received the anticonvulsant medication [MEDICATION NAME], Humalog and [MEDICATION NAME], Carvedilol, [MEDICATION NAME], and Aspirin while in the psychiatric hospital, prior to nursing facility transfer. The hospital physician had indicated on Resident #109's Discharge Medication Reconciliation Report to continue all the above-referenced medications upon transfer. However, in the absence of evidence that the nursing facility received, or attempted to obtain, Resident #109's hospital Discharge Medication Reconciliation Report upon her 10/03/2014 nursing facility admission, there was no evidence to indicate that facility nursing staff made Resident #109's attending physician aware of her receipt of [MEDICATION NAME] (for the [DIAGNOSES REDACTED]. On 10/22/2014, Resident #109 experienced multiple [MEDICAL CONDITION], was transferred to the hospital where she experienced two (2) witnessed tonic-clonic [MEDICAL CONDITION]. Resident #109's blood glucose level was documented as 682 mg/dL, and documented impressions included "[DIAGNOSES REDACTED]" in the absence of [MEDICATION NAME] drug therapy. Resident #109 was restarted on [MEDICATION NAME] anticonvulsant drug therapy, receive an insulin drip, and was admitted to the hospital ICU. Cross refer to F333 for more information regarding Resident #109. The facility presented an acceptable Credible Allegation of Jeopardy Removal (CAJR) on December 12, 2014. Based on this CAJR, it was determined that the immediate jeopardy had been removed on December 13, 2014, at which time the facility had implemented the following interventions: 1. On 10/23/2014, the facility reviewed its Admissions Required Date Policy, which specified the information that was required upon resident admission/readmission to the nursing facility. This Admissions Required Data Policy was found to require that, for residents transferring to the healthcare center, certain data would be obtained by the facility prior to, or upon, the resident's admission. This admission data included: Current physical examination; Admitting [DIAGNOSES REDACTED]. that the resident is free from communicable/infectious/contagious diseases; MI/MR pre-screening form; Pre-Admission Screening and Resident Review Form; Health Insurance Portability and Accountability Act information; Other necessary/appropriate data. 2. On 10/28/2014, the facility implemented an Admission/Readmission Checklist Form to be utilized upon the admission/readmission of residents to the nursing facility. This Admission/Readmission Checklist Form will be utilized to monitor for the presence of all required documentation in the medical record of each resident admitted , and will be completed by the admitting RN/LPN within twenty-four hours of resident admission/readmission. This Form will monitor for, and document, the presence of specific admission forms and data types including, but not limited to, the following: Admission/Readmission Physician's Orders Form, complete will all required data; Medication order reconciliation and verification with admitting physician; Admission/Readmission Physician's Orders Form reconciliation with the Medication Administration Record [REDACTED].; Laboratory testing orders, per facility Protocol, and the completion of the Master Laboratory Form to ensure laboratory tests are ordered and completed; Fall risk assessment; and Elopement Risk assessment. For residents admitted /readmitted from from a psychiatric facility or behavioral health unit, after completion by the admitting RN/LPN, the DHS or Assistant Director of Health Services (ADHS) will review each resident Admission/Readmission Checklist Form for completion and accuracy. 3. On 10/31/2014, a resident medical record audit was completed by facility RN/LPN staff of resident medical records for 100 percent of active resident physicians' orders to ensure the accurate reconciliation of all physicians' orders. This audit was documented by the signature of each reviewing RN/LPN on the bottom of each resident's Physician's Orders page. 4. On 12/10/2014, the facility developed and implemented an Admission/Readmission Audit Tool. This Admission/Readmission Audit Tool will be utilized to monitor for resident data metrics which include the resident's name and room number, the date of admission or readmission, the facility from which the resident was transferred (if applicable), and physician order reconciliation by two (2) nursing staff per facility Policy. This Tool will be completed by an RN or LPN upon resident admission/readmission, and will be utilized to ensure that both the medical and psychiatric needs of residents are met, and to ensure the coordination of care between the medical and psychiatric physicians. One-hundred percent of all Admission/Readmission Audit Tool audits, initially completed by the RN or LPN, regarding residents admitted from psychiatric facilities or behavioral health units will be reviewed by the DHS or ADHS for completion and accuracy. In addition, facility RN and LPN staff will utilize this Admission/Readmission Audit Tool to complete a sampled audit, to be completed monthly, of residents admitted /readmitted to the nursing facility from sources other than psychiatric facilities or behavioral health units. One-hundred percent of these sampled RN/LPN audits will then be reviewed by the DHS or ADHS for completion and accuracy. 5. On 12/10/2014, the facility implemented a procedure by which the results of management-level staff monitoring, completed by the DHS or ADHS via the Admission/Readmission Checklist Form and the Admission-Readmission Audit Tool, of resident admissions/readmissions from both psychiatric facilities and other sources will be submitted to the facility's Performance Improvement (PI) Committee for the Committee's review and analysis. This will allow for the PI Committee's ongoing analysis, via the data collected by this management-level staff monitoring, of direct-care nursing staffs' conformance with facility's Policies and procedures governing resident admissions/readmissions to the facility. This will include PI Committee's monitoring for the presence of the required medical record and resident care information, to include medication therapy, upon resident admission/readmission to the facility. This will also ensure the ongoing oversight and analysis by the facility's PI Committee of facility staffs' conformance with resident admission/readmission Policies and procedures, to therefore ensure the continuity of resident care upon and after residents' admission to the facility. 6. On 12/12/2014, the facility continued the process of staff in-service training, initially begun on 10/23/2014, which involved the training of facility licensed nursing staff regarding the facility's Admission Required Data Policy, the newly implemented procedures involving the use of the Admission/Readmission Checklist Form and the Admission-Readmission Audit Tool, and the procedure involving routine audits of the resident admission/readmission process. On 10/23/2014, specific in-service training was provided to the ADHS and Unit Managers regarding future resident admissions from behavioral health units and/or psychiatric hospitals to ensure both the medical and psychiatric needs were met. Specific instructions were given to these management-level staff, which included the need to pay close attention when admitting any resident from a behavioral unit or psychiatric hospital to ensure that all medical [DIAGNOSES REDACTED]. These management staff members were also instructed to ensure review and approval of all resident medication orders with the physician admitting each resident to the facility's care. Then, beginning on 12/10/2014, staff in-service training was expanded to include all licensed nursing staff related to the newly implemented processes and procedures involving residents admitted /readmitted residents from a psychiatric unit or facility, to include the coordination of care between the psychiatric physician and attending physician, and also admission from other sources. This was to ensure the provision of all medications, as deemed necessary by the physician, and to ensure that all Physician's Orders forms are reconciled per facility Policy, upon each resident admission/readmission. As of 12/12/2014, staff in-service training had been provided to management-level and direct-care licensed nursing staff, involving the facility's Policies, procedures, and newly-implemented processes involving the use of the Admission/Readmission Checklist Form and Admission-Readmission Audit Tool, to a total of sixty (60) of the facility's sixty-seven (67)licensed nursing staff members. The remaining seven (7) licensed nursing staff members were unavailable for training at that time, due to either being off-duty or on leave. All licensed nursing staff who had not received this in-service training as of 12/12/2014 would receive this in-service training upon their return to work, and no licensed nursing staff member will be allowed to provide direct resident care until having received this in-service training regarding the facility's resident admission/readmission processes. During this standard survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 12/13/2014, a review of facility's Admissions Required Data Policy revealed that this Policy specified the acquisition of resident-specific data required, upon resident admission/readmission to the nursing facility, related to resident care and treatment. Interview with the Administrator conducted on 12/13/2014 at 10:00 a.m. confirmed that the facility had reviewed and analyzed this Admission Required Data Policy on 10/28/2014, in accordance with Step #1 of the CAJR referenced above, after the 10/03/2014 incident involving the medication therapy of Resident #109. - On 12/13/2014, facility document review, and a 10:00 a.m. interview with the Administrator, confirmed that the facility had implemented the use of the Admission/Readmission Checklist Form, in accordance with Step #2 of the CAJR referenced above. It was confirmed that this Admission/Readmission Checklist Form would be utilized by the admitting RN/LPN upon each resident's admission/readmission to ensure all required documentation in each resident medical record, and that this process would have routine management-level audit oversight. - On 12/13/2014, a sampled review of resident records completed on that date, which had been ongoing throughout the standard survey, confirmed that the facility had completed a resident medical record audit to ensure the accurate reconciliation of all physicians' orders. This was in accordance with Step #3 of the CAJR referenced above. - On 12/13/2014, facility document review, and 10:00 a.m. interview with the Administrator, confirmed that on 12/10/2014, the facility had implemented the Admission/Readmission Audit Tool to be used to monitor multiple data metrics upon resident admission/readmission to ensure that medical and psychiatric needs were met and to ensure coordination of care between medical and psychiatric physicians. This process would have routine management-level audits to provide oversight and analysis of direct-care staff conformance. This was as indicated in Step #4 of the CAJR referenced above. - On 12/13/2014, a 