Every finding on record at Ramseur Rehabilitation and Healthcare Center

Based on record review, and staff and Physician interviews, the facility failed to notify the Physician when a STAT (immediately or urgently) x-ray was not completed as ordered for a resident that had right hip pain after a fall on 2/22/25. The order for the x-ray was called to the mobile x-ray provider the evening of 2/22/25. The nurse assigned to the resident on 2/23/25 contacted the mobile x-ray provider to follow up about the STAT x-ray order around 5:00 PM but did not notify the Physician the STAT x-ray had not been completed. Another nurse contacted the mobile x-ray provider on 2/24/25 and the x-ray was completed that afternoon and noted Resident #90 had a displaced right femoral neck fracture (a break in the upper part of the femur [thigh bone],near the hip joint, where broken bone fragments have moved out of their normal alignment). The lack of notification resulted in a delay of an evaluation at the hospital for stabilization or surgery for the fracture until 2/24/25. The deficient practice occurred for 1 of 4 residents reviewed for notification of changes (Resident #90).Findings included:Resident #90 was admitted to the facility on [DATE] with diagnoses that included dementia, hypertension and protein calorie malnutrition.Resident #90's admission Minimum Data Set (MDS) dated revealed he had cognitive impairment.A review of Resident #90's fall report dated 02/22/25 read in part, Resident was ambulating unassisted and lost his balance and fell landing on their right side, range of motion completed and movement of extremities without difficulty. The report read further Resident complained of (c/o) right hip pain.A review of Nurse #1's progress note dated 02/22/25 read in part, Nurse Practitioner (NP) notified at 10:24pm. Received new order for x-ray 2 view right hip STAT x-ray order through mobile company at 10:30pm.On 07/30/25 at 1:39 pm an interview was conducted with Nurse #1 (worked 7p-7a on 02/22/25) and she indicated Resident #90 had a fall on 02/22/25 that was witnessed. She indicated, Resident complained by moaning of right hip pain, however he was able to move all extremities without difficulty, and when she called the NP, she received an order to do a STAT x-ray of right hip. Nurse #1 stated, I did report off to oncoming nurse of fall, pain in his hip, and not getting the x-ray, and called the x-ray company with the order. Nurse #1 indicated the portable/mobile x-ray company did not come during her shift. A review of Nurse #2's progress noted dated 02/23/25 read in part, Resident status post (S/P) fall with no injures, c/o right hip area pain, awaiting on portable x-ray for 2 view x-rays of right hip area, in bed resting with eyes closed, respirations even with no distress noted, continue to monitor.An interview was conducted with Nurse #2 (worked 7a-7p shift on 02/23/25) on 07/29/25 at 3:28 pm. Nurse #2 indicated the 3rd shift nurse had called the portable/mobile x-ray company on the night of 02/22/25. She indicated she had contacted the portable/mobile company for the x-ray on 02/23/24 around 5 pm because they had not arrived and the representative that she spoke with stated the dispatcher would call her back to give the time they would arrive to perform the x-ray. Nurse #2 reported she was not aware the order for the x-ray was STAT and did not receive a return call from the portable/mobile x-ray company. Nurse #2 indicated she did not notify the Physician/NP that the STAT order had not been performed as she was waiting for a return call from the dispatcher from the portable/mobile company. A review of Nurse #3's progress note dated 02/24/25 read in part. Resident has been in bed this am resting, and staff went to get him out of bed (OOB) he grimaced with pain. The writer spoke with portable/mobile about stat x-ray, and they stated it depends on quality and severity of STAT x-ray, and they will continue to reschedule. She informed me of estimated time of arrival (ETA) time today is between 1-3 pm. Resident was administered acetaminophen for pain and discomfort. Staff will continue to monitor.A review of the radiology results report dated 02/24/25 revealed findings as follows: fracture of the right femoral neck (right hip bone) with displacement of the distal fragment. Femoral head appropriately positioned Conclusion: acute, displaced right femoral neck fracture as noted.On 07/30/25 at 1:07 pm an interview was conducted with Nurse #3 (worked 02/24/25 7a-7p shift) and she indicated Resident #90's x-ray had not been performed and she called the portable/mobile x-ray company to see why it had not been done. She stated the x-ray representative she spoke with indicated they would be out that day to perform the x-ray. Nurse #3 indicated the portable/mobile x-ray company arrived around 2:30 pm and performed the x-ray and it was revealed Resident had a fracture to his right hip. She stated she called and informed the Nurse Practitioner and received orders to send Resident out to the hospital due to the x-ray results. Nurse #3 stated she also informed the Residents' responsible party of x-ray results and the order to send him to the hospital.An interview was conducted with a Representative from the portable/mobile x-ray company on 07/31/25 at 9:54 am and she indicated the turn around time for a STAT x-ray was 4 to 6 hours from the time the order was received and the x-ray technician was on site. The Representative indicated a x-ray technician was unable to get in the door of facility early in the morning on 02/23/25 due to it being locked and no one answered the phone when the x-ray technician called the facility. She indicated they implemented a protocol to use back up numbers to reach facility staff if unable to get into the facility.An interview was conducted with the Director of Nursing (DON) on 07/20/25 at 1:26 pm and she indicated on 02/24/25 she was informed Resident #90 had a fall on 02/22/25 and had orders for an x-ray to be performed due to right hip pain. She stated she was informed by Nurse #3 the x-ray had not been performed, and they would be coming out that day to do the x-ray. The DON indicated the NP was in the facility and evaluated the Resident and according to the NP the Resident wasn't in any distress at the present time and did not present with any pain when she evaluated him and that it would be ok to wait for the portable/mobile x-ray to come. She stated the protocol now was anybody that had a fall with pain would be sent to the hospital. The DON also stated she called the portable/mobile company and spoke with the director, and a plan was implemented going forward.An interview was conducted with the Physician on 07/3/25 at 9:01 am and he indicated the NP evaluated Resident #90 on 02/24/25 and he was not experiencing pain at that time. The Physician indicated the staff provided the appropriate care for the Resident. He stated, He had chronic diseases, osteoporosis, which is a bone disease that could cause problem with fractures. The physician indicated communication would have been good as far as the x-ray not being performed STAT. He stated, in my opinion it was no delay in care, I was ok with the care the staff provided.The facility provided the following corrective action plan:1. Adress how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 2/24/2025 facility identified that a Stat X-Ray for Resident #90 was not completed, and the facility failed to notify the physician/nurse practitioner of delay in X-Ray services. The facility failed to notify the MD/NP of delay in X-Ray services until 2/24/2025. Resident #90 discharged from the facility on 2/24/25. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.All residents with falls have the potential to be affected. Per policy all residents that fall require MD/NP notification: On 2/24/2025 all nursing staff, including Certified Nursing Assistants and Licensed Nurses that had been scheduled on 2/22/2025 from 7pm-7am were interviewed, by the Director of Nursing, concerning any changes in condition for residents during the shift needing provider notifications or updates of previously identified changes of condition to the provider. No concerns beyond Resident #1 were identified. On 2/24/2025 the Director of Nursing reviewed the 24-hour reports/Progress notes for the last 30 days for all current residents with falls to ensure the physician/nurse practitioner were notified of all falls and notified of any delay in obtaining X Rays. No concerns were identified. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 2/24/2025 the Director of Nursing educated the Licensed Nurses, including agency Licensed Nurses on falls management program, process change for stat x-ray orders, including sending residents to the Emergency Department if needing a stat x-ray/change in condition/pain after a fall, notification of physician/nurse practitioner for any falls, delay in treatment/services from outside vendors. This education was completed on 2/25/2025. Any nursing staff that were not educated will receive this education prior to their next shift, from the Director of Nursing. This education will be added to the facility orientation program for licensed nurses, including new agency staff and will be the responsibility of the Director of Nursing/Assistant Director of Nursing or Nurse Manager.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Quality assurance performance improvement (QAPI) committee met on 02/25/2025 to determine need for monitoring.Beginning 2/26/2025 The Director of Nursing/Designee will review the 24-hour report 5 times a week, including all 7 days of the week, for 12 weeks to ensure provider notification of changes in condition and ensure the provider receives updates if diagnostic/laboratory testing had not been obtained per order.Beginning 3/1/2025 on the weekends, the charge nurse was assigned to contact the Director of Nursing or On-call nursing manager that includes the unit manager, Assistant Director of Nursing and Wound Care Nurse in addition to notifying the provider of any delays in X-Ray Services, diagnostic or laboratory testing.Beginning 2/28/2025, the Director of Nursing, Administrator, Nurse Practitioner and Medical Director will have weekly meetings to ensure that the providers have been updated timely. Alleged date of compliance: 2/26/25. An onsite validation of the facility's Corrective Action Plan was completed on 7/31/25. Reviewed education dated 2/24/25 through 2/25/25 of Licensed Nurses on falls management program, process change for stat x-ray orders, including sending residents to the emergency department if needing a stat x-ray/change in condition/pain after a fall, notification of physician/nurse practitioner for any falls, delay in treatment/services from outside vendors. Reviewed Inservice sign-in sheets with staff signage with dates of 2/24/25 through 2/25/25 and staff were found to be trained. Reviewed audit sheets for weeks 1-12 with dates 2/24/25 through 5/16/25 and no concerns were identified. Resident #90 was discharged to hospital on 2/22/25. Reviewed notification for 3 sampled residents and no concerns were identified. Staff interviewed were able to verbalize education training provided in reference to residents with process change for stat x-ray orders, including sending residents to the emergency department if needing a stat x-ray/change in condition/pain after a fall, notification of physician/nurse practitioner for any falls, delay in treatment/services from outside vendors.The corrective action plan's compliance date of 2/26/25 was validated.

Based on observation, record review, and staff and Physician interviews, the facility failed to provide immediate medical evaluation and treatment when Resident #90 fell and complained of right hip pain on 2/22/25. Nurse #1 notified the Nurse Practitioner and received an order for a STAT (immediately or urgently) of the right hip on 2/22/25. The x-ray was not completed until 2/24/25 and the results revealed a displaced right femoral neck fracture (a break in the upper part of the femur [thigh bone], near the hip joint, where the broken bone fragments have moved out of their normal alignment). In addition, nurses failed to document thorough ongoing assessments of the resident's condition and staff continued to turn and reposition the resident in the bed which was painful for the resident. Resident #90 was sent to the hospital for an evaluation on 2/24/25 and x-rays confirmed the displaced right femoral neck fracture. Initially the Orthopedic surgeon considered operating on Resident #90 but then further evaluating determined Resident #90 was a very high risk for surgery and would not do well postoperatively due to his significantly worsening dementia, severe protein calorie malnutrition, and already having frequent falls. After having long conversation with the family member hospice was consulted and Resident #90 was transferred to hospice services from the hospital on 2/27/25. The deficient practice occurred for 1 of 4 residents reviewed for falls (Resident #90). Findings included:Resident #90 was admitted to the facility on [DATE] with diagnoses that included dementia, hypertension and protein calorie malnutrition.Resident #90's admission Minimum Data Set (MDS) dated revealed he had severe cognitive impairment and needed partial/moderate assistance with eating, substantial/maximum assistance with toileting hygiene assistance, shower/bath, personal hygiene, substantial/maximum assistance to dependent assistance with transfers, dependent with walking, and supervision/touching assistance with bed mobility. A review of Resident #90's care plan last revised 02/20/25 revealed Resident was at risk for falls. The goal was Resident would be free from falls and free of minor injuries. The Interventions read in part, Resident would be kept in areas of observation while awake, anticipate and meet the Resident's needs, prompt response to requests for assistance, nonskid strips to be applied to left side of bed on floor, keep bed in lowest position, staff to offer toileting assistance during periods of restlessness, offer toileting prior to meals and bedtime, ensure proper footwear (nonskid socks/shoes) in place while awake, anti-rollbacks to wheelchair, bariatric bed with bolster, dycem (non-slip material) to wheelchair, provide diversional activities during periods of restlessness. A review of Resident #90's fall report dated 02/22/25 read in part, Resident was ambulating unassisted and lost his balance and fell landing on their right side, range of motion completed and movement of extremities without difficulty. The report read further residents complained of (c/o) right hip pain. A review of Nurse #1's progress note dated 02/22/25 at 10:40 pm read in part, Resident noted on the floor laying on his right side at 10:00pm. Fall was witnessed. Resident was noted ambulating unassisted and lost his balance and fell landing on his right side. The Resident did not hit his head. The Resident assisted off the floor x 2 staff. Resident c/o right hip pain. Temperature 97.3, respiration 18, blood pressure 144/94, pulse 60, oxygen saturation 94% on room air. Resident assisted to bed x 2 staff. As needed (PRN) acetaminophen administered 325 milligrams (mg) x 2 tablets administered for pain. Nurse Practitioner notified at 10:24pm. Received new order for X-ray 2 view right hip STAT. X-ray order through mobile company at 10:30 pm. Resident responsible party notified at 10:35 pm. No signs or symptoms (s/s) of acute distress noted. Will continue to monitor. Call light within reach. A review of Nurse #1's progress note dated 02/23/2025 at 4:58 am read in part, Resident status post (s/p) witnessed fall. No pain or discomfort. No apparent injuries noted. Able to move all extremities without any difficulty. Will continue to monitor.On 07/30/25 at 1:39 pm an interview was conducted with Nurse #1 (worked 7:00 pm to 7:00 am on 02/22/25) and she indicated Resident #90 had a fall on 02/22/25 that was witnessed. She indicated, Resident complained by moaning of right hip pain, however he was able to move all extremities without difficulty, and she administered acetaminophen as ordered for the pain in right hip after the fall. Nurse #1 indicated she called the NP and received an order to do a STAT x-ray of right hip. Nurse #1 stated, I did report off to oncoming nurse of fall, pain in his hip, and not getting the x-ray, and called the x-ray company with the order. Nurse #1 indicated the portable/mobile x-ray company did not come during her shift. Unable to contact Nursing Assistant #3 (NA) (worked 02/22/25 7p-7a).A review of the electronic medication administration record (EMAR) revealed Resident #90 received acetaminophen tablet 325 mg 2 tablets by mouth for s/s of pain/discomfort to right hip/leg on 2/23/2025 at 8:10 am.A review of Nurse #2's progress noted dated 02/23/25 at 10:13 am read in part, Resident status post (s/p) fall with no injuries, c/o right hip area pain, awaiting on portable x-ray for 2 view x-rays of right hip area, in bed resting with eyes closed, respirations even with no distress noted, continue to monitor.A review of the EMAR revealed Resident #90 received acetaminophen tablet 325 mg 2 tablets by mouth for mild pain: s/s of pain to right hip/leg on 02/23/25 at 5:30 pm.An interview was conducted with Nursing Assistant #1 (NA) (worked 02/23/25 7a-7pm) on 07/30/25 at 10:16 am. She indicated she provided activities of daily living (ADL) care with Nurse #2 on Resident #90 and he exhibited some pain during movement. She indicated Resident stayed in bed and rested quietly during the shift. An interview was conducted with Nurse #2 (worked 7:00 am to 7:00 pm shift on 02/23/25) on 07/29/25 at 3:28 pm. She indicated Resident #90 exhibited pain only when he was moved in bed and she administered pain medication as ordered. She stated he was able to move his extremities and there was no bruising, rotation or shortening of right leg. Nurse #2 indicated the 3rd shift nurse had called the x-ray company on the night of 02/22/25. She indicated she had contacted the portable/mobile company for the x-ray around 5:00 pm because they had not arrived and the representative that she spoke with stated the dispatcher would call her back to give time they would arrive to perform the x-ray. Nurse #2 stated she was not aware that the order for the x-ray was STAT. Nurse #2 indicated Resident did not get out of bed during the shift. A review of the EMAR revealed Resident #90 received acetaminophen tablet 325 mg by mouth for mild pain on 02/24/25 at 6:38 am.A review of Nurse #3's progress note dated 02/24/25 at 1:17 pm read in part, Resident has been in bed this am resting, and staff went to get him out of bed (OOB) he grimaced with pain. The writer spoke with portable/mobile about stat x-ray, and they stated it depends on quality and severity of STAT x-ray, and they will continue to reschedule. She informed me of estimated time of arrival (ETA) time today is between 1:00 and 3:00 pm. Resident was administered acetaminophen for pain and discomfort. Staff will continue to monitor. A review of the EMAR revealed Resident #90 received acetaminophen tablet 325 mg 2 tablets by mouth for mild pain noted for grimacing upon movement on 02/24/25 at 1:24 pm.An interview was conducted with NA #2 (worked 7:00 am to 7:00 pm on 02/24/25) on 07/30/25 at 10:42 am. She indicated she as assigned to Resident #90 on 2/24/25 and when she provided ADL care to the resident he exhibited pain in his right leg when she would turned him. NA # indicated Resident would moan when turned and repositioned. She indicated she did not attempt to get the Resident out of bed because they were waiting for the x-ray company to come to x-ray his right leg due to the fall on 02/22/25.On 07/30/25 at 1:07 pm an interview was conducted with Nurse #3 (worked 02/24/25 on the 7:00 am to 7:00 pm shift) and she indicated she had assessed Resident # 90, and he did not appear to be in pain except during movement of his right leg. She stated Resident #90's x-ray had not been performed and she called the portable/mobile x-ray company to see why it had not been done. She stated the x-ray representative she spoke with indicated they would be out to perform the x-ray that day between 1:00 and 3:00 pm. Nurse #3 indicated the portable/mobile x-ray company arrived around 2:30 pm and performed the x-ray and it was revealed Resident had a fracture of his right hip. She stated she called and informed the Nurse Practitioner and received orders to send Resident out to the hospital due to the x-ray results. Nurse #3 stated she also informed the Residents' responsible party of x-ray results and the order to send him to the hospital. Nurse #3 indicated Resident did not get out of bed during the shift until he transferred to the hospital.A review of the Nurse Practitioner note dated 02/24/25 read in part, Resident seen for recent fall with injury. He was saw ambulating in the hallway when he fell and landed on his right side. He did not hit his heard. x-ray of the right hip was ordered 02/22/25. Comorbidities: hypertension (HTN), dementia, physical deconditioning. Resident was sitting comfortably in no acute distress. Due to impaired cognition, resident is unreliable historian; information obtained through chart review and discussion of clinical staff. No complaints of pain or discomfort. No chest pain, shortness of breath, palpitations, cough. No other cardiopulmonary, gastrointestinal (GI), genitourinary (GU) signs or symptoms. Normal appetite, sleep, bowel and bladder functions. Musculoskeletal: no joint deformity, swelling, redness, pain, muscle weakness.Unable to contact Nurse Practitioner due to family medical leave.A review of the radiology results report dated 02/24/25 revealed findings as follows: fracture of the right femoral neck (right hip bone) with displacement of the distal fragment. Femoral head appropriately positioned. Conclusion: acute, displaced right femoral neck fracture as noted. A review of the emergency department (ED) report dated 02/24/25 read in part, Patient sent from rehabilitation facility with concerns for a broken hip. Patient slipped and fell landing on the right side, 2 days ago, since then he has not been bearing weight. Today the facility x-rayed and claimed the hip is broken. Patient has advanced dementia and provides no history. Further review of ED report read in part, Exam of extremities: internal rotation of the right hip with noted deformity in the right foot, leg shortened on right side, calves are non-tender to palpation. A review of hospital history and physical dated 02/24/25 read in part, Physical exam of musculoskeletal (muscles, bones, tendons, ligaments, joints, and cartilage): right hip painful to movement. Further review of hospital report read in part, Assessment and Plan (A/P): closed acute right hip fracture (a bone break with skin intact) from mechanical fall. Orthopedic surgery consulted, initially Orthopedic was thinking of operating on patient but then further evaluating the case it was felt patient is very high risk for surgery and will not do well postoperatively due to his significantly worsening dementia, severe protein calorie malnutrition, already having frequent falls. After having long conversation with family member hospice consulted.An interview was conducted with a Representative from the portable/mobile x-ray company on 07/31/25 at 9:54 am and she indicated the turn around time for a STAT x-ray was 4 to 6 hours from the time the order was received and the x-ray technician was on site. The Representative indicated a x-ray technician was unable to get in the door of facility early in the morning on 02/23/25 due to it being locked and no one answered the phone when the x-ray technician called the facility. She indicated they implemented a protocol to use back up numbers to reach facility staff if unable to get into the facility.An interview was conducted with the Director of Nursing (DON) on 7/31/25 at 1:26 pm and she indicated on 02/24/25 she was informed Resident #90 had a fall on 02/22/25 and had orders for a x-ray to be performed due to right hip pain. She stated she was informed by Nurse #3 the x-ray had not been performed, and they would be coming out on that day to do the x-ray. The DON indicated the NP was in the facility and evaluated the Resident and according to the NP the Resident wasn't in any distress at the present time and did not present with any pain when she evaluated him and that it would be ok to wait for the portable/mobile x-ray to come. She stated the protocol now was anybody that had a fall with pain would be sent to the hospital. The DON also stated she called the portable/mobile company and spoke with the director, and a plan was implemented going forward.An interview was conducted with the Physician on 07/31/25 at 9:01 am and he indicated the NP evaluated Resident #90 on 02/24/25 and he was not experiencing pain at that time. The Physician indicated the staff provided the appropriate care for the Resident. He stated, He had chronic diseases, osteoporosis, which is a bone disease that could cause problem with fractures. He stated, communication would have been good as far as the x-ray not being performed STAT. The Physician also stated, in my opinion it was no delay in care, I was ok with the care the staff provided. The facility provided a corrective action plan that was not approved due to not including audits or monitoring.

Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments for 2 of 23 residents reviewed for MDS accuracy (Resident #8 and Resident #14).The findings included: a. Resident #8 was admitted to the facility 11/2/2024 with diagnoses including schizoaffective disorder, bipolar type. Review of the physician orders for Resident #8 included an order dated 12/31/24 Haloperidol (an antipsychotic medication) 100 milligrams (mg) to be administered intramuscularly (injection into the muscle) one time per month. Review of the medication administration record revealed Resident #8 received Haloperidol in June and July 2025. The quarterly MDS assessment dated [DATE] documented Resident #8 did not take antipsychotic medications. b. Resident #14 was admitted to the facility 10/30/24 with diagnoses including obesity. Review of the physician orders for Resident #14 included an order dated 3/14/25 for semaglutide (a medication used to facilitate weight loss) weekly subcutaneously (into the fatty tissue). This order was modified on 6/9/25 to administer 1 mg every Monday for weight loss. Review of the medication administration record revealed Resident #14 received the semaglutide injection every Monday in June and July 2025 as ordered. The quarterly MDS dated [DATE] documented Resident #14 received 1 injection of insulin in the 7-day look-back period. Review of the physician orders for Resident #14 revealed no orders for insulin. The MDS coordinator (MDS Nurse #1) was interviewed on 7/30/25 at 2:29 PM. MDS Nurse #1 reviewed the assessments for Resident #8 and Resident #14 and agreed that Resident #8 should have been coded for antipsychotic medications, and Resident #14 should not have been coded for insulin. MDS Nurse #1 reported that MDS Nurse #2 had completed those assessments for Resident #8 and Resident #14. An attempt was made to interview MDS Nurse #2, but no response was received from voice messages or text messages sent. The Administrator was interviewed on 7/30/25 at 2:40 PM and she reported she did not know why the MDS for Resident #8 and Resident #14 were coded incorrectly, and she expected all MDS assessments to be accurate.

Based on record review, observations, and staff and Medical Director interviews the facility failed to implement the following components of the abuse policy: (a) immediately report an allegation of sexual abuse of a severely cognitively impaired female resident (Resident #7) by a moderately cognitively impaired male resident (Resident #39) to the Administrator; (b) the facility failed to provide a physical examination of a severely cognitively impaired female resident (Resident #7) by a trained/licensed professional for signs of sexual abuse; (c) the facility failed to protect a severely cognitively impaired female resident (Resident #7) and all other residents from the possibility of sexual abuse when they failed to put Resident #39 on one-to-one observations when there was an allegation of sexual abuse against Resident #7; (d) the facility failed to assess all other residents in the facility when an allegation of sexual abuse was reported; and (e) the facility failed to report the allegation of abuse to the Adult Protective Services. This deficient practice affected 1 of 3 residents (Resident #7) investigated for allegations of abuse and had the high likelihood of affecting other vulnerable residents residing in the facility. Immediate jeopardy began on 5/2/2024, when the facility failed to immediately report an allegation of sexual abuse to the Administrator, provide assessment of the alleged victim of sexual abuse, provide protection for the alleged victim of sexual abuse and protect other residents in the facility from the possibility of abuse by assessing other residents in the facility for signs of sexual abuse. Immediate jeopardy was removed on 5/17/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity level of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems that were put into place are effective. Findings included: 1.a. A review of the facility's Abuse Prevention, Intervention, Reporting, and Investigation Policy, revised 2/2021, indicated upon receiving an allegation of physical and sexual abuse the Executive Director and Director of Health Services should be notified immediately to arrange for the examination of the resident. Resident #7 was admitted to the facility on [DATE] with diagnoses of dementia, stroke, and cognitive communication deficit. Resident #39 was admitted to the facility on [DATE] with diagnoses of dementia and stroke. A written statement made by Nurse Aide #6 on 5/2/2024 stated she walked into Resident #7's room and Resident #39 was sitting next to her bed, and she saw something moving under the covers that appeared to be Resident #39's hand. The statement further stated Nurse Aide #6 asked Resident #39 what he was doing, and he said, Nothing. The written statement indicated when Resident #39 left the room he had stool on his fingers and Resident #7's brief was open and there was stool outside the brief and on her sheets. The written statement did not indicate who Nurse Aide #6 notified of the allegation of abuse. During an interview with Nurse Aide #6 on 5/14/2024 at 1:11 pm she stated she cared for Resident #7 on 5/2/2024 on the 7:00 am to 7:00 pm shift and she walked into the room between 9:00 am and 9:30 am and Resident #39 was sitting next to Resident #7's bed in his wheelchair and his hand was under the bed covers and she saw his hand moving around her groin area. Nurse Aide #6 stated Resident #7 was not upset but she is severely cognitively impaired. Nurse Aide #6 stated she asked Resident #39 what he was doing, and he said, Nothing. Nurse Aide #6 stated when asked Resident #39 to leave the room there was stool on his hand. Nurse Aide #6 stated when she returned to Resident #6, she pulled down the covers and her brief was open and there was stool on the outside of her brief and on the sheets. Nurse Aide #6 stated she told Medication Aide #4 about what she witnessed, and Medication Aide #4 told her she would notify Unit Supervisor #2. On 5/14/2024 at 1:29 pm Medication Aide #4 was interviewed and stated Nurse Aide #6 told her she found Resident #39 in Resident #7's room and he had his hand under Resident #7's covers and when he pulled his hand out from under the bed covers, he had stool on his hand and Resident #7's brief was open and there was stool on the outside of her brief and on the bed covers. Medication Aide #4 stated she told Unit Supervisor #2 about the allegation of sexual abuse about 30 minutes after Nurse Aide #6 told her because Unit Supervisor #2 was in a meeting, and she did not want to disturb the meeting. Medication Aide #4 stated when Unit Supervisor #2 came to the unit after the meeting she notified her of the allegation of sexual abuse. Unit Supervisor #2 was interviewed on 5/14/2024 at 1:35 pm and she stated she did not remember what time it was when she was notified of the allegation of sexual abuse, but it was before 10:00 am. She stated she was coming from the morning meeting, and she does a round of the facility after the meeting. When she went to 200-hall to check on Medication Aide #4 she was told about the allegation of sexual abuse. Unit Supervisor #2 stated she went to Resident #7's room and Nurse Aide #6 was providing incontinence care. She stated there was stool on the sheet, but the brief had been removed. Unit Supervisor #2 stated she reported the allegation of sexual abuse to the Director of Nursing after she checked on Resident #7. The Director of Nursing was interviewed on 5/14/2024 at 5:37 pm and stated she was in her office and between 9:30 am and 9:40 am on 5/2/24 when Unit Supervisor #2 came to her office and reported the allegation of sexual abuse of Resident #7. She stated she was told by Unit Supervisor #2 that Nurse Aide #6 went into Resident #7's room and Resident #38 was sitting beside her bed in his wheelchair with his hand under the sheet and when she came into the room, he pulled his hand out. The Director of Nursing stated she was told Resident #38 had stool on his hand. The Director of Nursing stated they began an investigation immediately and the police were called. She stated she was not aware Medication Aide #4 had not reported the allegation of sexual abuse to Unit Supervisor #2 until 30 minutes after it was reported to her. The Director of Nursing stated that all allegations of abuse should be reported immediately. The previous Administrator was interviewed on 5/15/2024 at 8:42 am and he stated he had moved to another facility but was the administrator of the building at the time of the allegation of sexual abuse. He stated he was told by the Director of Nursing about the allegation of sexual abuse, and an investigation was initiated immediately. He stated he was not aware Medication Aide #4 had not report the allegation until 30 minutes after she was told by Nurse Aide #6. He stated all allegations of abuse should be reported to the administration immediately. b. The facility's Abuse Prevention, Intervention, Reporting and Investigation Policy, revised 2/2021, indicated a physical examination of the resident should be conducted by an appropriately trained/licensed professional (attending physician, emergency room physician). Unit Supervisor #2 was interviewed on 5/14/2024 at 1:35 pm and she stated she was coming from her morning meeting on 5/2/2024 before 10:00 am, when she did a morning round, and went to the 200-hall to check on Medication Aide #4. She stated Medication Aide #4 told her Nurse Aide #6 walked into Resident #7's room and Resident #39 was sitting in his wheelchair beside the bed with his hand under the sheet. She stated she was told Resident #39 had stool on his hand and Resident #39's brief was open and there was stool on the sheet and on the outside of the brief. Unit Supervisor #2 stated she went to Resident #7's room and Nurse Aide #6 was providing incontinence care for Resident #7. Unit Supervisor #2 stated she did not assess Resident #7 and she did not know if anyone else assessed Resident #7. The Director of Nursing was interviewed on 5/14/2024 at 5:37 pm and she stated it was reported to her on 5/2/2024 between 9:30 and 9:40 am that Resident #38 was found by Nurse Aide #6 in Resident #7's room sitting beside her bed in his wheelchair with his hand under the covers. She stated when Resident #38 pulled his hand from the covers he had stool on his fingers and when Nurse Aide #6 pulled back Resident #7's covers her brief was open and there was stool on the outside of her brief and on the sheets. The Director of Nursing stated someone did assess Resident #7, but she was not sure who had provided the assessment. A follow-up interview was conducted with the Director of Nursing on 5/15/2024 and she stated there was not a physical assessment of Resident #7 immediately after the allegation of sexual abuse was reported. She stated there was a skin assessment completed on 5/2/2024 on the 7:00 pm to 7:00 am shift. A phone interview was conducted with Nurse #6 on 5/15/2024 at 12:03 pm and she stated she did a skin assessment on 5/2/2024 between 9:00 pm and 10:00 pm and Resident #7 did not have any bruising or injuries to her perineum. The previous Administrator was interviewed on 5/15/2024 at 8:42 am and he stated the Medical Director was made aware of the allegation of sexual abuse immediately, but he did not know when Resident #7 was physically assessed after the incident. c. The facility's Abuse Prevention, Intervention Reporting, and Investigation Policy stated a resident who is allegedly mistreated by another resident is removed from contact with that resident during the investigation. The policy further stated residents are to be protected during incident investigations; and residents will be protected from the alleged offender. A written statement made by Nurse Aide #6 on 5/2/2024 stated she walked into Resident #7's room and Resident #39 was sitting next to her bed, and she saw something moving under the covers that appeared to be Resident #39's hand. The statement further stated Nurse Aide #6 asked Resident #39 what he was doing, and he said, Nothing. The written statement indicated when Resident #39 left the room he had stool on his fingers and Resident #7's brief was open and there was stool outside the brief and on her sheets. During an interview with Nurse Aide #6 on 5/14/2024 at 1:11 pm she stated she cared for Resident #7 on 5/2/2024 on the 7:00 am to 7:00 pm shift and she walked into the room between 9:00 am and 9:30 am and Resident #39 was sitting next to Resident #7's bed in his wheelchair and his hand was under the bed covers and she saw his hand moving around her groin area. Nurse Aide #6 stated Resident #7 was not upset but she is severely cognitively impaired. Nurse Aide #6 stated she asked Resident #39 what he was doing, and he said, Nothing. Nurse Aide #6 stated when she sent Resident #39 out of the room there was stool on his hand. Nurse Aide #6 stated when she returned to Resident #6, she pulled down the covers and her brief was open and there was stool on the outside of her brief and on the sheets. Nurse Aide #6 stated she told Medication Aide #4 about what she witnessed, and Medication Aide #4 told her she would notify Unit Supervisor #2. Nurse Aide #6 stated Resident #39 was in his room when she went to tell Medication Aide #4 about the allegation of sexual abuse but there was not anyone with him and they did not put him on one-to-one observation until the Patient Care Associate (PCA) came to sit with him. She stated she did not know what time the PCA was assigned to Resident #39. On 5/14/2024 at 1:29 pm Medication Aide #4 was interviewed and stated Nurse Aide #6 told her she found Resident #39 in Resident #7's room and he had his hand under Resident #7's covers and when he pulled his hand out from under the bed covers, he had stool on his hand and Resident #7's brief was open and there was stool on the outside of her brief and on the bed covers. Medication Aide #4 stated she told Unit Supervisor #2 about the allegation of sexual abuse about 30 minutes after Nurse Aide #6 told her because Unit Supervisor #2 was in a meeting, and she did not want to disturb the meeting. Medication Aide #4 stated Resident #38 was not put on one-to-one observation until later that morning when the Patient Care Associate (PCA) was assigned to watch him and after she left at 3:00 pm that day he was put on every 15-minute checks. Medication Aide #4 stated staff were supposed to check to see where Resident #39 was every 15 minutes and document that we saw him. She stated she did not know why Resident #39 was not kept on one-to-one observation. Unit Supervisor #2 was interviewed on 5/14/2024 at 1:35 pm and she stated she did not remember what time it was when she was notified of the allegation of sexual abuse, but she stated it was before 10:00 am. She stated she was coming from the morning meeting, and she does a round of the facility after the meeting and when she went to 200-hall to check on Medication Aide #4 she was told about the allegation of sexual abuse. Unit Supervisor #2 stated she went to Resident #7's room and Nurse Aide #6 was providing incontinence care. She stated there was stool on the sheet, but the brief had been removed. Unit Supervisor #2 stated she reported the allegation of sexual abuse to the Director of Nursing after she checked on Resident #7. Unit Supervisor #2 stated Resident #39 was in the hallway away from his room when she went to check on Resident #7, she stated they did not put Resident #39 on one-to-one observation until after she reported the allegation of sexual abuse to the Director of Nursing and then he went to every 15-minute checks the next day. Unit Supervisor #2 stated Resident #39 is very mobile in his wheelchair and he wanders around the facility. The Police Officer was interviewed on 5/15/2024 at 10:05 am and he stated he came to the facility on [DATE] at 9:58 am to investigate. He stated when he arrived at the facility Resident #7 was in his wheelchair in the hallway and no one was supervising him when he approached him to interview him. During an interview with the Patient Care Associate (PCA) on 5/14/2024 at 2:01 pm, who spoke only Spanish, and the Director of Nursing provided interpretation, the PCA stated she was assigned to Resident #39 at 12:15 pm on 5/2/2024 and she observed him until 3:00 pm. She stated she kept notes in her notebook of where he went during the one-to-one observation. The PCA stated Resident #39 tried to get close to Resident #7 once on 5/2/2024 when she was observing him, but she redirected him. On 5/14/2024 at 11:12 am Resident #7 was observed in her wheelchair on the 200-hall and she went up and down the hallway but did not go into any resident rooms. Staff were observed at the nurses' desk but did not redirect Resident #7 back to the 100-hall where she resided. Resident #7 rolled past Resident #39's room door twice in her wheelchair during the observation. Resident #7 was observed until 11:20 am. The Director of Nursing was interviewed on 5/14/2024 at 5:37 pm and she stated they put Resident #39 on one-to-one observation after the incident was reported. On 5/15/2024 at 3:08 pm the Director of Nursing was interviewed again and stated she was not aware Resident #39 was not put on one-to-one observation until 12:15 pm. She stated they decided to monitor him on every 15-minute checks after 3:00 pm on 5/2/2024 because they felt they could watch him closely enough with every 15-minute checks to ensure Resident #7 and all other residents were safe. d. The facility's Abuse Prevention, Intervention, Reporting, and Investigation Policy, revised on 2/2021, indicated the facility will assess and interview all residents who came in contact with the accused when investigating an abuse allegation. Unit Supervisor #4 was interviewed on 5/14/2024 at 5:25 pm and stated she had not physically assessed Resident #7 on 5/2/2024 after the allegation of sexual abuse was reported. Unit Supervisor #4 stated she was not asked to do assessments or interviews with any other residents after the allegation of sexual abuse was reported on 5/2/2024. During an interview with the Director of Nursing on 5/15/2024 at 3:08 pm she stated the facility did not complete physical assessments with residents that were cognitively impaired or interview any residents that were not cognitively impaired to see if there were any further allegations of sexual abuse in the facility when the sexual abuse allegation was reported on 5/2/2024. The previous Administrator was interviewed by phone on 5/15/2024 at 8:42 am and he stated when the allegation of sexual abuse of Resident #7 by Resident #39 was reported on 5/2/2024 the facility moved Resident #7 to another room on a different hallway; placed Resident #39 on every 15-minute checks; and the Medical Director and police were notified of the allegation of abuse. The previous Administrator stated he spoke with the Medical Director after the incident on 5/2/2024 to see if the facility needed to do anything else to protect Resident #7 and other residents and the Medical Director stated they had done everything they could do. The current Administrator was interviewed on 5/17/2024 at 4:42 pm and stated the facility's staff have received in-service education regarding the facility's Abuse Prevention, Intervention, Reporting, and Investigation Policy. The current Administrator stated the staff should have assessed all residents who came in contact with the accused when the allegation was reported on 5/2/2024. e. The facility's Abuse Prevention, Intervention, Reporting, and Investigation policy, revised 2/2021, indicated the facility would notify Adult Protective Services when an allegation of abuse is reported. The Director of Nursing was interviewed on 5/15/2024 at 4:03 pm and she stated the facility did not notify the North Carolina Division of Social Services, Adult Protective Services regarding the allegation of sexual abuse of Resident #7 that was reported on 5/2/2024. She stated she was not aware she should notify Adult Protective Services. The previous Administrator was interviewed by phone on 5/15/2024 at 8:42 am and he stated when the allegation of sexual abuse of Resident #7 by Resident #39 was reported on 5/2/2024 the facility moved Resident #7 to another room on a different hallway; placed Resident #39 on every 15-minute checks; and the Medical Director and police were notified of the allegation of abuse. The previous Administrator stated he spoke with the Medical Director after the incident on 5/2/2024 to see if the facility needed to do anything else to protect Resident #7 and other residents and the Medical Director stated they had done everything they could do. The Administrator was notified of immediate jeopardy on 5/15/2024 at 4:43 pm. The facility provided the Credible Allegation of Immediate Jeopardy Removal: F607 Abuse Reporting: The facility failed to implement the abuse policy related to reporting and protection. Identify Those recipients who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance. On 5/2/2024 CNA #1 observed Resident # 39's hand under the covers of Resident #7 in her bed in resident #7's room at around 9:00am. CNA # 6 announced for Resident # 39 to abstain from touching Resident # 2. CNA #7 removed Resident # 39 from Resident # 7's room. After an allegation of sexual abuse, a nurse was not notified immediately; staff was cleaning up the resident before a nurse came to the room, a nurse did not complete an initial assessment until that night on 7p-7a shift. The facility failed to provide a physical examination of a cognitively impaired female resident (Resident #7) by an appropriately trained/licensed professional for signs of sexual abuse or other forms of abuse immediately after a moderately cognitively impaired resident (Resident #39) was found in his wheelchair at her bedside with his hand under her covers on 5/2/2024. Resident #7 was not assessed by the Medical Director until 5/6/2024. Medical Director ordered Zoloft 25 milligrams by mouth daily for aggression on 5/6/2024. Resident # 39 was not put on 1 on 1 monitoring until 12:15 pm. The resident stayed on 1 on 1 until 3 pm and then was on every 15-minute checks. Resident #39 was placed on one-to-one supervision on 5/15/2024 at around 5:30 pm. The facility failed to assess if other residents had been abused until 5/15/2024. The facility failed to report the abuse allegation to APS until 5/16/2024. Abuse questionnaires were completed by the Business Office Manager, MDS Nurse, Admissions Director and Unit Manager on all residents with Brief Interview for Mental Status (BIMS) score of 9 and above with no adverse responses. Questionnaires were completed on 5/15/2024. The questions asked were as follows, 1. Do you feel safe? 2. Has anyone ever touched you inappropriately? 3. Are you afraid of anyone in the facility? The Unit Manager and/or Floor Nurse completed skin assessment for all residents with a BIMS score below 9 as of 5/15/2024 with no negative outcomes. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. As of 5/15/2024 the Regional Director of Operations and Regional Clinical Nurse educated the Director of Nursing, Administrator, Medical and Staff Development Coordinator on abuse policy to include residents right to be free from abuse to include sexual, physical, mental, verbal and misappropriation of property as well as signs of abuse and reporting of abuse or potential abuse. Education also included the process and action to protect residents if any type of abuse including sexual abuse occurs according to facility policy and procedure on abuse. Actions to include assessment of all residents involved, immediate protection for all residents, immediate reporting to Management, state agencies, Ombudsman, APS, families, physician, immediate protection for all residents, and law enforcement. On 5/16/2024 Staff Development Coordinator and/or Director of Nursing educated all nursing staff on proper procedures for reporting any suspected abuse and immediate reporting to the Administrator and Director of Nursing for direction. Education will include direction for resident assessment immediately following incident, physician notification by Nurse for direction of care for resident and need to send out to hospital for further examination. On 5/2/2024 at 9:40am Social Worker talked with Resident #39 about the incident that occurred and explained to resident #39 what he had done wrong. On 5/7/2024 the physician changed resident #39's medication to add Zoloft 25mg tablet daily by mouth for aggression. As of 5/15/2024, around 5:30pm resident #39 has been placed on 1 on 1 observation. On 5/15/2024 the facility completed AdHoc QAPI to review investigation and current action plan to ensure all components were done and followed. The facility administrator and Director of Nursing are responsible for continued compliance. Alleged date of IJ removal: 5/17/2024 The Credible Allegation of IJ Removal was validated on 5/17/2024. The facility provided documentation of the in-service education that was provided to all staff which included the review of the facility's Abuse Policy and included immediate reporting of any allegations of abuse to the Administrator immediately; provide a physical examination by a trained/licensed professional for any signs of sexual abuse; provide protection for the resident that is the victim of abuse; provide protection for all other residents when an allegation of abuse is reported; and report any allegations of abuse to the proper authorities. The Staff Development Coordinator was interviewed and stated they have ensure all staff are educated regarding the reporting of abuse allegations to the administrator immediately; provide a physical examination by the physician or if the physician is not available send the resident to the emergency department for evaluation if there is an allegation of sexual abuse; provide protection for the abused individual and all other residents; and reporting of allegations of abuse to the proper authorities. She stated all staff that have been allowed to work have had the abuse education. During the validation of the Credible Allegation of IJ Removal observations of Resident #39 were made and the facility was providing one-to-one observation of the resident. The facility staff (sampled from all disciplines) were able to verbalize the types of abuse; what steps they should take to assess and protect the resident of an alleged abuse; and what authorities should be notified of allegations of abuse. The facility provided skin assessments that were completed on residents with a Brief Interview for Mental Status (BIMS) of less than 9 and interview forms that were completed on all residents with a BIMS of 9 or above that were conducted on 5/15/2024. The facility also notified Adult Protective Services of the allegation of sexual abuse for Resident #7 on 5/16/2024. The facility provided minutes of their Quality Assurance Performance Improvement (QAPI) meeting which was conducted on 5/15/2024. The alledged IJ removal date of 5/17 24 was validated.