10:00 a.m. interview with the Administrator confirmed that the results of all audits, as referenced in the CAJR intended to provide ongoing nursing management-level oversight of the admission/readmission of residents from psychiatric hospitals, behavioral health units, and other facilities, would be reviewed by the facility's PI Committee. This PI Committee review of audit results will allow the PI Committee to provide ongoing analysis and oversight of facility staffs' conformance with the Policies and procedures governing resident admissions and readmissions to the facility, to thus ensure the continuity of resident care. This was in accordance with Step #5 of the CAJR referenced above. - On 12/13/2014, a review of facility staff in-service records confirmed that as of the previous day of 12/12/2014, the facility had provided staff in-service training to management-level and direct-care licensed nursing staff, totaling sixty (60) of the facility's sixty-seven (67) licensed nursing staff, regarding the facility's Policies, procedures, and processes involving the use of the Admission/Readmission Checklist Form and Admission-Readmission Audit Tool. The remaining seven (7) licensed nursing staff members who had not yet received this in-service training would be trained upon their return to work, as indicated in Step #6 of the CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility on 12/12/2014 as outlined in the CAJR referenced above, it was determined that the immediacy of the deficient practice was removed on 12/13/2014; however, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility implemented an Admission/Readmission Checklist Form to be utilized upon the admission/readmission of residents to monitor for the presence of all required data in the medical record of each resident. This Form was to be completed by the admitting RN/LPN within 24 hours of resident admission/readmission from a psychiatric facility or behavioral health unit. Additionally, the facility developed and implemented an Admission/Readmission Audit Tool to be used by the admitting RN/LPN to monitor for resident data metrics to ensure that the medical and psychiatric needs of each resident were met, and to ensure coordination between the medical, psychiatric, and other physicians. The facility had provided staff in-service training to licensed nursing staff regarding the facility's Admission Required Data Policy and newly implemented procedures involving the use of the Admission/Readmission Checklist Form and the the Admission-Readmission Audit Tool. As of 12/12/2014, this in-service training had been provided to a total of sixty (60) of the facility's sixty-seven (67)licensed nursing staff members. However, as of the 12/13/2014 exit date of this survey, the seven (7) licensed nursing staff members who had been off-duty or on leave, and thus unavailable for training, would need to receive this in-service training upon their return to work. Therefore, the facility's completion of in-service training for these remaining licensed nursing staff members related to the newly-implemented procedures involving the acquisition of pertinent resident data upon facility admission/readmission would need further evaluation at a future date. Additionally, on 12/10/2014, the facility implemented a procedure by which the results of management-level nursing staff audits, to be completed by the DHS/ADHS via the Admission/Readmission Checklist Form and the Admission-Readmission Audit Tool, of resident admissions/readmissions would be submitted to the facility's PI Committee for the Committee's review and analysis. However, as of the 12/13/2014 exit date of this survey, the PI Committee had not yet met to begin the process of the review and analysis of management-level staff audits for conformance with facility's resident admission Policies and procedures. Therefore, the PI Committee's ongoing oversight of facility staff conformance with resident admission process regarding the acquiring of all necessary care information, to include physicians' orders for medications and resident care, could not be fully assessed at the time of survey exit, and will need further evaluation at a future date. Based on the above, due to the need for continued evaluation of the facility's corrective action plans to ensure ongoing effectiveness, application, and completion, the noncompliance continues, with the scope and severity reduced to the "D" level.

Based on clinical record review, hospital Patient Transfer Form review, hospital Discharge Summary review, hospital Discharge Medication Reconciliation Report review, hospital history and physical examination [REDACTED]#109's Care Plan referenced the administration of medication therapies for the [DIAGNOSES REDACTED]. The total survey sample was thirty-four (34) residents. The facility's failure to ensure care for Resident #109 in accordance with her Care Plan, regarding her [MEDICAL CONDITION] Disorder and Diabetes Mellitus, resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. Resident #109 had [DIAGNOSES REDACTED]. Resident #109 was admitted to the nursing facility on 10/03/2014 after transfer from a hospital on that date. The hospital Patient Transfer Form indicated to refer to the hospital Discharge Medication Reconciliation Report of 10/03/2014 for Resident #109's transfer medications; however, there was no evidence that the facility received this Report on 10/03/2014. Resident #109's nursing facility medication orders were obtained without evidence of the physician being informed of the transfer medication orders (as documented on Resident #109's missing hospital Discharge Medication Reconciliation Report). On 10/22/2014, Resident #109 was transferred to the hospital after having [MEDICAL CONDITION], and in the hospital, she experienced tonic-clonic [MEDICAL CONDITION], was found to have a blood glucose of 682 milligrams/deciliter (mg/dL), was indicated to have "[DIAGNOSES REDACTED]", was administered [MEDICATION NAME] anticonvulsant and Insulin drug therapies, and was admitted into the Intensive Care Unit (ICU). When Resident #109's hospital Discharge Medication Reconciliation Report of 10/03/2014 was later obtained, it was found that, prior to her 10/03/2014 nursing facility admission (and during her previous hospital stay), she had received [MEDICATION NAME] for [MEDICAL CONDITION], and Humalog and [MEDICATION NAME] for Diabetes Mellitus. The facility's Administrator, Director of Health Services (DHS), and Nurse Consultant were informed of the immediate jeopardy on December 11, 2014 at 1:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on October 22, 2014, the date Resident #109 was transferred to the hospital for [MEDICAL CONDITION] activity after the facility's failure on 10/03/2014 to confirm with the attending physician the resident's 10/03/2014 hospital transfer orders (including [MEDICATION NAME] anticonvulsant and Insulin drug therapies) upon the resident's 10/03/2014 transfer from the hospital to the nursing facility. The immediate jeopardy continued through December 12, 2014, and was removed on December 13, 2014. The facility implemented a Credible Allegation of Jeopardy Removal related to the immediate jeopardy on December 12, 2014. During an interview conducted on 12/10/2014 at 2:33 p.m., the DHS acknowledged the failure to provide Resident #109's drug therapy after nursing facility admission. A Credible Allegation of Jeopardy Removal was received on December 12, 2014. Based on the corrective plans which had been developed and implemented by the facility via this Credible Allegation of Jeopardy Removal on December 12, 2014, the immediacy of the deficient practice was determined to have been removed on December 13, 2014. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued management level staff oversight of resident admission/readmission procedures to ensure the continuity of resident medication therapy. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary resident information, including resident medication therapy, at the time of resident admission/readmission, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about facility Policies and Procedures governing Admission Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including physicians' orders for resident drug therapy, were current and accurate. Findings include: Resident #109's 10/15/2014 Admission Minimum Data Set assessment documented an admission date of [DATE], and Section I - Active [DIAGNOSES REDACTED]. The Care Plan of Resident #109 noted the resident's 10/03/2014 date of facility admission. This Care Plan identified a Problem/Need indicating that Resident #109 was at risk for injury related to [MEDICAL CONDITION] Disorder, with a Goal that the resident would suffer no injury related to this [DIAGNOSES REDACTED]. Another Problem/Need referenced on Resident #109's Care Plan identified that the resident had labile blood sugars related to Type II Diabetes Mellitus. This Care Plan identified as a Goal that Resident #109's blood sugar levels would remain within normal limits, within the constraints of the disease process, and identified as an Approach to administer medications as ordered. A hospital Discharge Summary for Resident #109 dated 10/03/2014 documented the resident had been in a psychiatric hospital prior to her nursing facility transfer on that date. Resident #109's medical record contained handwritten medication orders of 10/03/2014 by the hospital physician which specified that she receive the antipsychotic drugs [MEDICATION NAME] 400 milligrams (mgs) and [MEDICATION NAME] 3 mgs at bedtime, the antianxiety drug [MEDICATION NAME] 1 mg every 4 hours as needed, and the dementia drug [MEDICATION NAME] Patch every 24 hours. Resident #109's nursing facility admission physician's orders [REDACTED]. However, record review revealed no evidence of orders for Resident #109 related to the [DIAGNOSES REDACTED]. A 10/03/14 hospital Patient Transfer Form for Resident #109 instructed nursing facility staff to "see discharge med rec". In a 12/10/14, 1:30 p.m. interview, Registered Nurse (RN) "CC" stated that, upon resident transfer from another facility, the nursing facility received a list of transfer medications on a Discharge Medication Reconciliation form (the "discharge med rec" referenced on Resident #109's hospital Patient Transfer Form). However, review of Resident #109's record revealed no evidence of a Discharge Medication Reconciliation Report form which was to be received (per RN "CC"'s 12/10/2014, 1:30 p.m. interview referenced above) from the psychiatric hospital on [DATE] when Resident #109 transferred to the nursing facility, and which would have listed the medications Resident #109 received while in the hospital. During a 12/10/2014, 1:50 p.m. interview, Licensed Practical Nurse (LPN) "AA" (who transcribed Resident #109's admission physician's orders [REDACTED].#109's admission physician's orders [REDACTED].#109's hospital Patient Transfer Form (which referenced the Discharge Medication Reconciliation Report), but did not have Resident #109's Discharge Medication Reconciliation Form at that time. On 12/10/2014, the DHS provided a copy of Resident #109's psychiatric hospital Discharge Medication Reconciliation Report form dated 10/03/2014 (but which documented a facsimile-stamped date of 12/10/2014, indicating this Report was received from the hospital on [DATE]). Review of this Discharge Medication Reconciliation Report of 10/03/2014 revealed a physician's orders [REDACTED].#109 had received the anticonvulsant Levetiracetam ([MEDICATION NAME]), 750 mgs twice a day while in the hospital. Additional review of this hospital Discharge Medication Reconciliation Report revealed that while in the hospital, Resident #109 had physicians' orders for Humalog Insulin, 14 units subcutaneously before meals and 7 units subcutaneously at bedtime, and while at home had received [MEDICATION NAME], 28 units subcutaneously twice a day with meals. Notations located in the Action Taken section of this Discharge Medication Reconciliation Report indicated "Continue for Home Use" regarding Resident #109's [MEDICATION NAME], Humalog and [MEDICATION NAME] drug therapy. However, as referenced above, Resident #109's record revealed no evidence to indicate that the nursing facility received the Discharge Medication Reconciliation Report, or made an attempt to obtain the Report, when Resident #109 was admitted to the nursing facility on 10/03/2014. There was also no evidence to indicate that Resident #109's attending physician was made aware of Resident #109 having received [MEDICATION NAME] anticonvulsant drug therapy, and Humalog and [MEDICATION NAME], prior to her nursing facility admission, and of the hospital physician's instructions to continue the [MEDICATION NAME] and Insulin therapy. This was despite Resident #109's Care Plan identifying that the resident had the Problems/Needs of both [MEDICAL CONDITION] Disorder and Diabetes Mellitus, for which Care Plan Approaches referenced the administration of medication therapy to address both issues. Then, a Nurse's Notes (NN) entry of 10/22/2014 at 2:45 a.m. for Resident #109 documented [MEDICAL CONDITION] activity had been noted. A 10/22/2014, 1:45 p.m. NN then documented Resident #109 had several [MEDICAL CONDITION] that day, that Resident #109's physician was notified, and that an order was received to transfer the resident to the hospital. Resident #109's 10/22/2014 hospital history and physical examination [REDACTED]. The H&P documented that Resident #109 had five [MEDICAL CONDITION] at the nursing facility, then two tonic-clonic [MEDICAL CONDITION] once transferred to the hospital. The H&P documented Resident #109's glucose level was 682 mg/dL, with MayoClinic.org listing a glucose level above 200 mg/dL as high. This H&P further documented an Impression that Resident #109 had "[DIAGNOSES REDACTED]" and would be restarted on [MEDICATION NAME], and would also receive an insulin drip and be admitted to the ICU. During an interview with the DHS conducted on 12/10/2014 at 2:33 p.m., the DHS acknowledged Resident #109's failing to receive the needed medication therapy after the resident's 10/03/2014 admission to the nursing facility. Based on the above, Resident #109 (who had [DIAGNOSES REDACTED]. However, there was no evidence of the nursing facility having possession of this Discharge Medication Reconciliation Report, or of attempts to obtain this Report, when Resident #109 was admitted . Resident #109's Discharge Medication Reconciliation Report was later presented (with a facsimile-stamped date of 12/10/2014) and revealed that while in the hospital, Resident #109 had received the medication [MEDICATION NAME] for the [DIAGNOSES REDACTED].#109's nursing facility admission on 10/03/2014, and no evidence to indicate that facility nursing staff made Resident #109's attending physician aware of her receipt of [MEDICATION NAME], and of Humalog and [MEDICATION NAME]. On 10/22/2014, Resident #109 experienced multiple [MEDICAL CONDITION], was transferred to the hospital where she experienced two (2) tonic-clonic [MEDICAL CONDITION] and was determined to have a blood glucose level of 682 mg/dL. Resident #109's hospital H&P documented "[DIAGNOSES REDACTED]" in the absence of [MEDICATION NAME] drug therapy and that [MEDICATION NAME] therapy would be restarted, and that she would receive an insulin drip and would be admitted into the ICU. The facility thus failed to ensure the provision of care to Resident #109 in accordance with the resident's Care Plan by failing to ensure medication therapy, as specified by the Care Plan, to address the resident's identified problems of [MEDICAL CONDITION] Disorder and Diabetes Mellitus. Cross refer to F333 for more information regarding Resident #109. The facility presented an acceptable Credible Allegation of Jeopardy Removal (CAJR) on December 12, 2014. Based on this CAJR, it was determined that the immediate jeopardy had been removed on December 13, 2014, at which time the facility had implemented the following interventions: 1. On 10/23/2014, the facility reviewed its Admissions Required Date Policy, which specified the information that was required upon resident admission/readmission to the nursing facility. This Admissions Required Data Policy was found to require that, for residents transferring to the healthcare center, certain data would be obtained by the facility prior to, or upon, the resident's admission. This admission data included: Current physical examination; Admitting [DIAGNOSES REDACTED]. 2. On 10/28/2014, the facility implemented an Admission/Readmission Checklist Form to be utilized upon the admission/readmission of residents to the nursing facility. This Admission/Readmission Checklist Form will be utilized to monitor for the presence of all required documentation in the medical record of each resident admitted , and will be completed by the admitting RN/LPN within twenty-four hours of resident admission/readmission. This Form will monitor for, and document, the presence of specific admission forms and data types including, but not limited to, the following: Admission/Readmission physician's orders [REDACTED].; Laboratory testing orders, per facility Protocol, and the completion of the Master Laboratory Form to ensure laboratory tests are ordered and completed; Fall risk assessment; and Elopement Risk assessment. For residents admitted /readmitted from from a psychiatric facility or behavioral health unit, after completion by the admitting RN/LPN, the DHS or Assistant Director of Health Services (ADHS) will review each resident Admission/Readmission Checklist Form for completion and accuracy. 3. On 10/31/2014, a resident medical record audit was completed by facility RN/LPN staff of resident medical records for 100 percent of active resident physicians' orders to ensure the accurate reconciliation of all physicians' orders. This audit was documented by the signature of each reviewing RN/LPN on the bottom of each resident's physician's orders [REDACTED]. 4. On 12/10/2014, the facility developed and implemented an Admission/Readmission Audit Tool. This Admission/Readmission Audit Tool will be utilized to monitor for resident data metrics which include the resident's name and room number, the date of admission or readmission, the facility from which the resident was transferred (if applicable), and physician order [REDACTED]. This Tool will be completed by an RN or LPN upon resident admission/readmission, and will be utilized to ensure that both the medical and psychiatric needs of residents are met, and to ensure the coordination of care between the medical and psychiatric physicians. One-hundred percent of all Admission/Readmission Audit Tool audits, initially completed by the RN or LPN, regarding residents admitted from psychiatric facilities or behavioral health units will be reviewed by the DHS or ADHS for completion and accuracy. In addition, facility RN and LPN staff will utilize this Admission/Readmission Audit Tool to complete a sampled audit, to be completed monthly, of residents admitted /readmitted to the nursing facility from sources other than psychiatric facilities or behavioral health units. One-hundred percent of these sampled RN/LPN audits will then be reviewed by the DHS or ADHS for completion and accuracy. 5. On 12/10/2014, the facility implemented a procedure by which the results of management-level staff monitoring, completed by the DHS or ADHS via the Admission/Readmission Checklist Form and the Admission-Readmission Audit Tool, of resident admissions/readmissions from both psychiatric facilities and other sources will be submitted to the facility's Performance Improvement (PI) Committee for the Committee's review and analysis. This will allow for the PI Committee's ongoing analysis, via the data collected by this management-level staff monitoring, of direct-care nursing staffs' conformance with facility's Policies and procedures governing resident admissions/readmissions to the facility. This will include PI Committee's monitoring for the presence of the required medical record and resident care information, to include medication therapy, upon resident admission/readmission to the facility. This will also ensure the ongoing oversight and analysis by the facility's PI Committee of facility staffs' conformance with resident admission/readmission Policies and procedures, to therefore ensure the continuity of resident care upon and after residents' admission to the facility. 6. On 12/12/2014, the facility continued the process of staff in-service training, initially begun on 10/23/2014, which involved the training of facility licensed nursing staff regarding the facility's Admission Required Data Policy, the newly implemented procedures involving the use of the Admission/Readmission Checklist Form and the Admission-Readmission Audit Tool, and the procedure involving routine audits of the resident admission/readmission process. On 10/23/2014, specific in-service training was provided to the ADHS and Unit Managers regarding future resident admissions from behavioral health units and/or psychiatric hospitals to ensure both the medical and psychiatric needs were met. Specific instructions were given to these management-level staff, which included the need to pay close attention when admitting any resident from a behavioral unit or psychiatric hospital to ensure that all medical [DIAGNOSES REDACTED]. These management staff members were also instructed to ensure review and approval of all resident medication orders with the physician admitting each resident to the facility's care. Then, beginning on 12/10/2014, staff in-service training was expanded to include all licensed nursing staff related to the newly implemented processes and procedures involving residents admitted /readmitted residents from a psychiatric unit or facility, to include the coordination of care between the psychiatric physician and attending physician, and also admission from other sources. This was to ensure the provision of all medications, as deemed necessary by the physician, and to ensure that all physician's orders [REDACTED]. As of 12/12/2014, staff in-service training had been provided to management-level and direct-care licensed nursing staff, involving the facility's Policies, procedures, and newly-implemented processes involving the use of the Admission/Readmission Checklist Form and Admission-Readmission Audit Tool, to a total of sixty (60) of