Based on record review, observations, and staff and Medical Director interviews the facility failed to protect a resident's right to be free of sexual abuse for 1 of 3 residents investigated for abuse (Resident #7). A moderately cognitively impaired male resident (Resident #39) was found beside Resident #7's bed, a severely cognitively impaired female resident, with his hand moving under the covers around her groin area when a staff member entered Resident #7's room. Resident #7's brief was open and there was stool on the outside of her brief and on her sheets, and Resident #39 had stool on his hands. Resident #39 was interviewed and stated he was playing around with Resident #7 down there and waved his hand in a circular motion around his groin area. Resident #39 stated he had done something stupid, and he should not have done it. Resident #7 did not have the cognition to express or understand consent for physical sexual advances, and a reasonable person would have been traumatized by unwanted physical sexual advances. Immediate Jeopardy began on 5/2/2024, when the facility failed to protect Resident #7's right to be free of sexual abuse. Immediate Jeopardy was removed on 5/17/2024 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity level of D (no actual harm with potential for potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems that were put into place are effective. Findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses of dementia and cognitive communication deficit. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #7 was assessed as severely cognitively impaired; was dependent on staff for rolling from side to side in bed; was totally dependent for transferring to and from the bed to wheelchair; was always incontinent of bowel and bladder and was sometimes understood by others and sometimes understood others The Care Plan for Resident #7 which was reviewed on 3/21/2024 indicated she had difficulty with making her own decisions. Resident #39 was admitted to the facility on [DATE] with diagnoses of dementia and stroke. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #39 was moderately cognitively impaired and had no behaviors. Resident #39's Care Plan was reviewed and on 3/29/2024 the Care Plan indicated Resident #39 had episodes of verbally aggressive behaviors and should be approached in a calm manner. A Care Plan problem added on 4/4/2024 to the Care Plan indicated Resident #39 had a history of depression, he had scheduled psychiatric visits ordered, and he had difficulty recalling recent events due to dementia. A review of a written statement made by Nurse Aide #6 on 5/2/2024 indicated she walked into Resident #7's room and Resident #39 was sitting next to her bed, and she saw something move under the covers that appeared to be Resident #39's hand. The statement further stated she asked Resident #39 what he was doing, and he said nothing. The written statement further indicated when Resident #39 left the room he had stool on his fingers and Resident #7's brief was open and there was stool on the outside of her brief and on her sheet. On 5/14/2024 at 1:11 pm Nurse Aide #6 was interviewed, and stated she cared for Resident #7 on 5/2/2024 and walked into her room between 9:00 am and 9:30 am and Resident #39 was sitting beside her bed in his wheelchair and his hand was under the covers and she saw his hand moving around her groin area. Nurse Aide #6 stated Resident #7 was not upset but she was severely cognitively impaired. Nurse Aide #6 stated she asked Resident #39 what he was doing and when she asked him to leave the room, she noticed he had stool on his hand. She stated after Resident #39 rolled himself in his wheelchair to his room, Nurse Aide #6 stated she returned to Resident #7 to clean her up and when she pulled the sheet down her brief was open and there was stool on the outside of her brief and on her sheet. Nurse Aide #6 stated Resident #39 was sometimes confused and sometimes he was clear. Nurse Aide #6 stated Resident #38 could get up unassisted, moved himself in his wheelchair without assistance, and he wandered around the facility. Nurse Aide #6 stated Resident #38 sat in the doorway of Resident #7's room a lot but 5/2/2024 was the first time she found him in her room. A written statement dated 5/2/2024 by the Social Worker stated she interviewed Resident #39 and asked him what he was doing in Resident #7's room this morning and he stated, I was just playing around and when asked to elaborate on what he meant he said, I was just playing with her down there and he took his hand and waved it in a circular motion around his groin area and said, down there. The Social Worker's written statement indicated Resident #39 stated, I was doing something stupid that I should not have done. The Social Worker's written statement stated she explained to Resident #39 that Resident #7 was cognitively impaired and could not give consent to being touched sexually and he verbalized understanding that he knew what he did was inappropriate. On 5/14/2024 at 2:15 pm the Social Worker was interviewed and stated Resident #39 was coming down the hallway toward her office between 9:30 am and 9:45 am on 5/2/2024 and he stated, I was playing around with Resident #7 in her room, and he did a circular hand motion towards his groin area. The Social Worker stated he said, I did something stupid and the Social Worker stated because he said he did something stupid he understood what he had done was wrong. The Social Worker stated he told the Police Officer that investigated the sexual abuse allegation the exact same thing about an hour after she interviewed him. The Police Officer explained to Resident #39 that Resident #7's family would have to decide to press charges and the Police Officer returned to the facility later that day and notified Resident #7 of his court appearance date and that he was charged with sexual battery. A Police Report dated 5/2/2024 at 9:54 am indicated Resident #39 was charged with sexual battery of Resident #7. The Police Report further indicated Nurse Aide #6 entered Resident #7's room and found Resident #39 at her bedside with his hand under the blanket. Nurse Aide #6 indicated Resident #39 hand was moving under the blanket and Nurse Aide #6 confronted Resident #39 about what he was doing, and he stated, nothing. Nurse Aide #6 reported there was stool on Resident #39's fingers and she found Resident #7's brief open and there was stool outside the brief and on the bed. The Police Report stated Resident #7 was cognitively impaired and could not recall the alleged abuse or give consent. The Police Report stated the Responsible Party was interviewed and stated Resident #7 had dementia and frequently repeats what is said to her. The Responsible Party indicated he wished to pursue charges for the incident on behalf of Resident #7. An interview was conducted by phone on 5/15/2024 at 10:05 am with the Police Officer who responded to the allegation of sexual abuse on 5/2/2024. The Police Officer stated he interviewed Nurse Aide #6 and she stated she entered Resident #7's room and found Resident #39 in his wheelchair sitting beside the bed with his hand under the covers and when she approached him and asked what he was doing he said nothing, but she noticed stool on his fingers. The Police Officer stated Nursing Aide #6 stated after Resident #39 left the room she saw that Resident #7's brief was open and there was stool outside the brief and on the sheet. The Police Officer stated Resident #39 admitted to touching Resident #7 sexually and seemed to understand what he did was sexual battery. The Police Officer stated Resident #39 took advantage of a situation where no one was around, and Resident #7 confusion prevented her from stopping him. During an interview on 5/14/2024 at 10:00 am with Resident #7's Responsible Party by phone he stated the facility notified him on 5/2/2024 at 9:30 am that Resident #7 had been sexually abused. He stated Resident #7 is severely cognitively impaired and would not have understood what happened to her. The Responsible Party stated he felt Resident #7 was sexually abused because she was unable to call for help or report what was done to her. He stated Resident #7 was a very good woman and would not have instigated a sexual encounter and would have been very upset if she understood what happened. A Physician's Progress Note stated 5/6/2024 by the Medical Director indicated he saw Resident #7 and evaluated her mental status and ability to give/withhold informed consent. The Progress Note further stated Resident #7 was a poor historian due to her cognition and information was obtained through chart review and discussion with medical staff; and she was not able to give informed consent. A Physician's Progress Note dated 5/6/2024 indicated the Medical Director evaluated Resident #39 for the ability to give/withhold informed consent. The Progress Report stated Resident #39 had a history of dementia; had no recent cognitive decline noted; and Resident had cognitive impairment with poor ability to give or withhold consent and was unlikely to understand the nature of his actions. On 5/14/2024 at 5:32 pm the Medical Director was interviewed by phone and stated he did not believe Resident #39 understood what he was doing when he evaluated him on 5/6/2024 after the incident that occurred on 5/2/2024. The Medical Director stated Resident #39 responded, it was bad when he asked if he understood what he did was bad; and he responded, it was bad when he asked Resident #39 if he understood why what he did was bad. Resident #39 was interviewed on 5/14/2024 at 11:20 am and he stated he has lived at the facility for 2 years. When asked if he had any altercations with another resident he stated, I got in trouble for touching another resident. Resident #39 stated he did not know the name of the resident and stated he did not remember how long ago the incident happened. The Director of Nursing was interviewed on 5/14/2024 at 5:37 pm and stated Unit Manager #2 reported to her on 5/2/2024 around 9:30 am to 9:40 am that Resident #39 was found in Resident #7's room by Nurse Aide #6 sitting beside her bed in his wheelchair with his hand under the covers. She stated Nurse Aide #6 reported Resident #7's brief was open, and stool was on the outside of her brief and on her sheet, and Resident #39 had stool on his hand. The Director of Nursing stated they began an investigation and had substantiated the sexual abuse. On 5/15/2024 at 8:42 am the previous Administrator was interviewed by phone and stated the facility had initiated an investigation when Nurse Aide #6 reported Resident #39 was found in his wheelchair beside Resident #7's bed with his hand under the covers. The Administrator stated the Medical Director spoke with Resident #39 and the Medical Director felt Resident #39 did not understand what he had done wrong. The previous Administrator stated the Medical Director prescribed Zoloft (an antidepressant) to treat Resident #39's libido and aggression after the incident. The previous Administrator indicated Resident #39 was put on every 15-minute observations by nursing after the incident was reported and the Medical Director felt that every 15-minute observations by nursing was sufficient to protect Resident #7 and other resident's safety. He stated Resident #39 did wander in the facility between the every 15-minute observations. An interview was conducted with the Administrator on 5/17/2024 at 3:32 pm and he stated the facility had provided education to all staff regarding their Abuse Prevention, Intervention, Reporting, and Investigation Policy. He stated the facility was responsible for protecting the residents from all forms of abuse. The Administrator was notified of immediate jeopardy on 5/15/2024 at 4:24 pm. The facility provided the following Credible Allegation of Immediate Jeopardy Removal: Identify Those recipients who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance. On 5/2/2024 NA #6 observed Resident # 39's hand under the covers of Resident #7 in her bed in resident #7's room at around 9:00am. NA # 6 announced for Resident #39 to abstain from touching Resident # 7. NA #6 removed Resident #39 from Resident # 7's room. Nurse #6 completed a skin assessment on Resident #7 during 7p-7a shift on 5/2/2024 with no noted injuries. Law enforcement was notified on 5/2/2024 around 9:30 am. Resident # 7's responsible party was notified of occurrence on 5/2/2024. Resident # 7's emergency contact was also notified of the occurrence on 5/2/2024. Resident #7 was transferred to another room on 5/2/24 for her protection. Resident #39 had no prior history of sexual aggression prior to the incident on 5/2/2024. Abuse questionnaires were completed by the Business Office Manager, MDS Nurse, Admissions Director and Unit Manager on all residents with Brief Interview for Mental Status (BIMS) score of 9 and above with no adverse responses. Questionnaires were completed on 5/15/2024. The questions asked were as follows, 1. Do you feel safe? 2. Has anyone ever touched you inappropriately? 3. Are you afraid of anyone in the facility? The Unit Manager and/or Floor Nurse completed skin assessment for all residents with a BIMS score below 9 as of 5/15/2024 with no negative findings. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 5/2/2024 at 9:40am Social Worker talked with Resident #39 about the incident that occurred and explained to resident #39 what he had done wrong. On 5/7/2024 the physician changed resident #39's medication to add Zoloft 25mg tablet daily by mouth for aggression. As of 5/15/2024, around 5:30pm resident #39 has been placed on 1 on 1 observation. MDS Nurse updated resident #39's care plan to reflect new behavior of sexual aggression and interventions for managing behavior as of 5/16/2024. MDS Nurse updated care guide for resident #39 on 5/16/2024 and staff notified of changes through care guide on 5/16/2024. MDS Nurse will continue to update interventions as needed. As of 5/15/2024 the Staff Development Coordinator educated 100% of facility staff on the facility abuse policy to include residents right to be free from abuse to include sexual, physical, mental, verbal and misappropriation of property as well as signs of abuse and reporting of abuse or potential abuse. Staff development Coordinator will provide education for abuse training to new hires during orientation. 1:1 supervision will be documented and reported to the facility Administrator and Director of Nursing to ensure monitoring of resident. The Director of Nursing will ensure the 1:1 staff member is provided each shift with the staffing coordinator daily. As of 5/15/2024 all CNA's will be educated by the Director of Nursing/Staff Development Coordinator on supervision of resident during 1:1 duty. Education will include a goal of 1:1 in protecting other residents from any sexual aggression by resident #39 and ensuring resident #39 does not encounter resident #7 and documenting of any aggression during shift. On 5/15/2024 the facility completed Ad Hoc QAPI to review investigation and current action plan to ensure all components were done and followed. The facility administrator and Director of Nursing are responsible for continued compliance. Alleged date of IJ removal: 5/17/2024 Credible Allegation of IJ Removal: The Credible Allegation of IJ Removal was validated on 5/17/2024. The facility provided documentation of the in-service education that was provided to all facility staff which included review of the facility's Abuse Policy to include residents right to be free from abuse to include sexual, physical, mental, verbal and misappropriation of property; signs of abuse; and reporting of abuse or potential abuse. The Staff Development Coordinator provided the education to the staff which will also be covered in the facility's orientation of new employees. The Staff Development Coordinator was interviewed and stated they have ensured staff are educated on the abuse policy before they are allowed to care for residents. During interviews with staff from all departments, they were able to verbalize the types of abuse, resident's right to be free from abuse, signs of abuse, reporting of abuse and potential abuse and protection of residents from abuse. Observations were made of Resident #39 during the validation of the Credible Allegation, and he remained on 1 to 1 observation during the validation. The facility provided skin assessments that were completed on residents with a Brief Interview for Mental Status (BIMS) score of less than 9 and interviews forms that were completed on all residents with a BIMs score of 9 or above. The facility provided the minutes for their Quality Assurance Performance Improvement (QAPI) meeting which was completed on 5/15/2024. The alleged date of IJ removal of 5/17/24 was validated.

Based on record review, observations, and staff interviews, the facility failed to protect the residents right to be free from misappropriation of a narcotic medication (Oxycodone) prescribed to treat pain for Resident #16, Resident #75, and Resident #239. This was for 3 of 3 residents reviewed for misappropriation. The findings included: 1) Resident #16 was admitted to the facility on [DATE]. A review of Resident #16's quarterly Minimum Data Set assessment, dated 2/29/24, indicated her cognition was intact and she received opioid medication. Resident #16 had an order dated 2/13/24 for Oxycodone 10 milligrams (mg) every 6 hours as needed for 5 days and to record the resident's pain level. A review of Resident #16's February Medication Administration Record (MAR) revealed the resident received Oxycodone 10 mg administered by Nurse #2, #7, and #12 for pain on 2/14/24. The second Oxycodone order, dated 2/18/24, was for 10 mg every 6 hours as needed for pain. The Narcotic Count Sheet documented for Resident #16's Oxycodone 10 mg every 6 hours as needed for pain indicated the following: - On 2/22/24 the resident received her med at 6:22 am and one was wasted by Nurse #12. - On 2/25/24 the resident received her med at 1:00 am and one was wasted by Nurse #12. - On 2/26/24 the resident received her med at 3:10 am and one was wasted by Nurse #12. Resident #16 had a pain evaluation dated 2/28/24 which documented she had received pain medication within the past 5 days. She received pain medication and non-pharmacological interventions. The resident was satisfied with the current pain management plan and received her medication when requested. On 4/30/24 at 12:45 pm Resident #16 was interviewed and stated she received her pain medication and all medication as expected and had no concerns. On 5/1/24 at 11:40 am an interview was conducted with Resident #16. She remembered the surgical procedure and received pain medication as requested. The resident had not remembered any concerns regarding the treatment of her pain. A drug testing collection and results dated 2/16/24 for Nurse #2 was reviewed. She was tested for Amphetamines, Barbiturates, Benzodiazepine, Burprenorphine, Cocaine, Marijuana, Methylenedioxymethamphetamine, Methamphetamine, Methadone, Opiates/Morphine, Oxycodone, and Phencyclidine. All tested negative. A drug testing collection and results dated 2/16/24 for Nurse #7 was reviewed. She was tested for Amphetamines, Barbiturates, Benzodiazepine, Burprenorphine, Cocaine, Marijuana, Methylenedioxymethamphetamine, Methamphetamine, Methadone, Opiates/Morphine, Oxycodone, and Phencyclidine. All tested negative. On 5/6/24/at 10:02 am an interview was attempted by telephone with Nurse #7. She was not available, and a message was left. A review of the hand-written statement dated 2/28/24 by Nurse #12 documented the following: I previously have had an addiction to oxycodone and sought help through treatment. I was clean and stayed so for years. I got a couple of oxycodone from my sister that I took yesterday 2/27 before my shift. A drug testing collection and results dated 2/28/24 for Nurse #12 was reviewed. She was tested for Amphetamines, Barbiturates, Benzodiazepine, Burprenorphine, Cocaine, Marijuana, Methylenedioxymethamphetamine, Methamphetamine, Methadone, Opiates/Morphine, Oxycodone, and Phencyclidine. The Oxycodone tested positive, and all other drugs tested negative. On 5/6/24 at 10:05 am an interview was attempted by telephone with Nurse #12. She answered the phone and then hung up. 2) Resident #75 was admitted to the facility on [DATE]. Resident #75's 5-day Minimum Data Set assessment dated [DATE] documented her cognition as intact, received as needed pain medication, and received opioid medication. Resident #75 had an order dated 2/20/24 for Oxycodone 5 mg every 4 hours as needed for pain. A review of Resident #75's Narcotic Count Sheet for February 2024 documented on 2/24/24 at 7:00 pm, one tablet of oxycodone 5 mg was documented as wasted by Nurse #12 and witnessed by Nurse #6. A review of a typed statement, signed by Nurse #6 and dated 3/5/24 documented, I was called into the facility to write a statement to verify that I did waste Oxycodone with Nurse #12 for Resident #75. Those initials are not my initials. I had not wasted the Oxycodone with Nurse #12. On 5/3/24 at 2:52 pm an interview was attempted with Nurse #6 and a voicemail was left which requested a call back. A drug testing collection and results dated 2/16/24 for Nurse #6. She was tested for Amphetamines, Barbiturates, Benzodiazepine, Burprenorphine, Cocaine, Marijuana, Methylenedioxymethamphetamine, Methamphetamine, Methadone, Opiates/Morphine, Oxycodone, and Phencyclidine. All tested negative. 3) Resident #239 was admitted to the facility on [DATE] and was discharged on [DATE]. Resident #239 had an order for Oxycodone 10 mg every four hours as needed for pain dated 2/23/24. A review of Resident #239's Narcotic Count Sheet indicated Oxycodone 10 mg was signed out by Nurse #12 on 2/28/24 at 12:42 am, 3:42 am, and 7:42 am (night shift). Resident #239's pain assessment was completed on 2/27/24 at 12:07 pm, 2/27/24 at 4:47 pm, 2/28/24 at 9:21 am and 2/28/24 at 4:59 pm. She had no pain and required no Oxycodone pain medication as needed. Review of a 5-day Minimum Data Set assessment dated [DATE], documented Resident #239's cognition as intact and received opioid medications. Review of a facility interview with Resident #239 on 3/1/24 indicated she reported she had only requested Oxycodone at 8:00 PM on 2/27/24. The facility provided the follwing corrective action plan: 1. Corrective action for resident(s) affected by the alleged deficient practice: Day shift nurse reported to the Unit Manager and Director of Nursing on 2/28/24 a licensed nurse had potentially taken as needed narcotics from a resident narcotic card. The Regional Nurse Consultant and Staff Development Coordinator audited all active resident's narcotics and determined medication narcotic discrepancies with 4 residents, Oxycodone 10 mg as needed tablets. No negative outcomes for the 4 residents as they were as needed medication, and the facility had this medication in backup. The medications were replaced prior to residents requesting them. The Director of Nursing suspended the Licensed Nurse who was suspected of misappropriation during the investigation immediately on 2/28/24 upon learning of the incident. Director of nursing completed the 24-hour report to the Division of Health and Human Services on 2/28/24. The Director of Nursing then began an investigation of missing narcotics and interviewed the licensed nurses and medication aides who had worked on the carts of missing narcotics. The Director of Nursing submitted the five-day report upon completion of the investigation on 3/6/24 to DHHS. The Director of Nursing notified the local Police Department on 2/28/24, the Board of Nursing and Drug Enforcement Agency (DEA) on 2/29/24, by the Director of Nursing. Facility notified the Medical Director on 2/28/24 of the missing as needed narcotics and the residents involved. Residents were assessed on 2/28/24 with no adverse effects as the medications were as needed medications. 2. Corrective action for residents with the potential to be affected by the alleged deficient practice: A 100% audit was conducted on 2/28/24 by the Regional Nurse Consultant and Staff Development Coordinator of the control sheets and each medication on all medication carts to verify that all narcotic medication and control sheets were accounted for. It was discovered that the seven Oxycodone tablets among four residents were missing/not properly accounted for. 3. Measures/Systemic changes to prevent reoccurrence of alleged deficient practice: Education was initiated with all licensed nursing and medication aides by the Director of Nursing or Staff Development Coordinator on the pharmacy policy related to maintaining narcotics on the medication carts, signing of shift-to-shift count sheets, counting, and verifying the narcotic count was correct, wasting and signing with 2 nurses, following the physician order, as well as diversion of narcotics. Education was completed by 3/1/24. Staff will not be permitted to work after 3/1/24 until education is completed, including agency staff. Education will be a part of orientation for all new hire and agency licensed staff prior to working their first shift. The Director of Nursing will continue to maintain file folders for narcotics in the facility for receiving and returning meds and verify narcotic medication count of delivery manifest sheets received from pharmacy. The facility will follow the facility's policy in maintaining control medications. The licensed nurses will receive and document receiving the controlled medication from pharmacy. The nurses will document the number of sheets in the narcotic count book for the number of medication packages located in the locked medication cart. If a medication is discontinued two nurses will remove the card and the medication record and document the number of cards and the sheets that remain on the cart. The nurse will give the removed sheet to the Director of Nursing to maintain. Two nurses will return the discontinued meds to pharmacy, and two nurses will sign and verify. The medications will be placed in a locked tote and placed in the locked medication room to return to pharmacy. The nurses will give a copy of the record and a copy of the return to pharmacy sheet to the Director of Nursing to maintain in a file cabinet in her office. Two nurses will complete a shift-to-shift count to verify that the number listed on the narcotic record matches the amount of medication in the cart and verify that the numbers of sheets are correct. 4. Monitoring Procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements. The Director of Nursing and/or Designee began an audit of medication carts related to narcotic count being correct, the medication cards match the control sheets, the shift-to-shift count sheet are being signed at the start and the end of the shift and any narcotic that needs to be wasted is being signed appropriate by 2 nurses on 2/28/24. Auditing will be completed 5 times per week for 4 weeks, weekly for 4 weeks, then monthly. An ad hoc Quality Assurance and Performance Improvement (QAPI) team meeting was completed on 2/28/24 to review and discuss the action plan. The Director of Nursing will report all findings of audits to the QAPI team monthly for any needed improvement. The date of completion was 3/1/24. Validation of the corrective action plan was completed on 5/3/24: The action plan was validated by reviewing the education provided to the staff, reviewing the interviews with staff and residents, and reviewing the daily Quality Monitoring documentation. Residents were interviewed during the survey, and none reported untreated pain. Nursing staff were interviewed and indicated they had all received education on narcotic diversion. The facility completion date of 3/1/24 could not be validated because the facility was educating staff on 3/1/24. The competion date was 3/2/24.