the facility's sixty-seven (67)licensed nursing staff members. The remaining seven (7) licensed nursing staff members were unavailable for training at that time, due to either being off-duty or on leave. All licensed nursing staff who had not received this in-service training as of 12/12/2014 would receive this in-service training upon their return to work, and no licensed nursing staff member will be allowed to provide direct resident care until having received this in-service training regarding the facility's resident admission/readmission processes. During this standard survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 12/13/2014, a review of facility's Admissions Required Data Policy revealed that this Policy specified the acquisition of resident-specific data required, upon resident admission/readmission to the nursing facility, related to resident care and treatment. Interview with the Administrator conducted on 12/13/2014 at 10:00 a.m. confirmed that the facility had reviewed and analyzed this Admission Required Data Policy on 10/28/2014, in accordance with Step #1 of the CAJR referenced above, after the 10/03/2014 incident involving the medication therapy of Resident #109. - On 12/13/2014, facility document review, and a 10:00 a.m. interview with the Administrator, confirmed that the facility had implemented the use of the Admission/Readmission Checklist Form, in accordance with Step #2 of the CAJR referenced above. It was confirmed that this Admission/Readmission Checklist Form would be utilized by the admitting RN/LPN upon each resident's admission/readmission to ensure all required documentation in each resident medical record, and that this process would have routine management-level audit oversight. - On 12/13/2014, a sampled review of resident records completed on that date, which had been ongoing throughout the standard survey, confirmed that the facility had completed a resident medical record audit to ensure the accurate reconciliation of all physicians' orders. This was in accordance with Step #3 of the CAJR referenced above. - On 12/13/2014, facility document review, and 10:00 a.m. interview with the Administrator, confirmed that on 12/10/2014, the facility had implemented the Admission/Readmission Audit Tool to be used to monitor multiple data metrics upon resident admission/readmission to ensure that medical and psychiatric needs were met and to ensure coordination of care between medical and psychiatric physicians. This process would have routine management-level audits to provide oversight and analysis of direct-care staff conformance. This was as indicated in Step #4 of the CAJR referenced above. - On 12/13/2014, a 10:00 a.m. interview with the Administrator confirmed that the results of all audits, as referenced in the CAJR intended to provide ongoing nursing management-level oversight of the admission/readmission of residents from psychiatric hospitals, behavioral health units, and other facilities, would be reviewed by the facility's PI Committee. This PI Committee review of audit results will allow the PI Committee to provide ongoing analysis and oversight of facility staffs' conformance with the Policies and procedures governing resident admissions and readmissions to the facility, to thus ensure the continuity of resident care. This was in accordance with Step #5 of the CAJR referenced above. - On 12/13/2014, a review of facility staff in-service records confirmed that as of the previous day of 12/12/2014, the facility had provided staff in-service training to management-level and direct-care licensed nursing staff, totaling sixty (60) of the facility's sixty-seven (67) licensed nursing staff, regarding the facility's Policies, procedures, and processes involving the use of the Admission/Readmission Checklist Form and Admission-Readmission Audit Tool. The remaining seven (7) licensed nursing staff members who had not yet received this in-service training would be trained upon their return to work, as indicated in Step #6 of the CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility on 12/12/2014 as outlined in the CAJR referenced above, it was determined that the immediacy of the deficient practice was removed on 12/13/2014; however, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility implemented an Admission/Readmission Checklist Form to be utilized upon the admission/readmission of residents to monitor for the presence of all required data in the medical record of each resident. This Form was to be completed by the admitting RN/LPN within 24 hours of resident admission/readmission from a psychiatric facility or behavioral health unit. Additionally, the facility developed and implemented an Admission/Readmission Audit Tool to be used by the admitting RN/LPN to monitor for resident data metrics to ensure that the medical and psychiatric needs of each resident were met, and to ensure coordination between the medical, psychiatric, and other physicians. The facility had provided staff in-service training to licensed nursing staff regarding the facility's Admission Required Data Policy and newly implemented procedures involving the use of the Admission/Readmission Checklist Form and the the Admission-Readmission Audit Tool. As of 12/12/2014, this in-service training had been provided to a total of sixty (60) of the facility's sixty-seven (67)licensed nursing staff members. However, as of the 12/13/2014 exit date of this survey, the seven (7) licensed nursing staff members who had been off-duty or on leave, and thus unavailable for training, would need to receive this in-service training upon their return to work. Therefore, the facility's completion of in-service training for these remaining licensed nursing staff members related to the newly-implemented procedures involving the acquisition of pertinent resident data upon facility admission/readmission would need further evaluation at a future date. Additionally, on 12/10/2014, the facility implemented a procedure by which the results of management-level nursing staff audits, to be completed by the DHS/ADHS via the Admission/Readmission Checklist Form and the Admission-Readmission Audit Tool, of resident admissions/readmissions would be submitted to the facility's PI Committee for the Committee's review and analysis. However, as of the 12/13/2014 exit date of this survey, the PI Committee had not yet met to begin the process of the review and analysis of management-level staff audits for conformance with facility's resident admission Policies and procedures. Therefore, the PI Committee's ongoing oversight of facility staff conformance with resident admission process regarding the acquiring of all necessary care information, to include physicians' orders for medications and resident care, could not be fully assessed at the time of survey exit, and will need further evaluation at a future date. Based on the above, due to the need for continued evaluation of the facility's corrective action plans to ensure ongoing effectiveness, application, and completion, the noncompliance continues, with the scope and severity reduced to the "D" level.

Based on clinical record review, facility Admissions Required Data Policy review, facility Physician order [REDACTED].org review, attending physician interview, and staff interview, the facility failed to ensure that one (1) resident (#109), who was transferred to this facility from a psychiatric hospital and who had [DIAGNOSES REDACTED]. The total survey sample was thirty-four (34) residents. The facility's failure to ensure a review, with the attending physician of Resident #109's, of the resident's medication therapy she received during the hospital stay directly preceding her nursing facility admission, to thus ensure the continuity of care, resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. Resident #109 had [DIAGNOSES REDACTED]. Resident #109's hospital Patient Transfer Form instructed facility nursing staff to refer to the resident's 10/03/2014 hospital Discharge Medication Reconciliation Report for a list of transfer medications, but there was no evidence to indicate the nursing facility received this Report at the time of Resident #109's transfer, and no evidence of an attempt to obtain the Report. Rather, licensed nursing staff obtained Resident #109's admission physician's orders [REDACTED].#109's transfer medication orders (per the hospital Discharge Medication Reconciliation Report). On 10/22/2014, Resident #109 had multiple [MEDICAL CONDITION] and was transferred to the hospital, where it was discovered she had not been receiving the [MEDICATION NAME] anticonvulsant drug therapy she had received during the hospital stay prior to her 10/03/2014 nursing facility admission, and also that her blood glucose level was significantly elevated at 682 milligrams/deciliter (mg/dL). Resident #109's hospital H&P documented "[DIAGNOSES REDACTED]" and that the resident would receive [MEDICATION NAME] therapy and an insulin drip, and would be admitted into the Intensive Care Unit (ICU). Resident #109's 10/03/2014 hospital Discharge Medication Reconciliation Report was later obtained. This hospital Discharge Medication Reconciliation Report documented that while Resident #109 was in the psychiatric hospital, prior to her 10/03/2014 nursing facility admission, she had received Levetiracetam ([MEDICATION NAME]) for [MEDICAL CONDITION], Humalog Insulin for Diabetes Mellitus (having also received [MEDICATION NAME] while at home), and [MEDICATION NAME], Carvedilol, [MEDICATION NAME], and Aspirin medication therapy, all of which the hospital physician had recommended to continue upon the resident's 10/03/2014 hospital transfer. However, the facility failed to ensure the timely receipt of Resident #109's Hospital Discharge Medication Report, which documented the resident's receipt of these medications while in the hospital, and failed to review the hospital physician's recommendations for continuation of these medications with the attending physician upon the resident's nursing facility admission. The facility's Administrator, Director of Health Services (DHS), and Nurse Consultant were informed of the immediate jeopardy on December 11, 2014 at 1:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on October 22, 2014, the date Resident #109 was transferred to the hospital for [MEDICAL CONDITION] activity after the facility's failure to confirm with the attending physician the resident's 10/03/2014 hospital transfer orders (including [MEDICATION NAME] anticonvulsant and Insulin drug therapies) upon the resident's 10/03/2014 transfer from the hospital to the facility. The immediate jeopardy continued through December 12, 2014, and was removed on December 13, 2014. The facility implemented a Credible Allegation of Jeopardy Removal related to the immediate jeopardy on December 12, 2014. During an interview with the DHS conducted on 12/10/2014 at 2:05 p.m., the DHS acknowledged that handwritten physician's MEDICATION ORDERS FOR [REDACTED]. A Credible Allegation of Jeopardy Removal was received on December 12, 2014. Based on the corrective plans which had been developed and implemented by the facility via this Credible Allegation of Jeopardy Removal on December 12, 2014, the immediacy of the deficient practice was determined to have been removed on December 13, 2014. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued management level staff oversight of resident admission/readmission procedures to ensure the continuity of resident medication therapy. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary resident information, including resident medication therapy, at the time of resident admission/readmission, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about facility Policies and Procedures governing Admission Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including physicians' orders for resident drug therapy, were current and accurate. Findings include: Review of the facility's Policy entitled Admissions Required Data revealed the Policy to specify, in the Procedure Section, that upon a resident's admission to the facility, physician's orders [REDACTED]. This Procedure section also specified that, should the transferring center fail to provide the necessary medical data upon a resident's admission, the Director of Health Services or his/her designee would contact the transferring center and request that such data be made available so that nursing care could be implemented. Review of the facility's Physician order [REDACTED]. This section of the Policy also specified that it was the responsibility of the admitting nurse to reconcile/verify the medication list to the physician's admitting orders, initially via telephone, with the attending physician and to document the physician's decision on the physician's orders [REDACTED]. Record review for Resident #109 revealed an Admission Minimum Data Set (MDS) assessment having an Assessment Reference Date of 10/15/2014 which documented the resident's admission date of [DATE], and documented the resident's Birth Date of August 1938, thus indicating the resident's age as [AGE] years. Section I - Active [DIAGNOSES REDACTED].#109 to have [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented Resident #109 to have a Brief Interview for Mental Status Summary Score of 04, indicating the resident had severe cognitive impairment. A hospital Patient Transfer Form for Resident #109 documented the resident's 10/03/2014 transfer to the nursing facility from the hospital, and documented diagnoses, in the [DIAGNOSES REDACTED]. A hospital Discharge Summary for Resident #109 dated 10/03/2014 documented that, prior to the resident's transfer to the nursing facility on that date, the resident had been admitted to the hospital on [DATE] where she remained until her 10/03/2014 nursing facility transfer and admission. This hospital Discharge Summary documented that while an inpatient in the hospital, Resident #109 had attended both individual and group therapy. This hospital Discharge Summary documented that while in the hospital, Resident #109 had received the antipsychotic medications [MEDICATION NAME] 3 milligrams (mgs) at bedtime and [MEDICATION NAME] 400 mgs at bedtime, and further documented that at the time of hospital discharge, the resident would be discharged on a combination of [MEDICATION NAME] 3 mgs at bedtime, [MEDICATION NAME] 400 mgs at bedtime, the antianxiety medication [MEDICATION NAME] 1 mg on an as-needed basis, and the dementia medication [MEDICATION NAME] Patch 9.5/24 per 24 hours. Further review of Resident #109's nursing facility medical record revealed handwritten physician's medication orders, dated 10/03/2014 and written on hospital prescription forms, specifying that upon Resident #109's transfer from the hospital to the nursing facility, the resident was to receive [MEDICATION NAME] 400 mgs at bedtime, [MEDICATION NAME] 3 mgs at bedtime, [MEDICATION NAME] 1 mg every four (4) hours as needed, and an [MEDICATION NAME] 9.5/24 Patch every 24 hours. A nursing facility admission physician's orders [REDACTED].#109 dated 10/03/2013, handwritten and signed by Licensed Practical Nurse (LPN) "AA", documented that upon the resident's nursing facility admission of that date, physician's orders [REDACTED].#109's 10/03/2014 hospital physician's handwritten transfer MEDICATION ORDERS FOR [REDACTED]. This admission physician's orders [REDACTED].#109 also documented that the resident had [DIAGNOSES REDACTED]. However, further review of Resident #109's nursing facility admission physician's orders [REDACTED]. Further review of Resident #109's hospital Discharge Summary form referenced above for the resident's hospital stay of 09/22/2014 to 10/03/2014 revealed that while this Discharge Summary form referenced the resident's receipt of [MEDICATION NAME] 3 mg and [MEDICATION NAME] 400 mg drug therapy while in the hospital (for which the handwritten physician's orders [REDACTED]. The hospital Discharge Summary form further documented that while in the hospital (prior to nursing facility admission), Resident #109 had received a physician consultation for frequent [MEDICAL CONDITION], and that the physician had addressed these frequent [MEDICAL CONDITION] by adjusting the resident's anticonvulsant medication [MEDICATION NAME]. However, as referenced above, review of Resident #109's nursing facility admission physician's orders [REDACTED]. Record review also revealed no evidence to indicate that LPN "AA" (who transcribed and signed Resident #109's 10/03/2014 admission physician's orders [REDACTED].#109 had [DIAGNOSES REDACTED]. of [MEDICATION NAME] anticonvulsant drug therapy for frequent [MEDICAL CONDITION] during her hospital stay immediately preceding her nursing home admission, to therefore determine the need for continuation or renewal of this drug therapy (per the facility's physician's orders [REDACTED]. During an interview with LPN "AA" conducted on 12/10/2014 at 1:50 p.m., LPN "AA" stated that on 10/03/2014, at the time of Resident #109's admission to the nursing facility from the psychiatric hospital, this nurse had possession of the hospital Discharge Summary, the hospital Patient Transfer Form, and the handwritten transfer physician's medication orders (for [MEDICATION NAME], and [MEDICATION NAME] Patch), all referenced above. LPN "AA" stated that she called Resident #109's physician to let him know the resident was at the facility and to clarify the physician's orders [REDACTED]. However, during a subsequent interview with LPN "AA" conducted on 12/11/2014 at 10:45 a.m., LPN "AA" was specifically asked about the reference on Resident #109's hospital Discharge Summary which indicated that the resident had been receiving the drug [MEDICATION NAME] for [MEDICAL CONDITION] in the hospital immediately prior to her nursing home admission of 10/03/2014. During this interview, when LPN "AA" was asked if she had followed-up with Resident #109's physician to determine the need to continue this [MEDICATION NAME] anticonvulsant drug therapy for the resident after her nursing home admission, LPN "AA" stated that she had not actually read the hospital Discharge Summary form during the process of transcribing Resident #109's physician's orders [REDACTED]. During an interview with the Administrator conducted on 12/10/2014 at 5:11 p.m., the Administrator stated that she would expect a nurse to clarify with a resident's attending physician if a resident had been receiving [MEDICATION NAME] drug therapy that was then not ordered upon facility readmission. Additionally, review of Resident #109's hospital Patient Transfer Form referenced above, which was provided to the nursing facility by the transferring hospital upon the resident's 10/03/2014 transfer to the nursing facility, revealed that the Medications section of this hospital Patient Transfer Form instructed nursing facility staff to "See attached" for a listing of the resident's medications. A handwritten notation located in the Medication Section of this hospital Patient Transfer Form instructed nursing facility staff to "see discharge med rec". However, further review of Resident #109's medical record revealed no evidence of a form or other document by the name of, or with a name similar to, "discharge med rec". During an interview conducted on 12/10/2014 at 1:30 p.m. with Unit Manager Registered Nurse (RN) "CC", RN "CC" stated that upon a resident's admission to the nursing facility, it was the responsibility of the Unit LPN to conduct the resident's admission assessment. RN "CC" stated that at the time of a resident's facility admission from another facility such as a hospital, the nursing facility would receive a list of medications listed on a Discharge Medication Reconciliation form (i.e., a "discharge med rec" form as referenced above) which was obtained from the transferring facility at the time of transfer. However, as indicated above, review of Resident #109's clinical record revealed no evidence of a Discharge Medication Reconciliation form in the resident's record, even though this Discharge Medication Reconciliation form was referenced on the 10/03/2014 hospital Patient Transfer Form, and even though instructions on this hospital Patient Transfer Form instructed nursing facility staff to refer to this Discharge Medication Reconciliation form regarding the resident's medication therapy. Per RN "CC"'s 12/10/2014, 1:30 p.m. interview referenced above, this Discharge Medication Reconciliation form would have listed the medications Resident #109 received while in the hospital, should have been provided to the nursing facility upon the resident's 10/03/2014 transfer to the nursing facility, and was to be reviewed by nursing staff at the time of the resident's facility admission for a review of the drug therapy the resident had been receiving in the hospital. During the 12/10/2014, 1:50 p.m. interview with LPN "AA" referenced above, LPN "AA" had acknowledged that when she transcribed Resident #109's admission physician's orders [REDACTED]. ORDERS FOR [REDACTED]. This nurse did not have a Discharge Medication Reconciliation Form from Resident #109's hospital stay when the resident was admitted to the nursing facility. During an interview with the DHS conducted on 12/10/2014 at 11:10 a.m., the DHS was asked about the Discharge Medication Reconciliation form which was referenced on Resident #109's hospital Patient Transfer Form (referenced above), which listed the drug therapy the resident received prior to nursing home admission, and which was to be reviewed by nursing staff regarding drug therapy at the time of nursing facility admission. The DHS stated that the hospital facility might have sent the Discharge Medication Reconciliation form for Resident #109's hospital stay, prior to her 10/03/2014 nursing facility admission, to another nursing facility via facsimile. During a later interview with the DHS conducted on 12/10/2014 at 2:05 p.m., the DHS was specifically asked if the facility had received the Discharge Medication Reconciliation form for Resident #109, which was referenced on Resident #109's 10/03/2014 hospital Patient Transfer Form, to review the resident's drug therapy upon her 10/03/2014 admission to the nursing facility. The DHS stated that the only information received by the facility regarding Resident #109's drug therapy at the time of her 10/03/2014 transfer from the hospital and nursing facility admission were the four (4) handwritten physician's prescriptions referenced