Based on record review, observations and staff interviews, the facility failed to develop an individualized and comprehensive care plan for a resident with urinary incontinence, a resident at risk for aspiration and failed to care plan antibiotic use. This was for 4 of 25 residents whose care plans were reviewed (Resident #2, #85, #66, and #78). The findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnosis that included displaced subtrochanteric fracture of right femur, and diabetes mellitus with diabetic polyneuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2's cognition was intact. She had no behavior and no rejection of care. She was dependent on staff for toileting hygiene, shower/bath, and she required maximum assistance with personal hygiene. She was occasionally incontinent of bladder and always incontinent of bowel. Review of Resident #2's active care plan, dated [DATE], revealed no care plan related to incontinence care. An interview was conducted on [DATE] at 3:34 PM with the Director of Nursing (DON). She stated a focus or intervention area for incontinence care should have been part of Resident #2's care plan. An interview was conducted on [DATE] at 1:04 PM with the Minimum Data Set (MDS) Nurse. She verified there were no areas on Resident #2's care plan for assistance needed with incontinence care and there should have been an intervention added to the activities of daily living (ADL) focus. She stated it was an oversight that this intervention was not added on Resident #2's care plan. An interview was conducted on [DATE] at 3:21 PM with Resident #2. She stated she did have incontinent episodes of urine and she was always incontinent of bowel. She further stated she required staff to assist her with continence are. 2. Resident #85 was admitted to the facility on [DATE] with diagnosis that included dysphagia, oropharyngeal phase. Resident #85 expired on [DATE]. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #85's cognition was severely impaired. His swallowing and nutrition section was coded for swallowing disorder. Review of Resident #85's active care plan, dated [DATE], revealed no care plan related to dysphagia or aspiration precautions. An interview was conducted on [DATE] at 3:34 PM with the Director of Nursing (DON). She stated Resident #85's care plan should be person centered and should have included a focus or intervention for aspiration precautions due to his diagnosis for dysphagia. An interview was conducted on [DATE] at 1:04 PM with the Minimum Data Set (MDS) Nurse. She verified there were no areas on Resident #85's care plan to include aspiration precautions. She stated it was an oversight that this was not added on Resident #85's care plan. 3. Resident #66 was admitted to the facility on [DATE] with diagnosis that included infection and inflammatory reaction due to internal right knee prosthesis requiring intravenous (IV) antibiotics. Review of Resident #66's active care plan, dated [DATE], revealed no care plan related to intravenous (IV) antibiotics. An interview was conducted on [DATE] at 3:34 PM with the Director of Nursing (DON). She stated Resident #66's care plan should be person centered and should have included an area for intravenous (IV) antibiotics. An interview was conducted on [DATE] at 1:04 PM with the Minimum Data Set (MDS) Nurse. She verified there were no areas on Resident #66's care plan to include intravenous (IV) antibiotics. She stated it was an oversight that this was not added on Resident #66's care plan. 40197 4. Resident #78 was admitted to the facility on [DATE] with diagnoses that included neoplasm of the brain and dysphagia (difficulty swallowing). A review of Resident #78's medical record revealed an order dated [DATE] for Ciprofloxacin (an antibiotic) 750 milligrams (mg) 1 tablet twice a day for polymicrobial bacterial infection (acute and chronic diseases caused by various combinations of viruses, bacteria, and fungi). An Infectious Disease progress note dated [DATE] read that Resident #78 was on Ciprofloxacin for a polymicrobial bacterial infection for at least a year. Review of the active care plan, dated [DATE], revealed Resident #78 was not care planned for the use of an indefinite antibiotic. A significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #78 had severe cognitive impairment and was coded for the use of an antibiotic. On [DATE] at 12:00 PM, an interview occurred with the MDS Coordinator who reviewed Resident #78's active care plan, verified a care plan was not present for the indefinity use of an antibiotic and felt it was an oversight. The Director of Nursing was interviewed on [DATE] at 2:22 PM and stated it was her expectation for the care plan to be person centered and should have included the use of the indefinite antibiotic.

Based on record review, observations, and staff interviews, the facility failed to ensure a fall mat was in place according to the care planned fall safety interventions (Resident #31). This was for 1 of 4 residents reviewed for accidents. The findings included: Resident #31 was admitted to the facility on [DATE] with diagnoses that included dementia and lack of coordination. A review of Resident #31's medical record revealed on 1/27/23 she was found lying beside her bed and stated she fell off the bed while sleeping. It was noted that her room was rearranged and fall mat placed to the left side of the bed for safety. No further falls were indicated in Resident #31's medical record. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 had severe cognitive impairment and received supervision for bed mobility and moderate assistance with transfers. She was coded with no falls since the last assessment. Resident #31's active care plan, last reviewed 4/22/24, included a focus area for risk for falls due to impaired balance, history of falls, diagnosis of dementia with poor safety awareness and psychotropic medication use. An intervention, dated 1/27/23, included fall mat. On 4/30/24 at 11:35 AM, Resident #31 was observed lying in bed with her eyes closed. The bed was in the lowest position, however there was no fall mat beside the bed, in the room or bathroom. On 5/1/24 at 8:18 AM, Resident #31 was observed lying in bed with her eyes closed. The bed was in the lowest position but there was no fall mat beside the bed, in the room or bathroom. An interview occurred with Nurse #4 on 5/1/24 at 9:00 AM. She indicated she had worked at the facility for a few months and had not seen a fall mat being used for Resident #31. On 5/1/24 at 12:11 PM an interview occurred with Nurse Aide (NA) #6 and NA #7, who were familiar with Resident #31. They could not recall seeing fall mats in her room and were unaware one should be present. They stated they would have been informed during rounds and the nursing staff if a fall mat was to be utilized. An interview was completed with the Unit Supervisor #2 on 5/1/24 at 2:18 PM who recalled a fall mat present to the side of the bed for Resident #31 in the past but was unsure what happened to it. On 5/1/24 at 2:22 PM, the Director of Nursing (DON) was interviewed and recalled Resident #31 had a fall mat present in her room when an audit had been completed during March 2024. She was unaware the fall mat was not being used for Resident #31 nor why they were not present in her room. The DON stated it was her expectation for fall interventions to be implemented by the staff.

Based on record review, observations and staff interviews, the facility failed to clarify a consultation note and discontinue an order for PICC (peripherally inserted central catheter) line care (Resident #78). This was for 1 of 3 residents reviewed for antibiotic use. The findings included: Resident #78 was originally admitted to the facility on [DATE]. She was recently readmitted from the hospital on 2/16/24 with a diagnosis of polymicrobial bacterial infection (acute and chronic diseases caused by various combinations of viruses, bacteria, and fungi) with a PICC line present. A review of Resident #78's active physician orders included an order dated 2/17/24 for PICC line dressing change every seven days. Review of an Infectious Disease progress note dated 4/5/24, indicated the PICC line would be removed on 4/5/24. Resident #78's April 2024 Medication Administration Record (MAR) was reviewed and indicated the order to change the PICC line dressing every seven days was still active from 4/5/24 to 4/30/24. On 5/1/24 at 12:11 PM, an observation of personal care was made with Nurse Aides (NAs) #6 and #7 of Resident #78. There was no PICC line observed to either arm. Unit Supervisor #2 was interviewed on 5/1/24 at 2:18 PM. She indicated when a resident returned from an appointment the paperwork was reviewed by herself. She reviewed the Infectious Disease progress note dated 4/5/24 and stated she was unsure why the order to change the PICC line dressing every seven days had not been discontinued and removed from the MAR as the PICC line had been removed on 4/5/24 at the appointment. Unit Supervisor #2 felt it was an oversight. On 5/1/24 at 2:22 PM, the Director of Nursing stated she would have expected a clarification order to be obtained to discontinue the PICC line dressing change every seven days when it was removed on 4/5/24.

Based on record reviews, observations, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following an annual recertification and complaint survey on 06/11/21. This was for two deficiencies that were cited in the areas of Accuracy of Assessments and Free of Accident Hazards/Supervision/Devices. During a complaint survey on 05/16/23, one deficiency was cited in the area of Free of Accident Hazards/Supervision/Devices. In addition, four deficiencies were cited during the annual recertification and complaint survey on 02/23/23 in the areas of Encoding/Transmitting Resident Assessments, Accuracy of Assessments, Care Plan Timing and Revision, and Free of Accident Hazards/Supervision/Devices. The deficient practice in the areas of Encoding/Transmitting Resident Assessments, Accuracy of Assessments, Care Plan Timing and Revision, and Free of Accident Hazards/Supervision/Devices were recited on the current recertification and complaint survey of 05/06/24. The duplicate citations during three federal surveys of record and one complaint survey show a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: F640- Based on record review and staff interviews, the facility failed to complete a Minimum Data Set (MDS) discharge assessment within the required time frame for 1 of 6 residents reviewed for discharge (Resident #58). During the facility's recertification survey of 02/23/23 the facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment and failed to transmit a discharge MDS assessment. This was for 2 of 2 residents selected to be reviewed for submission of Resident Assessments within the required timeframe. In an interview with the Administrator on 05/02/24 at 1:07 PM, he felt the repeat citations were due to Minimum Data Set (MDS) Nurse turnover. F641- Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) in the area of medication for 1 of 26 residents whose MDS assessments were reviewed (Resident #24). During the facility's recertification survey of 06/11/21 the facility failed to code the Minimum Data Set (MDS) accurately in the areas of prognosis, range of motion, and Preadmission Screening Resident Review (PASRR) level 2. This was for 3 of the 19 MDS's reviewed for accuracy. During the facility's recertification survey of 02/23/23 the facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of medications for 2 of 21 residents whose MDS were reviewed. In an interview with the Administrator on 05/02/24 at 1:07 PM, he felt the repeat citations were due to Minimum Data Set (MDS) Nurse turnover. F657- Based on record review and staff interviews, the facility failed to review and revise the care plans in the areas of antibiotic use and JP drain (A Jackson Pratt (JP) drain is a surgical suction drain that gently draws fluid from a wound to help recover after surgery) for Resident #81. This was for 1 of 3 residents reviewed for care plans. During the facility's recertification survey of 02/23/23 the facility failed to review and revise the care plan in the areas of falls, pressure ulcers, and medications. This was for 6 of 18 resident records reviewed. In an interview with the Administrator on 05/02/24 at 1:07 PM, he felt the repeat citations were due to Minimum Data Set (MDS) Nurse turnover. F689- Based on record review, observations, and staff interviews, the facility failed to ensure a fall mat was in place according to the care planned fall safety interventions (Resident #31). This was for 1 of 4 residents reviewed for accidents. During the facility's recertification survey of 06/11/21 the facility failed to provide supervision to 2 residents with known behavioral symptoms to prevent the physical assault, unwanted physical contact, and/or unwanted advancements into the personal space of cognitively impaired residents. This was for 2 of 3 residents reviewed for resident to resident altercations. During the facility's recertification survey of 02/23/23 the facility failed to ensure a fall mat was in place according to the care planned fall safety interventions. This was for 1 of 8 residents reviewed for accidents. During a complaint investigation survey on 05/16/23 the facility failed to provide a safe transfer for a resident who was at high risk for fractures, was non-ambulatory and required extensive assistance with a mechanical lift for transfers. This deficient practice was for 1 of 3 sampled residents reviewed for accidents. In an interview with the Administrator on 05/02/24 at 1:07 PM, he felt the repeat citations were due to the facility's leadership turnover.

Based on record review and staff interviews, the facility failed to provide the resident and/or Resident Representative (RR) written notification of the reason for a hospital transfer for 2 of 2 residents reviewed for hospitalization (Residents #78 and #86) and the facility failed to send a copy of a 30-day discharge notice to the Ombudsman for 1 of 1 resident (Resident #64) reviewed for facility-initiated discharge. The findings included: 1. Resident #78 was originally admitted to the facility on [DATE]. Resident #78's medical record revealed she was transferred to the hospital on 1/5/24 and readmitted back to the facility on [DATE]. Additionally, Resident #78 was transferred to the hospital on 1/29/24 and readmitted back to the facility on [DATE]. There was no documentation of a written notice of transfer provided to the resident and/or RR. On 4/30/24 at 11:15 AM, an interview occurred with the wound nurse, who had transferred Resident #78 to the hospital on 1/29/24. She stated that when a resident was transferred to the hospital, a medication list, resident summary, and bed hold policy was sent with them. The RR was notified via phone. During an interview with the Social Worker on 4/30/24 at 3:32 PM, she stated she didn't provide any written information to the resident and/or RR when a resident was transferred to the hospital. The Director of Nursing was interviewed on 4/30/24 at 3:34 PM and explained when a resident was transferred to the hospital the nursing staff called the RR but didn't mail anything to them in writing. On 5/1/24 at 8:40 AM, an interview was conducted with the Administrator who was familiar with the regulation. He stated he was unaware written notification to the resident and/or RR for the reason for a hospital transfer was not being sent and would expect the regulation to be followed. 46095 2. Resident #86 was admitted to the facility on [DATE]. Resident #86's admission Minimum Data Set (MDS) dated [DATE] indicated his cognition was intact. Review of Resident #86's electronic medical record read he was transferred to the hospital on 01/02/24. There was no documentation in the resident's medical record that written notice of transfer or discharge was provided to the resident and/or Resident Representative (RR). Resident #86 returned to the facility on [DATE]. An interview was conducted on 4/30/24 at 3:32 PM with the facility Social Worker (SW). She stated she had been at the facility since [DATE] and was not mailing a notice of discharge or transfer to the RR when the resident was admitted to the hospital. She was unaware she needed to send notification to the resident or RR in writing. An interview was conducted on 4/30/24 at 3:34 PM with the Director of Nursing (DON). She stated when a resident was transferred to the hospital the nursing staff called the RR but did not provide written notice of transfer or discharge. An interview was conducted on 5/1/24 at 8:40 AM with the Administrator who was familiar with the regulation. He stated he was unaware of written notification to the resident and/or RR for the reason for a hospital transfer was not being sent and would expect the regulation to be followed. 38904 3. Resident #64 was admitted to the facility on [DATE] and continued to reside in the facility. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #64 was cognitively intact. Review of Resident #64's record revealed a 30-day notice of discharge was provided to the resident on 5/7/2024. Further review revealed no evidence a copy of the notice was provided to the Ombudsman. During an observation and interview with Resident #64 on 5/15/2024 at 10:32 am he stated he was told he would be discharged soon but was not able to state why he was being discharged . He stated the facility gave him a notice of discharge and told him he had to leave. Resident #64 stated he was ready to get out of the facility. During an interview by phone with the Ombudsman on 5/15/2024 at 11:59 am she stated the facility should report a 30-day discharge notice to her within 48 hours of issuing the notice to the resident. The Ombudsman stated she had not received the notification Resident #64 received a 30-day discharge notice. On 5/14/2024 a phone interview was conducted with the Social Worker, and she stated she issued the 30-day discharge notice on 5/7/2024 to Resident #64 but she did not notify the Ombudsman because she had waited for the Business Office Manager to give her the documentation of the facility's attempts to collect the debts Resident #64 owed to the facility. The Business Office Manager was interviewed on 5/15/2024 at 12:55 pm and she stated she supplied the documentation of the attempts to collect the debts of a resident who was issued a 30-day discharge notice for non-payment. She stated Resident #64 wanted to return home and he was able to care for himself. She stated the Social Worker did not need the documentation of the attempts to collect the debts to notify the Ombudsman of the 30-day discharge notice the Social Worker gave Resident #64 on 5/7/2024. On 5/17/2024 at 4:42 pm the Administrator was interviewed and stated the Social Worker should have notified the Ombudsman when Resident #64 was issued the 30-day discharge notice for non-payment.

Based on record review and staff interviews, the facility failed to complete a Minimum Data Set (MDS) discharge assessment within the required time frame for 1 of 6 residents reviewed for discharge (Resident #58). Findings include: Resident #58 had been admitted on [DATE]. An admission MDS assessment had been completed on 11/8/23. Nursing documentation dated 11/18/23 at 1:05 PM noted Resident #58 had been discharged home. No discharge MDS assessment was observed in Resident #58's record. An interview with the MDS Coordinator was conducted on 4/30/24 at 3:38 PM. She explained when she became aware of a resident's pending discharge, she opened the MDS assessment at that time. She stated yesterday she noticed Resident #58's MDS discharge assessment had not been transmitted and explained she was unsure how it had been missed. On 5/01/24 at 2:59 PM an interview with the corporate Nurse Consultant was conducted. She stated she would expect MDS assessments to be transmitted within the required timeframe.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) in the area of medication for 1 of 26 residents whose MDS assessments were reviewed (Resident #24). Findings include: Resident #24 had been readmitted on [DATE] with diagnoses including Stroke and coronary artery disease. Review of Resident #24's Significant Change in Status MDS assessment dated [DATE] noted he had received anticoagulant (blood thinner) and antiplatelet (blood clot inhibitor) medication. Review of Resident #24's February 2024 Medication Administration Record (MAR) did not reveal he had received anticoagulant medication but had received antiplatelet medication. On 4/30/24 at 3:38 PM an interview with the MDS Coordinator was conducted. She explained when she completed MDS assessments she also checked the MAR. She stated anticoagulant should not been coded, only antiplatelet medication. On 5/01/24 at 2:59 PM an interview with the Corporate Nurse Consultant was conducted. She stated she would expect MDS assessments to be accurate.

Based on record review and staff interviews, the facility failed to review and revise the care plans in the areas of antibiotic use and JP drain (A Jackson Pratt (JP) drain is a surgical suction drain that gently draws fluid from a wound to help recover after surgery) for Resident #81. This was for 1 of 3 residents reviewed for care plans. The findings included: Resident #81 was admitted to the facility on [DATE] with diagnosis that included urinary tract infection (UTI), abscess to left kidney requiring a JP drain, and right foot diabetic ulcer. Record review revealed the JP drain and the peripherally inserted central catheter (PICC) line were removed on 03/25/24. Resident #81's active care plan, dated 04/04/24, revealed a focus that read resident had a peripherally inserted central catheter (PICC) line and a JP drain, requiring intravenous (IV) antibiotics and IV antibiotics for renal abscess. Date initiated: 04/04/24. An interview was conducted on 05/01/24 at 1:04 PM with the Minimum Data Set (MDS) Nurse. She verified the areas on Resident #81's care plan for peripherally inserted central catheter (PICC) line, JP drain, and IV antibiotics for renal abscess should have been removed. She stated it was an oversight that these areas on Resident #81's care plan had not been updated and removed. An interview was conducted on 4/30/24 at 3:34 PM with the Director of Nursing (DON). She stated the focus areas for peripherally inserted central catheter (PICC) line, JP drain, and IV antibiotics for renal abscess should have been removed on Resident #81's care plan.