above (for [MEDICATION NAME], and [MEDICATION NAME] Patch). During a subsequent interview with the DHS conducted on 12/10/2014 at 3:30 p.m., the DHS was questioned to determine what information nursing staff had utilized (in the absence of a Discharge Medication Reconciliation form, as specified on the hospital Patient Transfer Form) to therefore review with the attending physician to obtain MEDICATION ORDERS FOR [REDACTED]. The DHS again stated (as she had stated in the 12/10/2014, 2:05 p.m. interview referenced above) that all information regarding drug therapy the facility had received on 10/03/2014, when Resident #109 arrived at the nursing facility from the hospital, were the four (4) handwritten physician's prescriptions for [MEDICATION NAME], and [MEDICATION NAME] Patch. During this interview, the DHS acknowledged that these handwritten medication orders from the hospital were used by the nursing facility nurse as a Medication Reconciliation sheet when Resident #109 was admitted to the nursing facility on 10/03/3014. However, during the 12/10/2014, 2:05 p.m. interview with the DHS referenced above, the DHS had been specifically asked if the handwritten physician's medication orders from the hospital listing only the four (4) medications [MEDICATION NAME], and [MEDICATION NAME] Patch, which were received by the facility on 10/03/2014 upon Resident #109's transfer, were actually considered to be the Discharge Medication Reconciliation Report referenced on the hospital Patient Transfer Form (to be used as a review of the medications Resident #109 received in the hospital prior to nursing facility transfer). The DHS acknowledged that the four (4) handwritten medication orders from the hospital (and which were used by the facility nurse to obtain Resident #109's nursing facility admission drug orders on 10/03/2014) was not the Discharge Medication Reconciliation Report. On 12/10/2014, the DHS then provided a copy of Resident #109's Discharge Medication Reconciliation Report form dated 10/03/2014, the date of the resident's transfer from the psychiatric hospital and admission to the nursing facility. This copy of Resident #109's Discharge Medication Reconciliation Report documented a notation, stamped on the top of the Report, which indicated that this Discharge Medication Reconciliation Report had been provided to the nursing facility from the psychiatric hospital via facsimile on 12/10/2014 (the date, during this standard survey, that the initial inquiry had been made to the DHS regarding the location of this Report). A printed notation on Resident #109's Discharge Medication Reconciliation Report also documented that the Report was completed by the hospital physician. Review of Resident #109's Discharge Medication Reconciliation Report of 10/03/2014 revealed that the Hospital Medications section of the Report documented that while in the hospital (and immediately preceding nursing facility admission on 10/03/2014), Resident #109 had physician's orders [REDACTED]. A notation located in the Action Taken section of Resident #109's hospital Discharge Medication Reconciliation Report, and by each physician's orders [REDACTED]. This was in accordance with Resident #109's subsequent nursing facility admission physician's orders [REDACTED]. feeding tube every four (4) hours as needed, and an [MEDICATION NAME] 9.5 mg/24 hour Patch every 24 hours. Continued review of Resident #109's hospital Discharge Medication Reconciliation Report of 10/03/2014 revealed a physician's orders [REDACTED].#109 had received the anticonvulsant medication Levetiracetam ([MEDICATION NAME]), 750 mgs per feeding tube twice a day. A notation located in the Action Taken section of the Discharge Medication Reconciliation Report indicated "Continue for Home Use" regarding Resident #109's [MEDICATION NAME] anticonvulsant drug therapy. As indicated above, Resident #109's hospital hospital Patient Transfer Form of 10/03/2014 referenced above (which was provided to the nursing facility, and which LPN "AA" had for review at the time of the resident's 10/03/2014 facility admission) specified in the Medications section that nursing facility staff refer to the resident's hospital Discharge Medication Reconciliation Report to review the resident's transfer medication orders (which included [MEDICATION NAME] anticonvulsant drug therapy). But, as also indicated above, review of Resident #109's clinical record revealed no evidence to indicate that the nursing facility received the Discharge Medication Reconciliation Report upon Resident #109's transfer from the psychiatric hospital to the nursing facility on 10/03/2014. Record review also revealed no evidence to indicate that facility nursing staff made any inquiry into obtaining Resident #109's Discharge Medication Report upon the resident's nursing home admission on 10/03/2014, to thereby ensure that the attending physician was made aware of the resident's transfer physicians' orders (which included the continuation of [MEDICATION NAME] anticonvulsant drug therapy), to therefore determine continuation or renewal of this drug therapy (per the facility's physician's orders [REDACTED]. In addition, as referenced above, even though Resident #109's hospital Discharge Summary form noted the resident's receipt of [MEDICATION NAME] for frequent [MEDICAL CONDITION] while in the hospital, and even though LPN "AA" had possession of this hospital Discharge Summary on 10/03/2014 at the time she transcribed Resident #109's admission physician's orders [REDACTED]. physician aware of the resident's receipt of [MEDICATION NAME] anticonvulsant drug therapy for frequent [MEDICAL CONDITION] while in the hospital. Review of Resident #109's clinical record revealed no evidence to indicate that, despite the resident's [DIAGNOSES REDACTED]. There was also no evidence of a physician's orders [REDACTED]. Further review of the 10/03/2014 hospital Discharge Medication Reconciliation Report for Resident #109 revealed physicians' orders, documented in the Hospital Medications section, which indicated that while in the hospital, Resident #109 had physicians' orders for Humalog Insulin at a dose of 14 units subcutaneously before meals, and for Humalog Insulin at a dose of 7 units subcutaneously every night at bedtime. Another physician's orders [REDACTED].#109's Discharge Medication Reconciliation Report indicated that the resident received [MEDICATION NAME] at a dose of 28 units subcutaneously twice a day with meals while in the hospital. Notations located in the Action Taken section of the Discharge Medication Reconciliation Report indicated "Continue for Home Use" regarding Resident #109's Humalog and [MEDICATION NAME] drug therapy. However, as indicated above, review of Resident #109's clinical record revealed no evidence to indicate that the nursing facility received this Discharge Medication Reconciliation Report from the hospital, and no evidence to indicate that facility staff made inquiry into obtaining this Report, to thereby ensure the attending physician was made aware of these transfer physicians' orders (which included orders for Humalog and [MEDICATION NAME]) upon the resident's nursing facility admission, to therefore determine continuation or renewal of this drug therapy (per the facility's physician's orders [REDACTED]. Review of Resident #109's clinical record revealed no evidence to indicate that, despite the resident's [DIAGNOSES REDACTED]. for the continuation of these insulin therapies. There was also no evidence of a physician's orders [REDACTED]. Additional review of Resident #109's 10/03/2014 hospital Discharge Medication Reconciliation Report revealed physicians' orders, documented in the Hospital Medications section, which indicated that while in the hospital, Resident #109 had physicians' orders (in addition to [MEDICATION NAME], Humalog insulin, and [MEDICATION NAME], as referenced above) for the following medications: [REDACTED]. Notations located in the Action Taken section of the Discharge Medication Reconciliation Report indicated "Continue for Home Use" regarding Resident #109's [MEDICATION NAME], Carvedilol, [MEDICATION NAME], and Aspirin medication therapy. However, as indicated above, review of Resident #109's clinical record revealed no evidence to indicate that the nursing facility received the Discharge Medication Reconciliation Report from the hospital, and no evidence to indicate that facility staff made inquiry into obtaining this Report, to thereby ensure the attending physician was made aware of these transfer physicians' orders (which included [MEDICATION NAME], Carvedilol, [MEDICATION NAME], and Aspirin drug therapy) upon nursing facility admission, to therefore determine continuation or renewal (per the facility's physician's orders [REDACTED]. Review of Resident #109's clinical record revealed no evidence to indicate that the attending physician was made aware of the resident having received [MEDICATION NAME], Carvedilol, [MEDICATION NAME], and Aspirin drug therapy in the hospital preceding her 10/03/2014 nursing facility admission. Further review of Resident #109's clinical record revealed that (after her 10/03/2014 facility admission in the absence of any physician consultation regarding orders for [MEDICATION NAME], or any other, anticonvulsant drug therapy, and for Insulin, or any other medication, for Diabetes Mellitus), a NN entry of 10/22/2014 timed at 10:30 a.m. for Resident #109 documented the resident was noted to be having [MEDICAL CONDITION] activity, but further documented that when the nurse checked Resident #109's medical chart, the resident's drug therapy did not reflect any orders for [MEDICAL CONDITION] medication. This NN entry documented that Resident #109's physician was notified and a new order was obtained for the [MEDICAL CONDITION] medication [MEDICATION NAME] 100 mgs, three tablets/capsules per day. This NN also documented that an order for [REDACTED]. However, a later NN entry of 10/22/2014 timed at 12:50 p.m. for Resident #109 documented she continued to have [MEDICAL CONDITION] activity, and a 10/22/2014 NN entry timed at 1:45 p.m. documented that Resident #109 had been noted to have several [MEDICAL CONDITION] that day. This 10/22/2014, 1:45 p.m. NN entry further documented that the period of Resident #109's [MEDICAL CONDITION] kept getting longer, and that the physician was notified and ordered the resident's transport to the hospital emergency room (ER). This NN also documented that Resident #109 left the facility with Emergency Medical Services personnel at 1:45 p.m. for transfer to the hospital. An SBAR Communication Form and Progress Note of 10/22/2014 for Resident #109 documented, in the Situation section, that on that date, Resident #109 had begun having [MEDICAL CONDITION] which started as focal [MEDICAL CONDITION], but the resident then developed jerking along with [MEDICAL CONDITION]. This SBAR Communication Form and Progress Note also documented, in the Assessment or Appearance section, that Resident #109 wa