Based on record review, observation and interview with the attending physician, resident and staff, the facility failed to provide a safe transfer for a resident who was at high risk for fractures, was non-ambulatory and required extensive assistance with a mechanical lift for transfers. On 4/18/23 agency Nursing Assistants (NAs) #1 and #2 transferred Resident #1 from her wheelchair to bed utilizing a stand pivot method resulting in the resident's right lower leg getting caught under the bed during the transfer. The resident reported pain in her leg and NA #1 and NA #2 did not report the injury to a nurse. Resident #1 sustained a fracture of the right tibial plateau (a break of the large lower leg bone below the knee that breaks into knee joint itself), required a knee immobilizer, orthopedic care, and experienced pain rated a 10 out of 10 (with 0 indicative of no pain and 10 being the worst pain imaginable). NA #1 and NA #2 had no knowledge of where the resident's Kardex (a care guide for NAs) was located and were unaware Resident #1 required a mechanical lift. This deficient practice was for 1 of 3 sampled residents reviewed for accidents (Resident #1). Findings included: Resident #1 was originally admitted to the facility on [DATE] with multiple diagnoses including hemiparesis (partial weakness/paralysis on one side of the body) and hemiplegia (complete loss of strength/paralysis on one side of the body) following cerebral infarction affecting the right dominant side. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had moderate cognitive impairment. The assessment further indicated the resident needed extensive assistance with two plus persons physical assist with transfers and ambulation did not occur over the entire 7-day period. Resident #1's Kardex (resident care guide) completed on admission (undated) revealed that the resident was non-ambulatory, and the transfer method was mechanical lift. The Kardex was observed on 5/8/23 at 2:30 PM in a binder located at the nurse's station. The Nurse Unit Manager was interviewed on 5/8/23 at 10:56 AM. She reported that Resident #1 had been using a mechanical lift for transfer for a long time, sometime in 2022. Review of the incident report dated 4/18/23 at 7:01 PM completed by Nurse #1 revealed Resident #1 was lying in bed with her right leg propped up on a pillow. Nurse #1 removed the pillow and the resident winced in pain and stated, can you please put that pillow back? Nurse #1 noticed the right leg was swollen and the resident stated that it hurt from her knee to her ankle. Resident #1 stated the pain was 10 on the scale of 1 to 10. The report indicated Resident #1 was alert and oriented to person, place, and time. A nursing progress note dated 4/18/23 at 10:02 PM revealed Nurse #1 went into Resident #1's room to obtain a urine specimen. The resident's right leg was propped up on a pillow. When the nurse removed the pillow under the resident's right leg, the resident winced for pain and stated, can you please put that pillow back? When asked, the resident stated her right leg hurt from her knee down to her ankle. She reported that when the 2 Nurse's Aides (NA #1 and NA #2) were transferring her from the wheelchair to bed, her foot got caught under the bed and she felt something pop, and it had been hurting bad. The resident was sent to the emergency room (ER) for evaluation. Nurse #1 was interviewed on 5/9/23 at 9:45 AM. She reported she had known Resident #1 since 2022. The resident was alert and oriented to person, place and time, and was reliable. The resident was non-ambulatory and had been using mechanical lift for transfer. The Nurse stated on 4/18/23 after 3:00 PM, she went to Resident #1's room and noticed a pillow under the resident's leg. She indicated when she removed the pillow under the resident's right leg, the resident winced in pain and requested to put the pillow back under her right leg. The nurse observed the resident's right leg to be swollen and the resident rated her pain as 10 on the scale of 1 to 10 when she removed the pillow. The nurse indicated nobody had informed her of the incident nor the resident's complaints of pain. The ER report dated 4/18/23 revealed that Resident #1 arrived in ER for an injury that happened approximately 2:00 PM at the nursing facility. The Emergency Medical Services (EMS) stated that resident's right lower leg got caught under the bed when the resident was being transferred back to bed from the wheelchair. The resident reported pain and swelling to lower leg and ankle. The resident was alert and oriented to person, place, date, and time. Evaluation in ER revealed a right tibial plateau fracture. She was placed in a knee immobilizer, non-weight bearing and Percocet (narcotic pain medication) for pain control and to follow up with the orthopedic in 1 week. The result of the Computerized Tomography (CT) of the lower right extremity dated 4/18/23 revealed acute, mildly depressed fracture of the anterior aspect of the lateral tibial plateau. Diffuse [spread or dispersing in many direction] severe osteopenia. Resident #1 was interviewed on 5/8/23 at 9:25 AM. She was in bed with a knee immobilizer on her right leg. She stated that she had the immobilizer since she fractured her leg and the Orthopedic Doctor had told her she would continue wearing the immobilizer for 4 more weeks. She reported that she fractured her right leg during transfer from the wheelchair to bed (on 4/18/23). She explained it was after lunch when she requested to be transferred back to bed. The 2 NAs (NA #1 and NA #2) transferred her, and during the transfer her right leg got caught under the bed. She heard a pop and her leg started to hurt badly. She screamed for pain and the NA stated she would let the nurse know. The resident indicated that she could not bear weight on her legs and the staff always use the mechanical lift for transfer. The written statement of NA #1 dated 4/20/23 was reviewed. The statement indicated that with the help of NA #2, she transferred Resident #1 from the bed to the wheelchair ready for her appointment. After the transfer, they left the room and started passing out breakfast trays. After breakfast, they started picking up breakfast trays when Resident #1 reported that she was sick and wanted to go back to bed. The statement indicated that NA #1 and NA #2 transferred the resident back to bed. NA #1 indicated that she was never told that Resident #1 was a mechanical lift for transfer. NA #1, an agency employee, was interviewed on 5/8/23 at 2:25 PM. She reported that 4/18/23 was her 3rd or 4th time working at the facility and she did not receive any orientation. She indicated she did not have access to the facility's kiosk, and she was not aware of the Kardex that was available at the nurse's station. She stated that on 4/18/23, after picking up the lunch trays, she assisted NA #2 in transferring Resident #1 back to bed by using the stand pivot transfer. She stated nothing happened during the transfer, and she did not hear the resident complain of pain. NA #2, an agency employee, was interviewed on 5/8/23 at 2:45 PM. NA #2 reported that 4/18/23 was her first day working at the facility and she did not receive any orientation. She was assigned to Resident #1. She stated she did not have access to the facility's kiosk, and she was not aware of the Kardex that was available at the nurse's station. She reported she was told that Resident #1 was two persons assist with transfers. She indicated that right after lunch, Resident #1 requested to be transferred back to bed from the wheelchair. NA #1 assisted her with the transfer using the stand pivot transfer. She reported that during the transfer, Resident #1 kept saying my leg hurts, my leg hurts and she told the resident that she would inform the nurse. NA #2 stated she did not inform the Nurse thinking that NA #1 did. NA #2 indicated she did not notice Resident #1's leg got caught under the bed during the transfer. NA #2 reported that she put a pillow under the resident's right leg since the resident was saying it hurt. The DON was interviewed on 5/8/23 at 10:05 AM. She reported she investigated the incident that happened on 4/18/23 with Resident #1. She interviewed Resident #1 on 4/19/23 and the resident reported that the 2 NAs transferred her from the wheelchair to bed. During the transfer, her right leg got caught under the bed. The resident indicated she screamed for pain and the NA told her she would inform the nurse. When in bed, a pillow was placed under her right leg. The DON indicated that the resident was alert and oriented to person, place and time and was reliable. The DON reported she interviewed NA #1 on 4/20/23 and obtained a written statement. NA #1 stated she was never informed that Resident #1 needed a mechanical lift for transfer. The DON reported she did not interview NA #2 since the NA had already left the building on 4/18/23 and she informed the agency not to send her back to work. A follow up interview was conducted with the DON on 5/9/23 at 11:05 AM. The DON revealed the resident's care summary including the resident's transfer status was posted in the kiosk, and the Kardex was available at the nurse's station. She reported the Staff Development Coordinator (SDC) was responsible for making sure all staff including agency staff had access to the kiosk and the Kardex at the nurse's station. She stated that if the agency staff did not know the transfer status of the resident, they should ask the nurse. The SDC was unavailable for interview. The Physician was interviewed on 5/9/23 at 11:53 AM. He stated Resident #1 had throat cancer and was on radiation therapy. She has a diagnosis of severe osteopenia and was a high risk for fractures. Using the lift for transfer could or could have not prevented the fracture. He indicated that minimal movement of resident with severe osteopenia could have caused spontaneous fracture. He stated that he expected the staff to use the appropriate transfer method for all residents to prevent injuries and to notify the nurse of any concerns voiced by the residents or any accident/injuries as they occur to the resident. The Administrator was interviewed on 5/9/23 at 10:15 AM. He stated he had just started as the administrator of the facility when the incident with Resident #1 happened. He reported the facility had plans to get rid of all the agency staff. He stated the incident was investigated by the DON, and a Quality Assurance and Performance Improvement (QAPI) was completed. A follow-up interview was conducted with the Administrator on 5/9/23 at 6:10 PM. He stated it was difficult to keep up with the agency staff. The facility received different staff from the agency every day, and it was unrealistic to educate each of them as they came. He reported the facility had planned to stop using agency staff. The corrective action with a compliance date of 4/25/23 was as follows: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non- compliance: The facility failed to ensure staff provided transfer per care plan and failed to report the incident to the nurse. NA #1 and NA #2 transferred resident using stand pivot instead, when resident was care planned for a 2-person mechanical lift. On 4/19/2023 resident #1's care plan was updated to reflect transfer status by the Regional Minimum Date Set (MDS) Nurse. On 4/20/2023 interview with NA #1 on 4/20/2023 informed the Director of Nursing that on 4/18/2023 she and NA #2, were assisting Resident #1 from wheelchair to bed as resident had asked to return to bed because she was sick. During a stand pivot transfer resident stated, I heard a pop. NA #1 and NA #2 continued to assist resident #1 to bed. Resident told staff that her leg hurt, and NA #1 and NA #2 placed a pillow under Resident #1's leg and resident appeared to be comfortable. NA #1 stated she didn't know Resident #1 was a lift transfer. Resident stated this was sometime between 11:00 am and 1:00 pm when this happened. Nursing Assistant #2 stated, On April 18th I was given the 200-hall assignment with Resident #1. I was given an assignment run down by NA #1. NA# 1 and was told Resident #1 was a two person assist. I was notified that she was getting a shower because she had an appointment. On update of the resident 200 hall. I was only aware of one Hoyer lift patient. NA #1 and I were informed by the nurse that Resident #1's appointment had been canceled and to lay her down after lunch. After lunch NA #1 and I went to transfer resident #1 to the bed and she stated, that her leg was hurting and we continued to transfer her to bed. Once we got her to bed, we asked if she needed the nurse, and she said yes. NA #1 said she would notify the nurse. On 4/18/2023 around 4:00 pm NA# 3 entered the room to change the roommate and states that when she completed the roommate's care, she decided to do Resident #1's care. Nurse #1 entered resident #1 room to obtain a urine sample as NA #3 assisted. The nurse removed the pillow under resident #1's right leg and resident #1 asked her to put it back. The nurse replaced the pillow and asked Resident #1 if she had any pain, at that time Resident #1 stated, she felt pain from her knee to her ankle. Resident #1 reported a pain scale of 3, on a 0-10 scale. This was the first time the Nurse was made aware of pain. Resident #1 made the NAs aware earlier when the CNAs had to position the resident's leg on a pillow for the resident's comfort. The nurse proceeded to ask Resident #1 had anything happened. Resident #1 informed the nurse when NA # 1 and NA #2 were putting her to bed her foot got caught under the bed and she heard a pop. At this time Nurse #1 reported the incident to the Director of Nursing and Physician. Nurse #1 assessed Resident #1 and noted swelling to the right leg, orders were received to send Resident #1 to the hospital. Emergency Medical Services (EMS) were called, and Resident #1 agreed to go out to the hospital. X-rays were obtained at the hospital and the results showed a fracture of Tibial plateau. Resident #1 returned on 4/18/2023 with orders for orthopedic follow up, a knee immobilizer and order for Percocet 5-325 Milligrams (MG) take 1 tablet by mouth as needed every 6 hours for pain. As of 4/19/2023 Nursing Assistant (NA) #1 and NA #2 were suspended pending investigation by the Director of Nursing. Director of Nursing notified the agency of the incident involving NA #1 and NA #2 and to remove them from the scheduling of this facility. The Agency was informed on 4/19/2023 by Director of Nursing that NA #1 and NA #2 were a do not return to the facility. How you will identify other residents having the potential to be affected by the same deficient practice, and what corrective action will be taken; All residents requiring assistance with transfers are at risk of being affected by this deficient practice when receiving care. Director of Nursing and/or Nurse Managers completed complete audit of all resident's transfer status as of 4/19/2023 and updated care plan as needed. All residents with a change in status are referred to the Rehab Department by nurse for further evaluation and transfer status change. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. As of 4/19/2023 4-point plan has been started to correct failing to follow proper transfers and reporting incident during transfer. Administrator and Director of Nursing completed 4-point Quality Assurance Improvement Plan (QAPI) as of 4/23/2023 to determine cause of incident. Investigation determined that re-education of care plan location and reporting of incident and accidents was needed. As of 4/19/2023 the Director of Nurses started education to ensure all licensed nurses and certified nursing assistants (full-time, part-time, as needed and agency) employees who do not complete the in-service training on transfers, resident transfer status and reporting change in condition related to pain will not be allowed to work until the training is completed. Staff Development Coordinator will ensure all new staff and agency staff have been educated. All nursing staff to include agency staff, must complete general orientation prior to working with residents. All staff, including agency staff, are given access to a kiosk prior to starting their shift. As of 4/23/2023 Director of Nursing and/or Staff Development Coordinator educated all licensed, non-licensed Nursing Staff and agency staff on proper transfer per care plan, resident transfer status location and reporting of resident pain or any change in condition. All employees to include agency staff, must complete general orientation prior to working with residents. AS of 4/23/2023 the Administrator, Director of Nursing and staffing coordinator will review staffing sheets daily to ensure staff scheduled have been educated and staff who have not been educated prior to starting their assignment receive education. As of 4/19/2023 Director of Nursing and or Nurse Manager will monitor 5 certified nursing assistants daily Monday- Friday for 4 weeks then 3 certified nursing assistants weekly for 3 weeks and then 3 certified nursing aides bi-weekly for 4 weeks to observe they are completing the transfer per care plan and reporting of any pain or change in condition. On 4/24/2023 Universal Healthcare at [NAME] conducted a QAPI meeting to review the findings of QAPI action plan and monitoring tools for effectiveness and any needed changes or improvements. Team consisted of Administrator, Director of Nursing, Nurse Managers, Social Worker, Rehab Director. Alleged Date of Compliance: 4/25/2023 On 5/16/23, as part of the validation process, the corrective action plan was reviewed and verified. Evidence of 100% auditing of residents' correct transfer and lift status on 4/19/23 and evidence of 100% all staff education on resident transfers, mechanical lifts and the Kardex on 4/19/23 was reviewed and verified. The facility provided evidence of daily Quality Assurance auditing of proper use of lifts and correct lift status starting 4/19/23 and ongoing. Observations revealed correct transferring method and correct use of mechanical lift during resident care. Interviews with agency and in-house aides reported they were able to access the Kardex and location of written Kardex and were educated on immediately reporting any resident accidents or resident pain during or after a transfer to the nurse. The validation process verified the facility's date of compliance as 4/25/23.

Based on record reviews and staff interviews, the facility failed to provide Registered Nurse (RN) coverage at least 8 consecutive hours a day for 7 out of 38 days reviewed for staffing. The failure to have RN coverage for the facility had the high likelihood to impact every resident in the facility. The findings included: Review of the Payroll Based Journal (PBJ) facility reporting, Posted Nurse Staffing as compared to the Staff Schedule/Assignment Sheets, and RN timecard reports revealed there was no RN coverage for eight consecutive hours on for 07/31/22, 08/07/22, 08/20/22, 08/21/22, or 08/28/22. This was for 5 of the 8 days reviewed from PBJ triggered days. Review of the Posted Nurse Staffing as compared to the Staff Schedule/Assignment Sheets and RN timecard reports for the period of 01/20/23 through 02/20/23 corroborated there was no RN coverage on 01/21/23 or 01/22/23. This was for 2 of the 30 days reviewed. An interview was conducted on 02/21/23 at 03:47 PM with the Administrator. She stated she did not have an RN on 07/31/22, 08/07/22, 08/20/22, 08/21/22, 08/28/22, 01/21/23 or 01/22/23. She further stated the agency did not have an RN available at that time. She stated she has had a hard time finding an RN to hire. An interview on 02/23/23 at 09:50 AM was conducted with the facility scheduler. She verified that the number of licensed staff and the total hours worked for licensed staff were incorrect for 21 out of 38 days. She stated she was counting the Minimum Data Set (MDS) nurse under 1st shift although she had not provided direct care to residents and that the accurate Posted Nurse Staffing Information Sheets had not been updated daily to reflect the correct hours that licensed staff had worked. She further stated they had hired a RN supervisor in January, who would have counted towards the RN hours, but she did not work out and was terminated. An interview was conducted on 02/23/23 at 10:17 AM with the Director of Nursing (DON). She stated she was aware they did not have RN coverage on some days. She further stated agency did not have an RN available at that time.

Based on record review and staff and resident interviews, the facility failed to resolve grievances which were reported in the Resident Council meetings for 4 out of 6 months reviewed (August 2022, September 2022, October 2022, November 2022, December 2022, January 2023). The findings included: Review of the grievance policy provided by the facility and dated October 2017 read as follows: The objective of the grievance policy is to ensure the facility makes prompt efforts to resolve grievances a resident may have. The intent of the grievance process is to support each resident's right to voice grievances (e.g., those about treatment, care, management of funds, lost clothing, or violation of rights) and to assure that after receiving a complaint/grievance, the facility actively seeks a resolution and keeps the resident appropriately apprised of its progress toward resolution. Observation of a Resident Council meeting was conducted on 02/21/23 at 3:16 PM and revealed an issue with resolution of grievance regarding activities on the weekend. Residents in the meeting had various ranges of cognition including, cognitively intact, moderately impaired, and severely impaired. The residents reported having expressed concerns about the lack of meaningful activities on the weekends The President of the Resident Council stated all we do is color. We want more activities on the weekends. She indicated it's frustrating and annoying that there are no activities on the weekends. We get bored. Another resident indicated we have to come up with our own activities on the weekends. A third resident indicated she would like to have more engaging activities on the weekends rather than coloring. The residents stated they had discussed their concerns of the activities several times during Resident Council meetings but felt like an appropriate resolution had not been made. Review of the Resident Council minutes dated 09/26/22 indicated activity concerns regarding coloring packets were not enough on the weekends and would like a crochet class and bingo on the weekends. The Resident Council Concern and Recommendation form completed by the Activities Director dated 10/25/22 indicated the plan of action from the 09/26/22 meeting was cards have been ordered. I will try to find someone that knows how to crochet to do a class and teach them how to do it. As far as activities on the weekends, there is lots of stuff they have access to on the weekends. Cabinets are full and are unlocked on weekends. They know they can go in them and do anything they want. Bingo cards are out as well. The form indicated the views, grievances, or recommendations from the group had not been acted upon by the facility to their satisfaction. Review of the Resident Council minutes dated 10/15/22 indicated activity concerns regarding needing an activity assistant on the weekends to assist with activities. Review of the Resident Council minutes dated 11/29/22 indicated activities concerns regarding there had not been communication regarding the Resident Council requesting an activity assistant on the weekends and would like an assistant on the weekends to assist with activities. Review of the Resident Council minutes dated 12/27/22 indicated see attached concern regarding concerns with activities. The Resident Council Concern and Recommendation Form (the attached concern from the Resident Council Meeting held on 12/27/22) completed by the Administrator dated 01/31/23 indicated the Resident Council Concerns were Residents voice concerns re: Activities being only independent and claim she is in the kitchen all of the time. Nothing on weekends . Activities Director is never in activities to coordinate programs. The Plan of Action indicated encourage residents to keep director or Social Worker informed of any activity they would like to have. Other residents do not always agree with the complaint. The Monitoring Process stated, as staffing improves and agency use is gone, will start another interview process to fill the assistant position. The form indicated the views, grievances, or recommendations from the group had been acted upon by the facility to their satisfaction. The former Activities Assistant was interviewed on 02/22/23 at 11:00 AM. She stated she was the Activities Assistant 6 months ago, but the facility had not found a replacement since she had become a Medication Assistant. She indicated she did not work on the weekends and there were no activities personnel on the weekends. She stated she was aware Resident Council expressed grievances regarding the lack of activities on the weekends; therefore, they would leave out activity packets which included 30 pages of coloring sheets and word searchers as well as left out board games. She stated a preacher came every Sunday, but they did not offer activities for non-religious residents on Sundays. An interview with the Social Worker on 02/23/23 at 9:25 AM revealed she met monthly with the Resident Council to discuss concerns, review old and new business, and encouraged residents to come up with recommendation for expressed concerns. She stated for every grievance expressed in Resident Council meetings, she identified the type of grievance and then provided it to the relevant department head. The Activities Director was made aware of Resident Council's concerns regarding the lack of activities on the weekend. The Activity Director was not available for interview. The Administrator was interviewed on 02/23/23 at 12:45 PM. She stated she was aware of Resident Council's grievances regarding wanting an activity assistant on the weekends and lack of activities on the weekends. She stated she has spoken with Resident Council several times regarding this concern and informed them an activities assistant cannot be hired due to staffing shortage. She stated she felt like she had responded to the Resident Council's grievances appropriately.

Based on record review and staff interviews, the facility failed to review and revise the care plan in the areas of falls (Residents #2, #38 and #58), pressure ulcers (Resident #14), and medications (Residents #43 and #77). This was for 6 of 18 resident records reviewed. The findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, muscle weakness and anxiety disorder. A review of Resident #2's medical record revealed she sustained an actual fall on 10/26/22 and another one on 1/22/23. Review of Resident #2's active care plan included a care plan for the risk for falls initiated on 1/26/23. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 had moderately impaired cognition and was coded with one fall with minor injury. On 2/23/23 at 10:53 AM, an interview was conducted with the Regional MDS Nurse Consultant. She reviewed Resident #2's active care plan and stated the care plan should have been revised to reflect the actual falls that occurred on 10/26/22 and 1/22/23. She felt it was an oversight. 2. Resident #38 was admitted to the facility on [DATE] with diagnoses that included history of falling, muscle weakness and pain to right knee. Review of Resident #38's medical record revealed she sustained an actual fall on 12/8/22 with injury. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 had moderately impaired cognition and had sustained a fall with injury. Review of Resident #38's active care plan, last reviewed 1/10/23, included a care plan for the risk for falls, initiated on 12/31/22. On 2/23/23 at 10:53 AM, an interview occurred with the Regional MDS Nurse Consultant. She reviewed Resident #38's active care plan and stated the care plan should have been revised to reflect the actual fall that happened on 12/8/22. She felt it was an oversight. 3. Resident #58 was admitted to the facility on [DATE] with diagnoses that included history of a stroke, history of falling and muscle weakness. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #58 had severely impaired cognition and was coded with one fall with injury and one fall with major injury. Review of Resident #58's active care plan, last reviewed 11/30/22, included a care plan for the risk for falls, initiated on 3/2/22. The care plan included the fall that occurred on 11/20/22 only. Review of Resident #58's medical record revealed he sustained falls on 8/15/22 with no injury, 11/19/22 with minor injury, 11/20/22 with injury, 11/23/22 with no injury, 12/18/22 with no injury and 1/13/23 with no injury. On 2/23/23 at 10:53 AM, an interview was completed with the Regional MDS Nurse Consultant. She reviewed Resident #58's active care plan and stated the care plan should have been revised to reflect the actual falls that occurred and felt it was an oversight. 14652 4. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #14 had severe cognitive impairment and she had no pressure ulcers. Resident #14's care plan with a review date of 12/29/22 was reviewed. One of the care problems was at risk for pressure ulcers and the goal was to remain free from additional pressure ulcers. The approaches included remove C collar to monitor skin for rash/breakdown. Resident #14 was observed on 2/21/23 at 8:55 AM and on 2/22/23 at 2:30 PM. The resident was not observed wearing a C collar. The Treatment Nurse was interviewed on 2/21/23 at 10:05 AM. She stated that she had not seen Resident #14 wearing a C collar. Nurse # 3 was interviewed on 2/21/23 at 10:10 AM. She stated that she had not seen Resident #14 wearing a C collar. She reported that the resident might have been admitted with a C collar way back in 2020. The Regional MDS Nurse Consultant was interviewed on 2/22/23 at 2:30 PM. She reviewed Resident #14's care plan and stated that the C collar should have been removed from the care plan when the C collar was discontinued. The Director of Nursing (DON) was interviewed on 2/23/23 at 12:20 PM. The DON stated that she expected the care plan to be reviewed and revised when indicated. 5. Resident #77 was admitted to the facility on [DATE] with multiple diagnoses including severe protein calorie malnutrition. Resident #77 had a physician's order dated 1/29/23 for a regular diet. Resident #77's care plan that was initiated on 1/30/23 was reviewed. One of the care plan problems was at risk for dehydration due to use of antibiotic medication for urinary tract infection and the approaches included diet: clear liquids as ordered and tolerated. Nurse # 3 was interviewed on 2/22/23 at 10:10 AM. She stated that Resident #77 was on a regular diet. The Regiona MDS Nurse Consultant was interviewed on 2/22/23 at 2:30 PM. She reviewed Resident #77's diet order and verified that Resident #77 was on a regular diet and not on a clear liquid diet. She indicated that the MDS Nurse might have checked the wrong diet on the selection of the care plan approaches. The Director of Nursing (DON) was interviewed on 2/23/23 at 12:20 PM. The DON stated that she expected the care plan to be reviewed and revised when indicated. 6. Resident #43 was admitted to the facility on [DATE] with multiple diagnoses including dementia. Resident #43 had a physician's order dated 1/19/23 for mechanical soft diet with thin liquids. Resident #43's care plan that was initiated on 1/30/23 was reviewed. One of the care plan problems was at risk for dehydration due to use of antibiotic medication for pneumonia and the approaches included diet: clear liquids as tolerated. Nurse # 3 was interviewed on 2/22/23 at 10:10 AM. She stated that Resident #43 was on a mechanical soft diet with thin liquids. The Regional MDS Nurse Consultant was interviewed on 2/22/23 at 2:30 PM. She reviewed Resident #43's diet order and verified that Resident #43 was on a mechanical soft diet and not on a clear liquid diet. She indicated that the MDS Nurse might have checked the wrong diet on the selection of the care plan approaches. The Director of Nursing (DON) was interviewed on 2/23/23 at 12:20 PM. The DON stated that she expected the care plan to be reviewed and revised when indicated.