Based on record review, facility document review, and staff interview, the facility failed to ensure the involvement of the Quality Assessment and Assurance Committee in the formulation of a corrective action plan developed in response to an incident during which facility nursing staff failed to review with the physician all drug therapy of one (1) resident (#109), who had [DIAGNOSES REDACTED]. The total survey sample was thirty-four (34) residents. Resident #109, who had [DIAGNOSES REDACTED]. However, despite Resident #109's Patient Transfer Form referring to the hospital Discharge Medication Reconciliation Report (which documented [MEDICATION NAME] anticonvulsant drug therapy, Insulin, and additional drug therapies) while in the hospital, evidence indicated that physician's medication orders were obtained in the absence of this Report, and in the absence of the physician being made aware of all transfer medication orders (including orders for [MEDICATION NAME] and Insulin). On 10/22/2014, Resident #109 had multiple [MEDICAL CONDITION] and was transferred to the hospital where she was determined to have a blood glucose level of 682 milligrams/deciliter (mg/dL) and an impression of "[DIAGNOSES REDACTED]". Upon hospital admission, Resident #109 was documented to receive [MEDICATION NAME] anticonvulsant and Insulin drug therapies, and also admission to the hospital Intensive Care Unit (ICU). This failure of the facility to ensure a thorough review of Resident #109's medication therapy with the attending physician resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator, Director of Health Services (DHS), and Nurse Consultant were informed of the immediate jeopardy on December 11, 2014 at 1:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on October 22, 2014, the date Resident #109 was transferred to the hospital for [MEDICAL CONDITION] activity after the facility's failure to confirm with the attending physician the resident's 10/03/2014 hospital transfer orders (including [MEDICATION NAME] anticonvulsant and Insulin drug therapies) upon the resident's earlier, 10/03/2014 transfer from the hospital to the facility. The immediate jeopardy continued through December 12, 2014, and was removed on December 13, 2014. The facility implemented a Credible Allegation of Jeopardy Removal related to the immediate jeopardy on December 12, 2014. A Credible Allegation of Jeopardy Removal was received on December 12, 2014. Based on the corrective plans which had been developed and implemented by the facility via this Credible Allegation of Jeopardy Removal on December 12, 2014, the immediacy of the deficient practice was determined to have been removed on December 13, 2014. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued management level staff oversight of resident admission/readmission procedures to ensure the continuity of resident medication therapy. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary resident information, including resident medication therapy, at the time of resident admission/readmission, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about facility Policies and Procedures governing Admission Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including physicians' orders for resident drug therapy, were current and accurate. Findings include: Cross refer to F333. Based on clinical record review, facility document review, hospital document review, and website MayoClinic.org review, attending physician interview, and staff interview, the facility failed to ensure that one (1) resident (#109), who was transferred to this facility from a hospital and who had [DIAGNOSES REDACTED]. The total survey sample was thirty-four (34) residents. Resident #109, who had [DIAGNOSES REDACTED]. The resident's hospital Patient Transfer Form instructed nursing facility staff to refer to the hospital Discharge Medication Reconciliation Report (which documented the resident's receipt of drugs which included [MEDICATION NAME] anticonvulsant and Insulin drug therapies, and additional drug therapies, while in the hospital). There was, however, no evidence to indicate the nursing facility received Resident #109's hospital Discharge Medication Reconciliation Report upon Resident #109's nursing facility transfer, but rather, evidence indicated that the resident's nursing facility physician's medication orders were obtained in the absence of the physician being made aware of all Resident #109's transfer medication orders (including [MEDICATION NAME] and Insulin drug therapies) upon her nursing facility admission. On 10/22/2014, Resident #109 was observed to experience multiple [MEDICAL CONDITION], was transferred to the hospital where she had additional [MEDICAL CONDITION], and was determined to have a significantly elevated blood glucose level of 682 milligrams/deciliter (mg/dL). Resident #109's hospital H&P documented "[DIAGNOSES REDACTED]" and that the resident would receive [MEDICATION NAME] therapy and an insulin drip, and would be admitted into the ICU. During an interview with the Administrator, Nurse Consultant, and Corporate Representative conducted on 12/13/2014 at 10:47 a.m., the facility's Quality Assurance Committee (Performance Improvement (PI) Committee) was discussed with these facility staff. These staff members were specifically asked about the PI Committee's involvement in the facility's analysis of, and response to, the 10/03/2014 incident involving the failure of nursing facility staff to ensure a thorough review with the attending physician of Resident #109's medications upon the resident's transfer to the facility from the hospital. During this interview, the Administrator stated that the PI Committee had not been made aware of the incident involving the omission of a portion of Resident #109's medication therapy, including [MEDICATION NAME] and Insulin, during the resident's facility admission on 10/03/2014. The Administrator stated that a PI Sub-Committee, which consisted of the Administrator, DHS, Administrator-In-Training, and a physician, had been made aware of the incident involving the omission of medications for Resident #109. The Administrator stated that the PI Sub-Committee was made aware of the incident involving Resident #109 on 10/23/2014 (the day after Resident #109's 10/22/2014 hospital transfer due to [MEDICAL CONDITION] activity after having failed to receive [MEDICATION NAME] anticonvulsant drug therapy upon her 10/03/2014 nursing facility admission). The Administrator stated that the PI Sub-Committee met on 10/23/2014, and again on 12/08/2014, to discuss the incident involving the failure of facility nursing staff to ensure a thorough review of transfer medication orders upon Resident #109's 10/03/2014 facility admission, and further stated that it was the PI Sub-Committee that developed the facility's corrective action plan formulated in response to the incident involving the omission of medication orders upon Resident #109's facility admission on 10/03/2014. The Administrator acknowledged that the facility's PI Committee had not been informed of the incident involving Resident #109, and that it was the PI Sub-Committee that formulated the response to this incident. The Administrator could provide no evidence to indicate that the facility's PI Committee had been informed of the 10/03/2014 incident involving the failure of facility nursing staff to ensure Resident #109's physician was informed of all drug therapy, which included [MEDICATION NAME] anticonvulsant and Insulin drug therapy, the resident had received in the hospital immediately preceding her nursing facility admission, and of the hospital physician's instructions to continue this medication therapy. The Administrator could provide no evidence to indicate that the PI Committee had been involved in any review or analysis of the facility's Policies regarding the acquisition of resident care data, including medication orders, upon a resident's facility admission, since the 10/03/2014 incident during which facility staff failed to conduct follow-up to obtain all necessary medical data (a complete medication list) upon Resident #109's admission after hospital transfer. Additionally, the Administrator could provide no evidence of any involvement of the PI Committee in the facility's analysis of the incident involving Resident #109's drug therapy, or of the Committee's involvement in the formulation of the corrective action plan (which included procedural changes involving management-level oversight and audits of the facility's resident admission process). Instead, the Administrator acknowledged that the PI Committee had not been involved in the analysis of the incident involving the omission of Resident #109's medication therapy and the formulation of the corrective action plan developed in response to this incident; rather, a Sub-Committee had conducted analysis and formulated the corrective action plan. The facility presented an acceptable Credible Allegation of Jeopardy Removal (CAJR) on December 12, 2014. Based on this CAJR, it was determined that the immediate jeopardy had been removed on December 13, 2014, at which time the facility had implemented the following interventions: 1. On 10/23/2014, the facility reviewed its Admissions Required Date Policy, which specified the information that was required upon resident admission/readmission to the nursing facility. This Admissions Required Data Policy was found to require that, for residents transferring to the healthcare center, certain data would be obtained by the facility prior to, or upon, the resident's admission. This admission data included: Current physical examination; Admitting [DIAGNOSES REDACTED]. 2. On 10/28/2014, the facility implemented an Admission/Readmission Checklist Form to be utilized upon the admission/readmission of residents to the nursing facility. This Admission/Readmission Checklist Form will be utilized to monitor for the presence of all required documentation in the medical record of each resident admitted , and will be completed by the admitting RN/LPN within twenty-four hours of resident admission/readmission. This Form will monitor for, and document, the presence of specific admission forms and data types including, but not limited to, the following: Admission/Readmission physician's orders [REDACTED].; Laboratory testing orders, per facility Protocol, and the completion of the Master Laboratory Form to ensure laboratory tests are ordered and completed; Fall risk assessment; and Elopement Risk assessment. For residents admitted /readmitted from from a psychiatric facility or behavioral health unit, after completion by the admitting RN/LPN, the DHS or Assistant Director of Health Services (ADHS) will review each resident Admission/Readmission Checklist Form for completion and accuracy. 3. On 10/31/2014, a resident medical record audit was completed by facility RN/LPN staff of resident medical records for 100 percent of active resident physicians' orders to ensure the accurate reconciliation of all physicians' orders. This audit was documented by the signature of each reviewing RN/LPN on the bottom of each resident's physician's orders [REDACTED]. 