Based on observations, record review, resident, and staff interview ' s the facility failed to provide nail care and incontinence care for 3 of 5 residents reviewed for activities of daily living (ADL ' s) (Resident #29, #1, and #2). The findings include: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses that included Dementia, stage 3 pressure ulcer, and contracture of right hand. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/14/22, revealed Resident #29 ' s cognition was severely impaired. Resident #29 required extensive assistance of one person for bed mobility, dressing, toilet use, personal hygiene, and toilet use. She required extensive assistance of two people for transfers. Resident #29 was coded for functional limitations in range of motion (ROM) on one side of her upper extremities. Review of Resident #29 ' s care plan with a revision date of 12/20/22 revealed a focus area for Activities of Daily Living (ADLs): required assistance for all ADLs related to polio syndrome, right hand contracture, and dementia. The following interventions were included: assist resident as needed and do not rush resident-allow extra time to participate in ADLS as much as possible and then complete task. a. Review of a grievance/concern initiated by Resident #29 ' s responsible party (RP) dated 11/18/22 revealed that Resident #29 was not assigned a Nursing Assistant (NA) from 7:00 AM through 1:00 PM on 11/18/22. Per grievance/concern form, the resident ' s RP came in to visit with Resident #29 at 2:15 PM and asked staff why resident was not out of bed. She was informed by NA #6 at 2:30 PM that Resident #29 was accidentally left off the assignment sheet from 7:00 AM through 1:00 PM. Assignment was immediately corrected to include Resident #29 when this was noted, and education was provided to staff on making sure all residents are included and are receiving care. Review of the assignment sheet for 11/18/22 revealed the assignment schedule had not been adjusted that morning and Resident #29 ' s room was clearly written and assigned to Nursing Assistant (NA) #6. NA #6 was unavailable for interview. An interview was conducted on 02/22/23 at 01:15 PM with the Team Leader. She indicated that she made the assignment schedule for staff the morning of 11/18/22. She stated on 11/18/22 the Nursing Assistants (NAs) assignments were changed that morning and Resident #29 ' s room was accidently left off the assignment sheet. She stated she fed Resident #29 breakfast that morning. She further stated a family member came in and was very upset that the resident had not been changed all morning/afternoon and that Resident #29 was wet. An interview was conducted on 02/22/23 at 01:35 PM with the Social Worker (SW). She stated on 11/18/22 Resident #29 ' s responsible party (RP) came to her because Resident #29 was accidently left off the Nursing Assistants (NAs) assignment sheet. She stated the RP said the resident was soaked in urine and it was unacceptable. An interview was conducted on 02/22/23 at 04:43 PM with Resident #29 ' s responsible party (RP). She stated she came to facility around 2:15 PM on 11/18/22 and Resident #29 was still in bed. She stated she was to be up by 10:00 AM every day. She further stated she was informed by staff that Resident #29 was overlooked on the assignment sheet. She stated she was very upset that Resident #29 had not been bathed, changed, or gotten up until 1:00 PM. An interview was conducted on 02/23/23 at 10:17 AM with the Director of Nursing (DON). She stated she expected all residents to be included on the daily assignment sheet and that every resident should receive care. She acknowledged that Resident #29 was missed on the assignment sheet on 11/18/22 and that all staff were educated on the importance of making sure all residents are listed and receiving care. b. An observation was conducted on 02/20/23 at 11:32 AM and on 02/22/23 at 10:14 AM revealed Resident #29 ' s fingernails on her left hand extended approximately 1/8th to 1/4th of an inch beyond her fingertips as did the index and thumb nails on the resident's right hand. Her left pointer finger was jagged, and the right ring finger was jagged. The resident's 3rd, 4th, and 5th fingers were observed curled into the right palm. An interview was conducted on 02/22/23 at 09:50 AM with the Team Leader. She stated the Nursing Assistants (NAs) are responsible for cutting residents nails during showers/baths and/or when they see that it needs to be done. She also stated she does rounds monthly to check to see if nails have been done. An observation and interview were conducted on 02/22/23 at 10:16 AM with the team leader and NA #2. They both confirmed Resident #29 ' s nails were long, the left pointer finger was jagged, and the right ring finger was jagged. They both confirmed her nails needed to be cut. The Team Leader stated nails are to be cut as needed and during showers/baths. An interview was conducted on 02/22/23 at 03:50 PM with the Director of Nursing (DON). She expected nails to be cut as needed. She stated she normally cuts Resident #29 ' s fingernails but she was unaware they needed to be cut. 2. Resident #1 was admitted to the facility on [DATE] with diagnoses that included stroke, Hemiplegia/hemiparesis (Hemiparesis is a mild or partial weakness on one side of the body. Hemiplegia is paralysis on one side of the body), and diabetes mellites. Review of quarterly Minimum Data Set (MDS) assessment, dated 01/30/23, revealed Resident #1 ' s cognition was severely impaired. She was totally dependent of one person for personal hygiene and bathing. There was no rejection of care or behaviors coded. She was coded for functional limitations in range of motion (ROM) on both sides of her upper extremities and impairment on 1 side of her lower extremities. Review of Resident #1 ' s care plan with a revision date of 11/01/22 revealed a focus for Activities of Daily Living (ADLs): only read the following: total care for ADLs. No interventions were listed related to ADLs other than splint application and skin checks under splints. A focus that she exhibits aggressive behavior with ADLs. Interventions included: to allow opportunity to make choices and participate in care and provide diversional activities. Observations on 02/20/23 at 10:14 AM and at 01:10 PM, and on 02/21/23 at 12:57 PM revealed Resident #1 ' s fingernails on her left and right hands extended approximately 1/8th of an inch beyond her fingertips. The middle finger on her left hand was jagged. An observation and interview were conducted on 02/22/23 at 10:16 AM with the team leader and NA #2. They both confirmed Resident #1 ' s nails were long, the middle finger on her left hand was jagged. They both confirmed her nails needed to be cut. The Team Leader stated nails are to be cut as needed and during showers/baths. An interview was conducted on 02/22/23 at 09:50 AM with the Team Leader. She stated the Nursing Assistants (NAs) are responsible for cutting residents nails during showers/baths and/or when they see that it needs to be done. She also stated she does rounds monthly to check to see if nails have been done. An interview was conducted on 02/22/23 at 03:50 PM with the Director of Nursing (DON). She expected nails to be cut as needed. 40197 3. Resident #2 was admitted to the facility on [DATE] with diagnoses that included history of a stroke, Alzheimer's disease, and muscle weakness. Resident #2's active care plan, with a start date of 1/26/23, included an area that read Resident requires assistance for eating, mobility, transfers, dressing, grooming, toileting and bathing related to impaired mobility, hearing impairment, vision impairment, some cognitive decline, fractured right wrist and incontinence. The interventions included to assist with Activities of Daily Living (ADLs) as needed A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 had moderately impaired cognition and displayed no rejection of care. She required total assistance from staff for personal hygiene. A review of Resident #2's nursing progress notes from 11/1/22 through 2/22/23 revealed no refusals of nail care documented. On 2/20/23 at 12:17 PM, an observation of Resident #2 occurred while she was sitting up in the wheelchair. Fingernails to both hands were medium length, and the left thumb and right fifth nails were jagged. Resident #2 was observed on 2/21/23 at 8:30 AM, while sitting in bed eating breakfast. Her fingernails remained unchanged from the previous observation. On 2/21/23 at 3:17 PM, Resident #2 was observed while sitting up in the wheelchair. Her left thumb and right fifth fingernails remained jagged. An interview occurred with Nurse Aide (NA) #3 on 2/21/23 at 3:21 PM and was assigned to care for Resident #2 on the evening shift (3:00 PM to 11:00 PM). She stated nail care was normally rendered during personal care or bathing tasks and was unable to state why Resident #2's nails had not been cared for. On 2/22/23 at 10:04 AM, an interview and observation occurred of NA #4 who was providing personal care to Resident #2. She stated she saw Resident #2 had jagged nails to both hands and had just finished cutting and filing them. NA #4 could not explain why nail care had not been completed prior to this day. She added nail care should be rendered during personal care and bathing. On 2/22/23 at 11:40 AM, an interview was conducted with NA #5 who was familiar with Resident #2 but not assigned to care for her. He explained nail care should be done daily to ensure nails were short and clean. The Director of Nursing was interviewed on 2/23/23 at 11:00 AM and stated she was not aware of any refusals of nail care from Resident #2 or that nail care was needed. She added that she would expect fingernails to be observed on shower days and during personal care with nail care rendered as needed.

Based on record review, resident interview, and staff interview, the facility failed to ensure group activities were planned on weekends to meet the needs of residents who expressed that it was important to them to attend group activities (Residents #35, #13, #3) for 3 of 3 residents reviewed for activities. The findings included: A review of the Activities Calendar from August 2022 through January 2023 revealed there was 1 activity planned every Saturday and 1 religious activity on every Sunday. a. Resident #35 was originally admitted to the facility on [DATE] with diagnoses that included major depressive disorder and anxiety disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #35's cognition was fully intact. This assessment indicated that it was very important to Resident #35 to do activities with groups of people. The Activity assessment dated [DATE] indicated Resident #35 preferred to participate in activities in the morning and afternoon, in the day/activity room, and was motivated to participate in activities. The assessment indicated she preferred to participate in cards, games, crafts/arts/hobbies, exercise/walking/jogging, music, baking/cooking, spiritual/religious, time outdoors, watching TV/radio, watching movies, talking/conversing, helping others/volunteer work, parties/social events, and keeping up with the news. Resident #35's active care plan dated 12/01/22 included the focus area of Resident #35 to verbalize her preferences and she stated she enjoyed cards, games, crafts, exercise, music, baking/cooking, spiritual/religious, watching TV, movies, talking/conversing, helping others, parties/social events, and keeping up with the news. The goal included Resident #35 will participate in activities she prefers. Interventions included to assist Resident #35 with getting to activities, remind her when activities are scheduled, and post a personal activity calendar in her room. During a Resident Council meeting held on 02/21/23 at 3:16 PM Resident #35 indicated residents had to come up with their own activities on the weekends. She indicated the weekends can be boring due to the lack of activities. She would like more activities rather than coloring and worksheets. b. Resident #13 was originally admitted to the facility on [DATE] with diagnoses that included major depressive disorder and anxiety disorder The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9's cognition was moderately impaired. The Activities assessment dated [DATE] indicated Resident #13's current interests included cards, games, crafts/arts/hobbies, exercise, music, baking/cooking, spiritual, time outdoors, watching tv and movies, gardening, talking, helping others, parties/social events, and keeping up with the nose. Resident #13's care plan dated 05/29/22 included a focus area of verbalizing her preferences and had stated she enjoyed cards, crafts, games, exercise, music, baking/cooking, spiritual/religious, spending time outdoors, watching TV and movies, gardening, talking and conversing, helping others, parties/social events, keeping up with the news, and community outings. The goal included for Resident #13 to participate in her preferred activities. Interventions included post a personal activity calendar in her room; encouraged her to attend activities that include music, and invited and encouraged her to participate in activity groups of interest. During a Resident Council meeting held on 02/21/23 at 3:16 PM Resident #13 indicated there were very few meaningful activities on the weekends and stated All we do is color. She stated she would like more activities on the weekends. She indicated she gets bored on the weekends because of the lack of activities. c. Resident #3 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 cognition was severely impaired and it was important for her to do favorite activities with groups of people. The Activities assessment dated [DATE] indicated she was interested in cards, games, crafts/arts, music, baking/cooking, spiritual, time outdoors, watching TV and movies, listening to the radio, talking/conversing, parties/social events, and keeping up with the news. She was assessed as being motivated and interested in attending activities. Resident #3's active care plan dated 12/24/19 included the focus area of verbalizing her preferences and stated she enjoyed cards, crafts, games, music, reading, spiritual/religious, spending time outdoors, watching TV and movies, talking, conversing, baking/cooking, parties, social events, and keeping up with the news. The goal included for her to participate in her preferred activities. Interventions included to encourage her to attend activities that involve music; staff will take her outside when the weather is nice for fresh air; and invite and encourage her to participate in activities. During a Resident Council meeting held on 02/21/23 at 3:16 PM Resident #3 indicated she mostly does coloring sheets and word searches on the weekends. She stated she would prefer more activities on the weekends. She stated she does not attend the religious services. The former Activities Assistant was interviewed on 02/22/23 at 11:00 AM. She stated she was the Activities Assistant 6 months ago, but the facility had not found a replacement. While she was an Activities Assistant she assisted with activities such as playing music for residents, assist with snack time, play balloon toss with residents, and facilitate exercise class. She indicated she did not work on the weekends and there were no activities personnel on the weekends. They would leave out activity packets which included 30 pages of coloring sheets and word searchers as well as left out board games. She stated a preacher came every Sunday, but they did not offer activities for non-religious residents on Sundays. An interview with the Social Worker on 02/23/23 at 9:25 AM revealed she met monthly with the Resident Council to discuss concerns, review old and new business, and encouraged residents to come up with recommendation for expressed concerns. She indicated the lack of weekend activities was an ongoing issue with Resident Council, and was working with Resident Council to resolve the concern. She stated the residents would like more variety of activities on the weekends. The Activity Director was not available for interview. The Administrator was interviewed on 02/23/23 at 12:45 PM. She stated she felt she had attempted to accommodate the residents several times, but the residents seem to not find the resolutions acceptable. She had attempted to make changes, but residents did not attend the alternative activities. She stated she had attempted to provide additional activities to celebrate Thanksgiving, but very few residents attended. She indicated she was swamped with staffing issues and was focused on resident care rather than additional activities on the weekends.