4. On 12/10/2014, the facility developed and implemented an Admission/Readmission Audit Tool. This Admission/Readmission Audit Tool will be utilized to monitor for resident data metrics which include the resident's name and room number, the date of admission or readmission, the facility from which the resident was transferred (if applicable), and physician order [REDACTED]. This Tool will be completed by an RN or LPN upon resident admission/readmission, and will be utilized to ensure that both the medical and psychiatric needs of residents are met, and to ensure the coordination of care between the medical and psychiatric physicians. One-hundred percent of all Admission/Readmission Audit Tool audits, initially completed by the RN or LPN, regarding residents admitted from psychiatric facilities or behavioral health units will be reviewed by the DHS or ADHS for completion and accuracy. In addition, facility RN and LPN staff will utilize this Admission/Readmission Audit Tool to complete a sampled audit, to be completed monthly, of residents admitted /readmitted to the nursing facility from sources other than psychiatric facilities or behavioral health units. One-hundred percent of these sampled RN/LPN audits will then be reviewed by the DHS or ADHS for completion and accuracy. 5. On 12/10/2014, the facility implemented a procedure by which the results of management-level staff monitoring, completed by the DHS or ADHS via the Admission/Readmission Checklist Form and the Admission-Readmission Audit Tool, of resident admissions/readmissions from both psychiatric facilities and other sources will be submitted to the facility's Performance Improvement (PI) Committee for the Committee's review and analysis. This will allow for the PI Committee's ongoing analysis, via the data collected by this management-level staff monitoring, of direct-care nursing staffs' conformance with facility's Policies and procedures governing resident admissions/readmissions to the facility. This will include PI Committee's monitoring for the presence of the required medical record and resident care information, to include medication therapy, upon resident admission/readmission to the facility. This will also ensure the ongoing oversight and analysis by the facility's PI Committee of facility staffs' conformance with resident admission/readmission Policies and procedures, to therefore ensure the continuity of resident care upon and after residents' admission to the facility. 6. On 12/12/2014, the facility continued the process of staff in-service training, initially begun on 10/23/2014, which involved the training of facility licensed nursing staff regarding the facility's Admission Required Data Policy, the newly implemented procedures involving the use of the Admission/Readmission Checklist Form and the Admission-Readmission Audit Tool, and the procedure involving routine audits of the resident admission/readmission process. On 10/23/2014, specific in-service training was provided to the ADHS and Unit Managers regarding future resident admissions from behavioral health units and/or psychiatric hospitals to ensure both the medical and psychiatric needs were met. Specific instructions were given to these management-level staff, which included the need to pay close attention when admitting any resident from a behavioral unit or psychiatric hospital to ensure that all medical [DIAGNOSES REDACTED]. These management staff members were also instructed to ensure review and approval of all resident medication orders with the physician admitting each resident to the facility's care. Then, beginning on 12/10/2014, staff in-service training was expanded to include all licensed nursing staff related to the newly implemented processes and procedures involving residents admitted /readmitted residents from a psychiatric unit or facility, to include the coordination of care between the psychiatric physician and attending physician, and also admission from other sources. This was to ensure the provision of all medications, as deemed necessary by the physician, and to ensure that all physician's orders [REDACTED]. As of 12/12/2014, staff in-service training had been provided to management-level and direct-care licensed nursing staff, involving the facility's Policies, procedures, and newly-implemented processes involving the use of the Admission/Readmission Checklist Form and Admission-Readmission Audit Tool, to a total of sixty (60) of the facility's sixty-seven (67)licensed nursing staff members. The remaining seven (7) licensed nursing staff members were unavailable for training at that time, due to either being off-duty or on leave. All licensed nursing staff who had not received this in-service training as of 12/12/2014 would receive this in-service training upon their return to work, and no licensed nursing staff member will be allowed to provide direct resident care until having received this in-service training regarding the facility's resident admission/readmission processes. During this standard survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 12/13/2014, a review of facility's Admissions Required Data Policy revealed that this Policy specified the acquisition of resident-specific data required, upon resident admission/readmission to the nursing facility, related to resident care and treatment. Interview with the Administrator conducted on 12/13/2014 at 10:00 a.m. confirmed that the facility had reviewed and analyzed this Admission Required Data Policy on 10/28/2014, in accordance with Step #1 of the CAJR referenced above, after the 10/03/2014 incident involving the medication therapy of Resident #109. - On 12/13/2014, facility document review, and a 10:00 a.m. interview with the Administrator, confirmed that the facility had implemented the use of the Admission/Readmission Checklist Form, in accordance with Step #2 of the CAJR referenced above. It was confirmed that this Admission/Readmission Checklist Form would be utilized by the admitting RN/LPN upon each resident's admission/readmission to ensure all required documentation in each resident medical record, and that this process would have routine management-level audit oversight. - On 12/13/2014, a sampled review of resident records completed on that date, which had been ongoing throughout the standard survey, confirmed that the facility had completed a resident medical record audit to ensure the accurate reconciliation of all physicians' orders. This was in accordance with Step #3 of the CAJR referenced above. - On 12/13/2014, facility document review, and 10:00 a.m. interview with the Administrator, confirmed that on 12/10/2014, the facility had implemented the Admission/Readmission Audit Tool to be used to monitor multiple data metrics upon resident admission/readmission to ensure that medical and psychiatric needs were met and to ensure coordination of care between medical and psychiatric physicians. This process would have routine management-level audits to provide oversight and analysis of direct-care staff conformance. This was as indicated in Step #4 of the CAJR referenced above. - On 12/13/2014, a 10:00 a.m. interview with the Administrator confirmed that the results of all audits, as referenced in the CAJR intended to provide ongoing nursing management-level oversight of the admission/readmission of residents from psychiatric hospitals, behavioral health units, and other facilities, would be reviewed by the facility's PI Committee. This PI Committee review of audit results will allow the PI Committee to provide ongoing analysis and oversight of facility staffs' conformance with the Policies and procedures governing resident admissions and readmissions to the facility, to thus ensure the continuity of resident care. This was in accordance with Step #5 of the CAJR referenced above. - On 12/13/2014, a review of facility staff in-service records confirmed that as of the previous day of 12/12/2014, the facility had provided staff in-service training to management-level and direct-care licensed nursing staff, totaling sixty (60) of the facility's sixty-seven (67) licensed nursing staff, regarding the facility's Policies, procedures, and processes involving the use of the Admission/Readmission Checklist Form and Admission-Readmission Audit Tool. The remaining seven (7) licensed nursing staff members who had not yet received this in-service training would be trained upon their return to work, as indicated in Step #6 of the CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility on 12/12/2014 as outlined in the CAJR referenced above, it was determined that the immediacy of the deficient practice was removed on 12/13/2014; however, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility implemented an Admission/Readmission Checklist Form to be utilized upon the admission/readmission of residents to monitor for the presence of all required data in the medical record of each resident. This Form was to be completed by the admitting RN/LPN within 24 hours of resident admission/readmission from a psychiatric facility or behavioral health unit. Additionally, the facility developed and implemented an Admission/Readmission Audit Tool to be used by the admitting RN/LPN to monitor for resident data metrics to ensure that the medical and psychiatric needs of each resident were met, and to ensure coordination between the medical, psychiatric, and other physicians. The facility had provided staff in-service training to licensed nursing staff regarding the facility's Admission Required Data Policy and newly implemented procedures involving the use of the Admission/Readmission Checklist Form and the the Admission-Readmission Audit Tool. As of 12/12/2014, this in-service training had been provided to a total of sixty (60) of the facility's sixty-seven (67) licensed nursing staff members. However, as of the 12/13/2014 exit date of this survey, the seven (7) licensed nursing staff members who had been off-duty or on leave, and thus unavailable for training, would need to receive this in-service training upon their return to work. Therefore, the facility's completion of in-service training for these remaining licensed nursing staff members related to the newly-implemented procedures involving the acquisition of pertinent resident data upon facility admission/readmission would need further evaluation at a future date. Additionally, on 12/10/2014, the facility implemented a procedure by which the results of management-level nursing staff audits, to be completed by the DHS/ADHS via the Admission/Readmission Checklist Form and the Admission-Readmission Audit Tool, of resident admissions/readmissions would be submitted to the facility's PI Committee for the Committee's review and analysis. However, as of the 12/13/2014 exit date of this survey, the PI Committee had not yet met to begin the process of the review and analysis of management-level staff audits for conformance with facility's resident admission Policies and procedures. Therefore, the PI Committee's ongoing oversight of facility staff conformance with resident admission process regarding the acquiring of all necessary care information, to include physicians' orders for medications and resident care, could not be fully assessed at the time of survey exit, and will need further evaluation at a future date. Based on the above, due to the need for continued evaluation of the facility's corrective action plans to ensure ongoing effectiveness, application, and completion, the noncompliance continues, with the scope and severity reduced to the "D" level.