Based on record review and interviews with staff, Medical Director, and Physician's Assistant, the facility failed to provide supervision to 2 residents (Residents #80 and #74) with known behavioral symptoms to prevent the physical assault, unwanted physical contact, and/or unwanted advancements into the personal space of cognitively impaired residents (Residents #8, #17, #35, #37, #41, #64, #81, and #82). This was for 2 of 3 residents reviewed for resident to resident altercations. Immediate Jeopardy began for Resident #74 on 8/19/20 when she approached Resident #17 from behind and attacked her by striking her multiple times in the arm. Immediate Jeopardy began for Resident #80 on 3/26/21 when he attempted to grab Resident #37's genital area. Immediate Jeopardy for Residents #74 and #80 was removed on 6/5/21 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy Removal. The facility will remain out of compliance at a lower scope and severity level E (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to correct the deficient practice and to ensure that the education and the systems put in place to remove the Immediate Jeopardy are effective. The findings included: 1. Resident #80 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] (TBI) and dementia. The facility's status listing indicated Resident #80 resided on the secured memory care unit (400 hall) at the time of admission. On 3/3/21 a care plan was initiated for Wandering: unsafe situations. The goal was for wandering not to contribute to injury. The following interventions were initiated on 3/3/21: - Place resident in area where frequent observation is possible - Provide diversional activities - Place monitoring device on resident that sounds alarms when resident leaves building - Note which exits resident favors for elopement from facility and alert staff working near those areas - Monitor and document target behaviors - Implement facility protocol for locating an eloped resident - If wandering away from unit, instruct staff to stay with resident, converse and gently persuade to walk back to designated area with them - Approach wandering resident in a positive, calm, and accepting manner - Alert staff to wandering behavior The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #80 ' s cognition was severely impaired. He was assessed with no behaviors, no rejection of care, and no wandering. Resident #80 required extensive assistance of 2 or more for bed mobility and transfers and the extensive assistance of 1 for locomotion on/off the unit. He utilized a wheelchair and had impairment with range of motion on 1 side of his upper and lower extremities. Resident #80 was administered no [CONDITION(S)] medications. The Medication Administration Record (MAR) indicated Resident #80 refused routine medications on 3/15/21. A nursing note dated 3/15/21 at 1:56 PM by Nurse #1 indicated Resident #80 grabbed Resident #64 by the wrist. When staff attempted to remove Resident #80's hand from Resident #64 he became combative and started swinging at staff member and trying to get back to the resident who had been moved away. The Physician's Assistant (PA) advised to give as needed (PRN) [MEDICATION(S)] (antianxiety medication) and continue to monitor. Nurse #1 wrote that she spoke with Resident #80 ' s Responsible Party (RP) and she was advised that Resident #80 had a history of elopement and exit seeking. He also had a history of sexual behaviors and aggression toward others. The RP was made aware of the incident with Resident #64. (Resident #64's 2/9/21 MDS indicated she had severe cognitive impairment and no behavioral symptoms.) A physician's order for Resident #80 dated 3/15/21 indicated a PRN order for [MEDICATION(S)] Intramuscular (IM) 2 milligrams (mg)/milliliter (ml) vial administer 0.25 ml (0.5 mg) IM every 6 hours PRN for agitation. This order had a discontinue date of 3/16/21. Review of the MAR indicated that was administered 1 time on 3/15/21 and was noted to be effective. During a phone interview with Nurse #1 on 6/3/21 at 3:30 PM she revealed Resident #80 resided on the secured memory care unit (400 hall) and that on 3/15/21 he grabbed Resident #64 by the wrist and was holding really tight. She stated that this was inappropriate contact and was unwanted by the other resident. When attempting to redirect Resident #80 and asking him to let go of Resident #64 he became violent, agitated, and combative. Nurse #1 revealed that Resident #80 then visibly held Resident #64 ' s wrist tighter. Nurse #1 stated that she was able to redirect Resident #80 eventually and she contacted the PA and received an order for PRN [MEDICATION(S)]. She indicated she also spoke with his RP and the Director of Nursing (DON) to inform of this incident. Nurse #1 stated Resident #80 frequently wandered in other resident rooms by self-propelling his wheelchair. She reported that he moved quickly in his wheelchair throughout the unit. Nurse #1 revealed that prior to this incident she was informed by other nursing staff, unable to recall whom, of Resident #80's inappropriate physical contact with female residents such as rubbing female residents' thighs and holding their hands. On 3/15/21 a care plan was initiated for Resident #80 related to socially inappropriate, disruptive behavior, combative, grabbing staff, grabbing residents, and a history of sexual behaviors. The goal was for Resident #80 to have no more than 1 episode of inappropriate and/or combative behaviors through the next review period (6/20/21). The interventions, all initiated on 3/15/21, read: - Talk in calm voice when behavior is disruptive - Refer to Social Services for evaluation - Remove from public area when behavior is disruptive and unacceptable - Do not argue with resident - Administer behavior medications as ordered by physician - Provide diversional activities A care plan was also initiated for Resident #80 on 3/15/21 related to physically aggressive behaviors. The goal was for episodes of physically aggressive behaviors to decrease by 50% within specified timeframe (6/25/21). The interventions, all initiated on 3/15/21, read: - Do not argue with resident - Talk in calm voice when behavior is disruptive - Refer to Social Services for evaluation - Reinforce unacceptability of verbal abuse - Remove from public area when behavior is disruptive and unacceptable - Praise for demonstrating desired behavior - Monitor and document target behaviors - Identify causes for behavior and reduce factors that may provoke aggressive behaviors - Discuss options for appropriate channeling of anger - Assist in selection of appropriate coping mechanisms - Administer behavior medications as ordered by physician - Provide diversional activities A nursing note dated 3/18/21 at 1:46 PM completed by Unit Manager (UM) #1 indicated Resident #80 became agitated with the Nursing Assistant (NA) when he was attempting to go into another resident's room. Resident #80 began yelling and she (UM #1) intervened and determined the resident wanted to lay down in his bed. He was noted to be easily redirected. The MAR indicated Resident #80 refused routine medications on 3/18/21, 3/19/21, 3/20/21, 3/21/21, 3/22/21, and 3/23/21. A nursing note for Resident #80 for 3/23/21 (entered as a late entry note on 3/25/21 at 4:44 AM) completed by Nurse #2 indicated that Resident #80 was extremely combative, uncooperative, verbally aggressive, and was refusing medication. The physician on call was notified and made aware of behaviors and new orders were received. A physician's order dated 3/24/21 for Resident #80 indicated [MEDICATION(S)] IM 2 mg/ml vial 1 mg IM once. The MAR indicated that this was administered 1 time on 3/24/21 at 2:11 AM and was noted to be effective. The MAR indicated Resident #80 refused routine medications on 3/24/21. A nursing note dated 3/25/21 at 4:51 AM by Nurse #2 indicated Resident #80 continued to have episodes of extreme combativeness, was refusing medications, and would not allow staff to assist him. He had to constantly be redirected out of other residents ' rooms and when staff attempted to remove him he began to swing at staff. Nurse #2 wrote that staff would continue to attempt to redirect Resident #80 and continue to monitor behaviors. The MAR indicated Resident #80 refused routine medications on 3/25/21 and 3/26/21. A nursing note dated 3/26/21 at 10:10 PM completed by UM #1 read, Resident [#80] noted with inappropriate sexual behaviors - Resident observed in another residents room, resident pulled the blanket off of a resident that was resting in her bed and attempted to grab her genital area . UM #1 wrote that staff intervened and removed Resident #80 from the other resident (Resident #37) and he was assisted to common area. UM #1 further wrote that Resident #80 soon left common area and began going in and out of other resident rooms again. She indicated that staff attempted to monitor frequently and keep Resident #80 away from female residents as he was often observed rubbing others legs and other unwanted physical contact. (Resident #37 ' s 1/14/21 MDS indicated she had severe cognitive impairment and no behavioral symptoms.) An interview was conducted with UM #1 on 6/3/21 at 2:00 PM. UM #1 revealed that on 3/26/21 she observed Resident #80 in Resident #37's room. She indicated Resident #37 was sleeping and Resident #80 had pulled down her covers and his hand was about 6 inches away from her brief and she believed he was reaching down to touch her in the genital area, but she was able to intervene in time to prevent this. UM #1 stated that after this incident she and the two NAs, unable to recall names, who were working kept a close eye on him the rest of the shift. She stated that she was aware Resident #80 had previously exhibited combative behaviors and sexually inappropriate behaviors that included rubbing females ' thighs and holding their hands. She stated that to her recollection these behaviors began occurring within a week of his admission (3/3/21). The MAR indicated Resident #80 refused routine medications on 3/27/21, 3/28/21, and 3/29/21. A physician's order dated 3/29/21 indicated [MEDICATION(S)] 2 mg/ml administer 0.25 ml (0.5 mg) 3 times daily 9:00 AM, 5:00 PM, 9:00 PM). The first scheduled administration on the MAR was 3/29/21 at 5:00 PM. The MAR revealed that Resident #80 refused IM [MEDICATION(S)] on 3/29/21. A nursing note for Resident #80 for 3/29/21 (entered as a late entry note on 3/30/21 at 1:58 PM) completed by Nurse #3 indicated she was called to the memory care unit by NA #1 at 7:00 PM. Resident #80 had been found in the doorway of Resident #8's room. Resident #80 was bleeding and Resident #8 was on the floor out of bed with her shirt ripped and her left arm out of shirt. Resident #80 stated to NA #1 this [b***h] scratched me and bit my finger. Resident #80 was assessed and had skin tears to his right forearm which were treated. Nurse #3 wrote that when asking Resident #80 if he pulled Resident #8 out of bed he stated, I may have done that. The DON was contacted immediately and notified of incident. Resident #80 was later noted in another resident ' s room by NA #1. NA #1 reported Resident #80 had a female resident (Resident #35) by the leg and when she attempted to redirect him he threw a trash can at her. Nurse #3 indicated that later that day when she returned to the secured unit Resident #80 was in another female resident ' s room (Resident #81) and he was again redirected. Resident #80 was placed with a one to one (1:1) sitter for the 3rd shift. Physician and RP were made aware. (Resident #8's 3/3/21 MDS indicated she had severe cognitive impairment and no behavioral symptoms. Resident #35 ' s 2/2/21 MDS indicated she had severe cognitive impairment and no behavioral symptoms. Resident #81's 4/4/21 MDS indicated she had severe cognitive impairment and no behavioral symptoms.) A nursing note for Resident #8 for 3/29/21 (entered as a late entry note on 3/30/21 at 1:58 PM) completed by Nurse #3 indicated she was called to Resident #8's room by NA #1 and Resident #8 was on the floor beside her roommate ' s bed with her head at the foot of the roommate's bed. Another resident (Resident #80) was in Resident #8's doorway. Resident #8's shirt was ripped and her left arm was noted to be out of the shirt. Resident #8 was assessed with no injuries. Nurse #3 indicated that she immediately contacted the DON to make aware of incident and the physician and RP were notified. A facility fall report completed by Nurse #3 indicated on 3/29/21 at 7:00 PM Resident #8 was noted on the floor beside the bed. Another resident (Resident #80) was noted pulling on Resident #8's arm. Resident #8 scratched Resident #80's arm. The following hard copy statements were completed in relation to incidents with Resident #80 that occurred on 3/29/21: - A hard copy typed statement signed by the DON and dated 3/30/21 indicated that she spoke with Resident #80 and Resident #8 due to the incident report on 3/29/21. Resident #80 stated that he had not remembered any incident that happened on 3/29/21. Resident #8 was not oriented enough to answer if something had happened on 3/29/21. The DON wrote that she interviewed staff to see if the 3/29/21 incident with Resident #80 and #8 was witnessed and staff stated that it was not witnessed, but was an assumption due to Resident #80 sitting in his wheelchair in Resident #8 ' s doorway. - A hard copy typed statement signed by NA #1 (undated) indicated she was working on the memory care unit (400 hall) on the night of 3/29/21 when she heard Resident #35 screaming. NA #1 wrote that she went to Resident #35's room and saw him holding her legs and starting to pull her out of bed. When Resident #80 was redirected from Resident #35 he threw a trash can at NA #1 and then attempted to hit her with his fists. NA #1 revealed, [Resident #80] is very combative and dangerous to the women in this facility. He is constantly in and out of female resident rooms. - A hard copy written statement signed by Nurse #3 on 3/29/21 indicated NA #1 observed Resident #80 in Resident #35 's room pulling on her leg. Resident #80 was later noted in another female resident ' s room, Resident #81. Resident #80 was removed from Resident #81's room. Nurse #3 wrote that all information was reported to the DON and Resident #80 was put with a 1:1 sitter on the 3rd shift. - A hard copy typed statement signed by the SW and dated 3/30/21 indicated that on 3/30/21 she received information from the DON and Administrator of the incidents that occurred with perpetrator Resident #80 and victims Resident #8 and #35. Resident #80 reported no memory of the incidents and the victims, Resident #8 and #35, were unable to provide any information on the incident. SW interviewed NA #1, the NA who was working at the time of the incidents, and she reported that Resident #80 was seen coming out of Resident #8's room saying, that b***h scratched me. NA #1 stated that Resident #8 was found on the floor with head positioned by roommate's bed. Resident #8 had no visible injuries or signs of pain per NA #1. Resident #80 had sustained a scratch on his forearm. The SW wrote that later that day Resident #80 was found in Resident #35's room pulling on her ankles and Resident #35 was stating, get that man out of my room. The SW indicated that she was instructed by the Administrator to initiate an IVC on Resident #80 as he was a threat to other residents. The IVC order was denied by the county Magistrate's Office and a referral was then given to mobile crisis. SW contacted mobile crisis, but staff declined to proceed with mental health evaluation due to COVID-19 testing protocols at the facility. The DON contacted the Medical Director and Resident #80 was moved from the memory care unit (400 hall) to another unit in the facility (200 hall). During an interview with Nurse #3 on 6/3/21 at 1:30 PM she confirmed the information in her documentation and hard copy statement. She indicated that there were 2 NAs working in the secured unit on the 2nd shift on 3/29/21 and she was working a split hall with the secured unit (400 hall) and the 300 hall. She explained that when she was on the 300 hall she was not able to see into the hallway of the secured unit as it was around the corner from the 300 hall. Nurse #3 further explained that she had not witnessed Resident #80 pull Resident #8 out of bed as she was administering medications on the 300 hall at the time of the incident, but when she was called over by NA #1 it seemed obvious that Resident #80 pulled Resident #8 out of bed and ripped her shirt as the shirt was previously intact. She added that Resident #8 had scratched Resident #80 in what appeared to be self-defense. Nurse #3 stated that on 3/29/21 after the incident with Resident #8, Resident #80 was placed on 15 minute observations. She indicated that sometime after that, unsure of the time, Resident #80 was found in Resident #35's room holding her leg, and then again later that shift he was found in Resident #81's room. She was asked why Resident #80 was not placed on 1:1 during the second shift she stated that there was not enough staff to assign someone to Resident #80 for 1:1 until the 3rd shift. During an interview with NA #1 on 6/3/21 at 4:18 PM she stated that she regularly worked with Resident #80 when he was at the facility and that it was known by all staff who worked on the secured unit that he regularly wandered in and out of other resident rooms and frequently was seen with his hands rubbing female residents' legs or holding their hands. She reported that they tried to redirect him the best they could. She confirmed she was working on 3/29/21 during the 2nd shift. She stated that she was working with one other NA (unable to recall the NA) and Nurse #3 was split with the secured memory care unit (400) and the 300 hall. She indicated that during that shift she heard Resident #8 yelling out. She stated that this was a normal behavior for Resident #8 so initially she had not reacted. She indicated that Resident #8 kept yelling and that at some point the yelling sounding different indicating that it sounded like she was in distress so that's when she went over to her room and found Resident #8 laying on the floor with Resident #80 seated in his wheelchair in the doorway. Resident #80 said to her, I got her, I got her and he held out his arm and showed her the scratches he had on his arm. She indicated that Resident #8 stopped yelling as soon as she saw her come to the room. She stated that Resident #8's shirt was ripped and one arm was out of the sleeve to the shirt and it was bunched up to her neck. NA #1 indicated that she had not known how long Resident #80 was in the room with Resident #8 because she was providing care to another resident and initially had not responded to the yelling because this was her baseline behavior. She reported that the other NA was in a different resident ' s room. She stated the other NA had not even come to Resident #8's room when she was yelling as she was in the middle of care. She confirmed Resident #80 had another incident that same night in which she found him in Resident #35's room grabbing her leg and holding it out off of the bed. She had not recalled Resident #80 being found in Resident #81 ' s room on 3/29/21 as was indicated by Nurse #3's interview and nursing note. NA #1 reported that Resident #80 was placed on 15 minute observations for the remainder of the 2nd shift and was then on 1:1 during the 3rd shift. She stated that there was not enough staff to assign someone for 1:1 during the 2nd shift. She revealed that there were times during the shift that she and the other NA were both in rooms with other residents providing care and Nurse #3 was on the 300 hall and no one was supervising Resident #80. The Resident Status History List indicated that Resident #80 was moved off the memory care unit (400 hall) on 3/30/21. The MAR indicated Resident #80 refused routine medications on 3/30/21. These medications included routine IM [MEDICATION(S)]. A note dated 3/30/21 at 10:10 PM completed by the Social Worker (SW) read, On 3/15/21 [Resident #80] is agitated and threw cup of water at staff, holding another resident's wrist, swinging and combative at staff. On 3/18/21 [Resident #80] is agitated with staff. Resident has [history] of sexual behaviors and aggression towards others. On 03/18/21 [Resident #80] is agitated with staff, attempting to enter another resident's room. On 03/25/21 [Resident #80] is combative with staff and attempting to go in another resident's room. A note dated 3/30/21 at 10:54 PM completed by the SW indicated that on 3/26/21 Resident #80 grabbed another female resident's genital area and was rubbing her legs and on 3/30/21 Resident #80 entered another female resident's room and was holding her legs. Staff intervened and Resident #80 threw a trash can at staff. The SW wrote that she made a prior psychiatry referral with nursing facility ' s psychiatric provider, but Resident #80 ' s insurance had not covered this service. SW indicated she made referral for Involuntary Commitment (IVC) at the magistrate ' s office on 3/30/21 for immediate in-patient psychiatry services, but the magistrate ' s office denied IVC. SW then made referral for mobile crisis assessment, but mobile crisis staff declined to follow up with resident via face to face due to nursing home protocols for rapid COVID testing and they also declined virtual assessment due to their lack of virtual service capabilities. SW consulted with DON and administrator regarding care plan for psychiatry follow up. DON contacted on call facility physician and resident was transferred to another hall with behavioral monitoring. An interview was conducted with the SW on 6/3/21 at 12:54 PM. She stated that the information in her 3/30/21 notes came from nursing notes and staff report and that she had not observed any of these behaviors. She indicated that she was aware Resident #80 had physical behaviors and verbal behaviors directed toward staff, but she had not been aware of his inappropriate sexual behaviors until 3/29/21. She explained that on Monday 3/29/21 she learned about the incident that occurred on Friday 3/26/21 in which Resident #80 was observed attempting to touch Resident #37 ' s genital area. The SW stated that on 3/30/21 she was informed of the incidents that occurred with perpetrator Resident #80 and victims Resident #8 and Resident #35 on 3/29/21. The SW indicated that she tried to get Resident #80 psychiatric services with the facility ' s provider, but they denied him services due to insurance reasons. She stated that she was instructed by the Administrator and DON to make a referral for an IVC, but that this was denied by the magistrate (3/30/21). She indicated that she then contacted mobile crisis to see if they would complete an emergency assessment, but they declined to come to the facility for a face to face visit as the facility was requiring all persons who came into the facility to be rapid tested for COVID-19 prior to entrance. She reported that mobile crisis also refused to complete a virtual visit stating that they had not had the capabilities to do this. The SW stated that mobile crisis suggested that she speak with the facility ' s physician and have them file for an IVC. She reported that this was when she spoke with the PA and he agreed to file for an IVC for Resident #80. A PA note dated 3/31/21 indicated an acute visit was conducted with Resident #80 (entered as a late entry note on 4/5/21 at 3:06 PM). The PA wrote that Resident #80 had assaulted several staff and residents at the facility and he was signing for an IVC to a more secure setting. The PA indicated that he was notified by the nursing staff that Resident #80 had, over the past five days, been combative and uncooperative and was not taking his medications. He's also been going into other residents' rooms, females and groping them in a sexual manner. This has been going on for several days. The PA revealed that on this date, 3/31/21, staff told him that on the third shift, he went into a female resident ' s room, pulled her out of her bed, was groping her genital area, and rubbing her legs. When this behavior was discovered and Resident #80 was confronted by the staff he threw a trash can at the staff. The PA indicated that efforts were made to have a psychiatric evaluation but unfortunately his insurance had not covered that type of consultation. He indicated that an involuntary commitment request was made at the Magistrate's Office and they refused to issue the involuntary commitment. He further wrote that on his examination of Resident #80 on this date (3/31/21) the resident was sitting in his room eating his lunch. When asked about these recent behaviors he denied any of these incidents / behaviors. Resident #80 had been moved out of the secured memory care unit and into another hallway for fear of any further harm to the memory care patients. He indicated that Resident #80 had been refusing to take his medications over the last 5 days and along with the above mentioned behaviors, there were other reported incidents including cursing and slurs at the staff, swinging, and attempting to assault the staff members and other residents. Resident #80 was noted to be confined to a wheelchair and [CONDITION(S)] (weakness of one side of the body) on his non-dominant side, but he had full range of motion with his dominant upper extremity and was able to propel himself in his wheelchair. The PA indicated that he was a large male and his general strength was fairly well preserved in his upper body and lower body on his dominant side. He further indicated that Resident #80 had been causing issues with the other older, weaker and demented patients in the memory care unit. He wrote that an attempt of trial [MEDICATION(S)] IM was to be conducted to see if this would help with his behaviors, but that the DON asked that an involuntary commitment form be completed on Resident #80 to transfer him out of this facility. A phone interview with the PA on 6/3/21 at 2:42 PM confirmed the information in the above note. He stated that the behavioral information was reported to him by nursing staff. He indicated that he also spoke with the DON. The PA revealed that in his opinion, Resident #80 was cognitive enough to be aware of his actions and that he also was aware enough to deny it. He acknowledged that Resident #80 physically assaulted Resident #8 and that he made unwanted sexual advances towards multiple female residents. The PA was asked if he was aware Resident #80 had 2 more incidents of being found in female resident rooms on the same night as of incident with Resident #8 (3/29/21). He indicated he was not aware there were multiple incidents on the same night. He was asked if expected staff to provide the supervision necessary to prevent repeat incidents for residents with known behaviors and to keep other residents safe and free of physical assault, unwanted advancements, and inappropriate sexual behaviors he indicated that this was his expectation. He stated that Resident #80 was abusing the residents and throwing things and swinging at staff and that they could not have him hurting people at the facility so Resident #80 had to be sent out in order to receive a psychiatric evaluation. The PA explained that he wanted Resident #80 to have a psychiatric evaluation as this was their area of expertise. He stated that he was told by facility staff that due to insurance reasons Resident #80 was unable to see the facility ' s psychiatric provider. The PA reported that these reasons as well as the DON ' s request was the reason he filed for an IVC of Resident #80. During a phone interview with Former Administrator #1 on 6/4/21 at 8:30 AM he stated that during Resident #80 ' s time at the facility he was regularly wandering in and out of residents ' rooms and was taking liberties with female residents as evidenced by trying to put his hands on the women on the memory care unit. He indicated that Resident #80 required 1:1 care to prevent reoccurrences of behavioral issues and that the facility was limited with staffing and were not able to provide 1:1 staffing all the time. Former Administrator #1 indicated that this was why an IVC was completed by the PA for Resident #80. He stated that the hospital notified the facility when Resident #80 was stable and they wanted to discharge him back to the facility, but he was not accepted back as he felt they were unable to provide the 1:1 care that would have been necessary to protect the other residents at the facility. During an interview with the DON on 6/3/21 at 3:30 PM she stated that when Resident #80 was admitted to the facility (3/3/21) she was aware that he had a TBI, was diagnosed with dementia, and had wandering behaviors. She indicated that prior to his admission she was hesitant to accept him as a resident at the facility as resident ' s who suffered a TBI could be unpredictable and volatile. She reported that ultimately it was a corporate decision for Resident #80 to be admitted . She stated that she became aware of Resident #80 ' s combative behaviors after the 3/16/21 incident in which he was holding Resident #64 by the wrist, but she had not been aware of his inappropriate sexual behaviors until 3/29/21. She explained that on Monday 3/29/21 she learned about the incident that occurred on Friday 3/26/21 in which Resident #80 was observed attempting to touch Resident #37 ' s genital area. She further explained that staff had not reported to her Resident #80 ' s behavior of frequently rubbing females ' thighs and hand holding. The DON reported that had she known of this frequent behavior she would ' ve considered moving him off of the secured memory care unit and into a private room on a less populated hall to prevent any further inappropriate physical contact/sexual behaviors being enacted by Resident #80 on cognitively impaired female residents. She indicated that on 3/29/21 after the incident with Resident #8 being found on the floor with Resident #80 in her room, Resident #80 was placed on 15 minute observations. She reported that on the 3rd shift he was placed on 1:1 and on the following day he was moved to the 200 hall and an IVC by the SW was attempted and was refused. When asked why he had not been placed on 1:1 during the second shift after the incident with Resident #8 on 3/29/21 she revealed that there was not enough staff to put him 1:1 for the remainder of that shift. She acknowledged that the necessary supervision had not been provided to prevent Resident #80 from enacting any further physical and/or sexual advances from occurring. She verified Resident #80 was IVC by the PA on 3/31/21. She revealed that the hospital Resident #80 was sent to on 3/31/21 contacted them when he was stabilized as they wanted to send him back to the facility, but the facility refused to take him back. A phone interview was conducted with the Medical Director on 6/4/21 at 4:20 PM. He stated that he was not very familiar with Resident #80 as he only had 1 visit with him. He indicate that his expectation was for residents at the facility to be protected from harm, from unwanted advancements into their personal space, and from sexually inappropriate behaviors. He further indicated that the facility needed to be able to provide the necessary care and the level of supervision required to meet the needs of all residents who were admitted . 2. Resident #74 was admitted to the facility on [DATE] with multiple diagnoses that included dementia with behavioral disturbance. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #74 ' s cognition was severely impaired. She had no behavioral symptoms, but she had rejected care and wandered on 1 to 3 days during the MDS review per [TRUNCATED]

Based on record review and staff and resident interview, the facility failed to administer pain medication as ordered due to unavailability of medication resulting in acute pain (level of 10 pain for 1 to 10 with 10 being the worst) for 1 of 2 reviewed for pain (Resident #65). Findings included: Resident #65 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident ' s physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident ' s care plan dated 5/5/2021 had problems and interventions for surgical wound and pain. A review of Resident #65 ' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 5/5/21 9:11 am Pain score 8 start documentation 1:28 pm Pain score 9 5:30 pm Pain score 9 11:44 pm Pain score 10 5/6/21 5:51 am Pain score 10 10:08 am Pain score 8 2:22 pm Pain score 9 7:29 pm Pain score 8 11:28 pm Pain score 7 5/7/21 5:19 am Pain score 7 9:24 am Pain score 9 2:02 pm Pain score 8 6:07 pm Pain score 8 11:33 pm Pain score 8 5/8/21 9:04 am Pain score 5 4:02 pm Pain score 6 5/9/21 12:31 am Pain score 8 4:45 am Pain score 8 5/10/2110:21 pm Pain score 8 (ran out of medication) 5/11/21 2:09 pm Pain score 8 (obtained medication) 10:47 pm Pain score 8 5/12/21 3:03 am Pain score 8 The resident ' s admission Minimum Data Set (MDS) dated [DATE] review revealed her cognition was intact. The resident was dependent for most of her activities of daily living. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had frequent moderate pain, spinal surgery, and surgical wound with dressing. The resident's Narcotic controlled drug record for Oxycodone/APA 10-325 mg every 4 hours as needed for pain documented on 5/10/21 at 1 pm last dose administered, and amount left was 0. Next dose administered was 5/11/2021 at 1:48 pm left was 30 (new order). A review of the narcotic record form revealed the resident was requesting as needed pain medication 6 doses per day (24-hour period) for post orthopedic surgical pain since admission when the medication was available. On 5/10/2021 the resident received 4 doses (last dose 1 pm). On 5/11/2021 the resident received 3 doses (first dose at 1:48 pm). Medication administration documentation: 5/5/21 4:35 am, 9:11am, 1:27 pm, 5:27 pm, 11:44 pm 5/6/21 5:51 am, 10:08 am, 2:22 pm, 7:20 pm, 11:18 pm 5/7/21 4:40 am, 9:24 am, 2:02 pm, 6:02 pm, 11:35 pm 5/8/21 4:38 am, 9:00 am, 1:00 pm, 4:00 pm, 8:00 pm 5/9/21 12:00 am, 9:00 am, 1:00 pm, 4:00 pm, 8:00 pm 5/10/21 12:00 am, 4:30 am, 9:00 am, 1:00 pm (no medication available) 5/11/21 (medication obtained) 1:48 pm, 5:54 pm, 10:42 pm Nurses ' notes from 5/5/2021 to 5/11/2021 documented in 3 notes that the resident ' s pain medication gave her pain relief (was satisfied). Documentation from the stock medication revealed that one dose of Oxycodone was retrieved from the medication stock supply for Resident #65 on 5/11/2021 at 8:49 am. There was no medical record documentation that it was administered to the resident. Resident agreed this pain medication dose was provided. Grievance form dated 5/11/21 for Resident #65 documented that she had not received her pain medication as ordered/needed on 5/10/21 and 5/11/21 and complained of severe (after orthopedic surgery). There was no pain medication available because the script was not faxed to the pharmacy. A stat (immediate) order from the physician assistant (he was notified) was requested as a substitute until the pain medication was received from the pharmacy. The documented resolution determined that there were problems with the faxing of the resident ' s narcotic script (identified when the medication was out). The Unit Coordinator called the physician assistant for another script to be electronically sent to the pharmacy and a stat (immediate) order for a stock pain medication replacement (Oxycodone from stock) was ordered (1 dose) until the narcotic medication order was received (on 5/11/2021 at approximately 1:30 pm 30 tablets). On 6/1/21 at 11:20 am the resident participated in an interview. The Resident stated that the facility ran out of her pain medication oxycodone on 5/10/21, and she did not receive any pain medication for 20 hours (documented 10 hours over night without medication and stock dose was used in the morning). The resident also commented that she was not receiving her medication regularly on 5/8/21 so the staff started to place her on a schedule (every 4 hours) until the medication ran out. The resident stated she had orthopedic surgery, a laminectomy and has pain daily and requires pain medication. The pain medication lowers the pain to relief about a score of 3, but I need another dose of medication after 4 hours. The resident also stated that her spinal nerves were crushed and caused her pain. The pain was sharp in her lower back and caused decreased use of her legs. The resident stated that when she did not have her pain medication she could hardly move in her bed, and no other alternate pain medication was offered when her medication was out (1 stock dose of pain medication was used). The resident was able to participate in her bed bath, eat all her meals and communicate with family on her cell phone. An interview was conducted on 6/3/2021 at 11:30 am with Nurse #7. The nurse stated she was assigned to Resident #65 and commented that there were narcotic count sheets to ascertain when the medication was ordered, used, ran out and reordered. The nurse was aware that the resident ' s pain medication had ran out because the resident complained of acute pain and filed a grievance. The nurse was unsure how long the resident was without her pain medication. The resident ' s assessment of pain was evaluated to be a 10 at times. (Score of 1 to 10, with 10 being the worst pain.) Nurse #7 assessed the resident after pain medication administration and the resident would score her pain about a 3 documented in the nurses ' notes. On 6/4/2021 at 5:31 pm an interview was conducted with the Director of Nursing (DON). Medication was required to be reordered before it was completed. The DON commented that she was aware of the resident ' s grievance regarding her pain medication not available and that the resident was in acute pain (up to level 10). The pain medication was reordered before it ran out, but there was a fax error where the script was not received by pharmacy to refill. This error was not identified until the medication ran out.

Based on record review and interviews with the Speech Therapist (ST), physician, and staff, the facility failed to provide the necessary care and services recommended by the ST and ordered by the physician by neglecting to provide supervision and cueing for swallowing precautions during meal time for a resident at risk for aspiration for 1 of 3 residents reviewed with aspiration precautions. Resident #89 was observed by nursing staff with a mouth full of food making a vomiting noise after meal time. She was transferred to the emergency room by Emergency Medical Services and died in the ambulance on the way to the hospital. Immediate Jeopardy began on [DATE] at approximately 1:30 PM when Nursing Assistant #1 observed Resident #89 making a vomiting sound following the lunch meal that she had eaten in the dining room. She was assessed by nursing staff to have a large amount of ground/chewed food, estimated at 4 ounces, in her mouth. Emergency Medical Services (EMS) were contacted by facility staff to evaluate Resident #89 for the chief complaint of choking. Resident #89 was en route to the hospital with EMS when she went into [MEDICAL CONDITION] and [MEDICAL CONDITION] and was pronounced dead on [DATE] at 2:29 PM. The cause of death was asphyxia due to an occlusion of airway by bolus (a ball-like mixture of food and saliva) of food. Immediate Jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated and no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. The findings included: Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#1. The order indicated Resident #89, .needs (one on one) supervision or dining room supervision to cue (resident) to take small bites, eat slow and swallow between bites, and to alternate solids (and) liquids. This [DATE] order remained in place throughout the remainder of Resident #89's stay at the facility. The Nutrition/Dehydration Risk assessment dated [DATE] indicated Resident #89 had severely impaired decision making, she was rarely/never understood, and she had impairment on one side of her upper extremities. She was assessed as dependent on staff for assistance with eating. Resident #89 was noted to have no swallowing disorders. Resident #89's plan of care indicated she needed monitoring of nutritional status and weight status related to a [DIAGNOSES REDACTED]. This care plan, initiated on [DATE] and most recently reviewed/revised on [DATE]. The interventions included, in part: - Provide Resident #89 with assist at meals to ensure optimal and safe oral intake. - Remind Resident #89 of swallowing precautions. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #89's cognition was severely impaired. She had short-term and long-term memory problems and severely impaired decision making. Resident #89 was assessed as requiring the extensive assistance of 1 for eating. She was on a mechanically altered diet and had no swallowing disorders. Resident #89 had not received Speech Therapy during this MDS period. Resident #89's Nursing Assistant (NA) Kardex (care guide), undated, indicated Resident #89 she required one to one (1:1) supervision or dining room supervision. A review of the NA documentation of Resident #89's eating assistance for (MONTH) (YEAR) indicated: - 8 meals were documented as independent with no set up - 8 meals were documented as supervision with set up only - 10 meals were documented as limited assistance of 1 - 1 meal was documented as extensive assistance of 1 - 28 meals were documented as dependent of 1 A review of the NA documentation of Resident #89's eating assistance for [DATE] through [DATE] indicated: - [DATE]: 2 meals were documented with 1 noted as limited assistance of 1 and 1 noted as dependent of 1 - [DATE] 1 meal was documented, and it was noted as limited assistance of 1 An incident report dated [DATE] completed by Nurse #1 indicated Resident #89 had an incident of substance ingestion on [DATE] at 1:30 PM. The incident was initially reported by NA #1. The narrative of the incident read, (NA #1) brought (Resident #89) out of dining room to nurses station, stating ' I think she needs some help ' . Nurse assessment completed with food noted in oral cavity. Another nurse (Nurse #2) removed some food particles from mouth and dentures. There was a large amount of well ground food and (Nurse #2) continued to remove food until no longer visible. As (Resident #89) began to wheeze, [MEDICATION NAME] maneuver was performed on resident. Mouth check repeatedly with no food noted. Resident #89's vital signs (VS) were noted as temperature 95.7, pulse 75, respirations 28, blood pressure (B/P) ,[DATE], and pain scale 0. The physician was notified at 1:40 PM. The immediate actions taken were noted as a mouth sweep, [MEDICATION NAME], VS, oxygen (O2), 911 called, and Emergency Medical Services (EMS) transported Resident #89. The immediate post-incident actions indicated Resident #89 was sent to the emergency room (ER). A nursing note dated [DATE] completed by Nurse #1 indicated the following: 1:30 PM - (Resident #89) was brought into hallway by (NA #1) out of the dining room and stated resident was choking. Upon assessment (Resident #89) had a mouth full of food and was trying to chew and swallow the food. Encouraged resident to spit out food and resident refused to do so and clamped teeth together while still trying to swallow the food. At this time writer attempted the [MEDICATION NAME] maneuver with no results. Able to remove dentures and resident had large amount of food in mouth and pockets of food in cheek as well as food stuck to the top denture. (Resident #89) began to have audible wheezing noted, oxygen saturation was 79% on (room air), heart rate 75, respirations 28, lips were cyanotic ((bluish discoloration indicating poor oxygen circulation)). (Resident #89) taken to room and oxygen applied at 5 (liters per minute) via mask. 1:40 PM - Notified (Physician's Assistant) and (Responsible Party) of incident. New order given to send to ER. 1:45 PM - Called EMS for transport services. 2:00 PM - EMS arrived - VS oxygen saturation is 79%, (heart rate) 104, (respirations) 32, B/P ,[DATE]. 2:15 pm EMS transported (Resident #89) to ER at this time. A physician's orders [REDACTED].#89 indicated send to ER for evaluation per family request and (physician). A Resident Transfer Form dated [DATE] completed by Nurse #1 indicated Resident #89 was transferred to a local hospital. The reason for the transfer was noted to be choking while eating chicken. The EMS record dated [DATE] was reviewed. The record indicated the following: The chief complaint for Resident #89 was choking. While EMS were en-route to the facility the first responders on scene advised them Resident #89 was condition red (critical) with possible aspiration. The first responders advised EMS that Resident #89 had been reported to have placed a large amount of chicken in her mouth and began choking on it. Facility staff removed all they could from Resident #89's mouth and throat. Resident #89 was moved from wheelchair to EMS stretcher and was taken out of facility onto the transport. During transportation to the ER Resident #89 was examined and was found to have chicken in her trachea. The chicken was removed. Resident #89 was then noted with decreased respiratory effort and her heartrate was decreasing into an extremely bradycardic (slow) rhythm. Approximately 2 minutes prior to arrival at the ER Resident #89 was noted with [MEDICAL CONDITION] and [MEDICAL CONDITION]. A valid Do Not Resuscitate (DNR) was present with the resident and no resuscitative efforts were made. Resident #89's death was pronounced on [DATE] at 2:29 PM. Upon arrival at the ER the physician advised that since Resident #89 expired prior arrival that she was to be transferred to the morgue. Resident #89's physician was contacted, and he advised that since it was an un-natural death it needed to be a Medical Examiner ' s (ME) case. Resident #89 was transported to the morgue and was to be examined by the ME. A death certificate, signed by the Medical Examiner on [DATE], indicated Resident #89 choked on a bolus (a ball-like mixture of food and saliva) of chicken at the facility resulting in an accidental death on [DATE] with the immediate cause identified as asphyxia - occlusion of airway by bolus of food. A phone interview was conducted with ST #1 on [DATE] at 3:30 PM. ST #1 indicated she no longer worked at the facility and she was unable to recall any specifics about Resident #89 without reviewing the speech therapy records. The speech therapy plan of care, speech therapy discharge plan, and dietary order for Resident #89 were reviewed with ST #1. The speech therapy plan of care dated [DATE] completed by ST #1 indicated speech therapy was necessary for Resident #89 due to dysphagia and [MEDICAL CONDITION]. The physician's orders [REDACTED].#1, . (Resident #89) needs (one on one) supervision or dining room supervision to cue (resident) to take small bites, eat slow and swallow between bites, and to alternate solids (and) liquids. Resident #89 ' s speech therapy discharge instructions dated [DATE] completed by ST #1 indicated aspiration precautions were to be continued with the provision of compensatory strategies for swallowing as well as strategies to maximize communication. ST #1 was asked about her expectations related to meal supervision for Resident #89. She stated that if Resident #89 ate in her room that 1:1 supervision was to be provided. She indicated if Resident #89 ate in the dining room she expected a staff member to be in the vicinity of her and for the staff member to provide compensatory strategy cues/aspiration precaution cues to the resident throughout the meal. She explained that these cues included reminders to take sitting up straight in her wheelchair, taking small sips, taking small bites, alternating between solids and liquids, and to swallow her food. Based on the staff schedule, the assignment schedule, and an interview with the Director of Nursing on [DATE] at 8:20 AM the NAs that were supposed to be in the dining room during lunch on [DATE] were NA #1, NA #2, and NA #3. The DON reported that NA #1 was supervising Resident #89 at the time of the incident. The DON revealed it was unknown how many residents were eating lunch in the dining room at the time of the incident ([DATE]). A written statement (incorrectly dated [DATE]) completed by NA #1 was reviewed. NA #1 indicated that between 12:15PM and 1:30 PM on [DATE] she was in the dining room helping pass out trays and feeding residents. She noted that she set up Resident #89 ' s tray reporting that she had grilled chicken that was cut up into small pieces. NA #1 wrote, I saw her eating while I was helping feed another resident. She indicated that around 1:30 PM lunch was over, and another NA removed Resident #89's tray. NA #1 reported she then started pushing Resident #89 in her wheelchair out of the dining room. She indicated that when she reached the dining room door with Resident #89 she heard the resident making a noise like she was trying to throw up. NA #1 wrote that she pushed Resident #89 down the hall in her wheelchair and started yelling for Nurse #4 to help her. She indicated that when she reached the nurse's station Nurse #1, Nurse #2, and Nurse #4 were there. She indicated that the nurses removed about 4 ounces of food from Resident #89 ' s mouth. A phone interview was conducted with NA #1 on [DATE] at 5:08 PM. The incident report and her written statement related to the incident of substance ingestion on [DATE] for Resident #89 was reviewed with NA #1. NA #1 was asked to describe the seating arrangements in the dining room for herself and Resident #89 on [DATE] during the lunch meal. She reported that Resident #89 was seated at one end of a rectangular table that had seating for 6 residents. She indicated that 2 seats were on each side of the table and one seat on each end of the table. She was unable to recall if all 6 of the seats were occupied by residents on [DATE] during the lunch meal. She reported that she was assisting another resident with eating on this date ([DATE]) during lunch and she believed the resident she was assisting was seated next to Resident #89. NA #1 was unable to recall with certainty if she was seated between Resident #89 and the resident she was assisting or if she was seated on the opposite side of the resident she was assisting. She stated that she recalled setting up Resident #89 ' s tray. She reported that Resident #89 had grilled chicken that had been cut up into small pieces as well as some vegetables. She indicated Resident #89 ate independently after set-up during lunch in the dining room on [DATE]. She stated that she looked over at Resident #89 during the meal to make sure she was eating, but that she had not observed her during the whole meal as she was helping someone else. NA #1 was asked if she noticed if Resident #89 was eating fast, if she was swallowing, if she was holding food in her mouth, or if she required any cues to ensure she was safely eating. NA #1 stated, to be honest with you I don't recall. She explained that she knows that Resident #89 was not choking or making any unusual sounds during the meal so she didn't think there was anything she needed. She reported that after Resident #89 ' s tray had been cleared she was going to take her back to her room to lay down. She stated that she began to push Resident #89 by wheelchair out of the dining room when the resident started coughing. She indicated Resident #89 was making a noise like she was trying to throw up. She reported she called out for one of the nurses to help and that it was Nurse #1 who first realized Resident #89 had food in her mouth. NA #1 was asked if she had observed Resident #89's mouth prior to transporting her out of the dining room and she revealed she had not. She stated that she would've approached Resident #89 from the side and then from behind, so she could push her wheelchair. She revealed she had not observed Resident #89 from the front before exit the dining room. She additionally revealed she had not noticed during the lunch meal that Resident #89 was not swallowing her food. This interview with NA #1 continued. NA #1 was asked if Resident #89 required assistance with eating. She stated that most of the time Resident #89 ate independently after set-up and required no assistance. She was asked if Resident #89 had any specific dietary orders or care plan interventions related to aspiration precautions. She stated that Resident #89 was supposed to be observed while eating but explained that this was not 1:1 observation it was just checking on her to make sure she was eating. She was asked if Resident #89 required any specific cueing and she stated that the only cueing Resident #89 required was encouragement to eat as sometimes she just sat there rather than feeding herself. The physician's orders [REDACTED].#89 needed cueing to take small bites, eat slow, swallow between bites, and to alternate solids liquids was reviewed with NA #1. NA #1 revealed she was not aware of this order and she had not provided any of these cues to Resident #89 on [DATE] or on any prior date. A written statement dated [DATE] completed by NA #2 was reviewed. This indicated NA #2 walked into the dining room around 1:15 PM ([DATE]) and saw Resident #89 eating with her fingers. The resident was noted to be putting pieces of chicken in her mouth. NA #2 indicated that NA #1 told her she would stay in the dining room. NA #2 then left the dining room. An interview was conducted with NA #2 on [DATE] at 10:37 AM. The incident report and her written statement related to incident of substance ingestion on [DATE] for Resident #89 was reviewed with NA #2. She stated that she was in and out of the dining room during the lunch meal on [DATE] and that she had not assisted Resident #89 with eating. She reported she saw Resident #89 in the dining room and that she was eating independently. This interview with NA #2 continued. NA #2 was asked if Resident #89 required assistance with eating. She stated that some days Resident #89 ate independently after set-up and required no assistance, but other days she would just sit there and not eat so she needed some verbal encouragement. She was asked if Resident #89 had any specific dietary orders or care plan interventions related to aspiration precautions. NA #2 stated that the NAs were just supposed to watch Resident #89 to ensure she was eating. She indicated that this was not 1:1 observation it was just checking on her throughout the meal. NA #2 was asked if Resident #89 required any specific cueing and she stated that the only cueing Resident #89 required was encouragement to eat on some days. The physician's orders [REDACTED].#89 needed cueing to take small bites, eat slow, swallow between bites, and to alternate solids liquids was reviewed with NA #2. NA #2 revealed she was not aware of this order and she had not provided any of these cues to Resident #89 when she assisted her with meals. An interview was conducted with NA #3 on [DATE] at 2:45 PM. She stated that she recalled being in the dining room during lunch on [DATE]. She reported that she was helping another resident eat and that she had not observed Resident #89. NA #3 was asked if Resident #89 required assistance with eating. She indicated that sometimes she fed herself and sometimes she needed assistance in the form of encouragement. She was asked if Resident #89 had and specific dietary orders, care plan interventions, or cues related to aspiration precautions. NA #3 reported she recalled that Resident #89 needed checked up on while she was eating just to make sure she was feeding herself because sometimes she just sat there with her food in front of her and had not fed herself. A written statement dated [DATE] completed by Nurse #1 was reviewed. Nurse #1 indicated at approximately 1:30 PM NA #1 brought Resident #89 out of the dining room stating that I think she needs some help. She indicated Resident #89 was assessed with [REDACTED]. Nurse #1 wrote that she encouraged Resident #89 to spit out the food, but the resident had not done so. Nurse #2 was noted to also tell Resident #89 to spit out the food, but the resident had clamped her mouth shut and was still chewing the food in her mouth. Nurse #2 removed the dentures from Resident #89's mouth and performed a mouth sweep. There was a large amount estimated at 4 ounces of well ground food removed from Resident #89's mouth. Nurse #2 continue to sweep Resident #89's mouth until no visible food was seen in her mouth. Resident #89 was then noted to begin wheezing and her lips were blue. Nurse #1 indicated she performed the [MEDICATION NAME] on Resident #89 with no more food expelled from her mouth. NA #1 and Nurse #3 took Resident #89 to her room as Nurse #1 contacted the Physician's Assistant (PA) and the Responsible Party (RP) at approximately 1:40 PM. The PA gave the order for transfer to the ER. A phone interview was conducted with Nurse #1 on [DATE] at 12:20 PM. The incident report, nursing note, and her written statement related to Resident #89's [DATE] incident of substance ingestion were reviewed with Nurse #1. She verified that she had completed all of these documents and confirmed the information as written. Nurse #1 stated that when NA #1 brought Resident #89 as brought out to the nurse's station that she visibly could see (Resident #89) had a mouth full of food and that she wouldn't spit the food out. Nurse #1 was asked if Resident #89 required any assistance with eating. She revealed she believed Resident #89 had an order to be supervised while eating and that she, needed to be reminded to chew and swallow. A written statement, undated, completed by Nurse #2 indicated that she was standing at the medication cart on [DATE] at approximately 1:30 PM when NA #1 brought Resident #89 up to the nurse's station and stated that something was wrong and that she thought the resident was choking. Nurse #2 indicated Resident #89 had a large amount of food in her mouth and that she was still chewing on the food. She wrote that she asked Resident #89 to spit the food out, but she had not done so. She reported that she had been able to do a mouth sweep and removed a large amount of well ground food and continued to remove food until no visible food was seen. She indicated that Resident #89 then began wheezing and had a noted change in color. Nurse #2 reported that Nurse #1 performed the [MEDICATION NAME] on Resident #89. Resident #89 was then taken to her room by Nurse #3 and Nurse #4. A phone interview was conducted with Nurse #2 on [DATE] at 4:11 PM. The incident report and her handwritten statement were reviewed with Nurse #2. She verified that when Resident #89 was brought out to the nurse's station by NA #1 and that it was apparent on visual observation alone that the resident had a mouth full of food. A written statement dated [DATE] completed by Nurse #3 was reviewed. Nurse #3 indicated that around 1:30 PM on [DATE] she was walking toward the nurse ' s station when Nurse #1 and Nurse #2 called her over. They were surrounding Resident #89 who was seated in her wheelchair and were removing chewed food from her mouth. Nurse #3 wrote that Nurse #1 and Nurse #2 told her that Resident #89 had too much food in her mouth to allow her to swallow. Resident #89 had audible wheezing and her lips and fingertips were discolored. Nurse #3 wrote that she and Nurse #4 took Resident #89 to her room and applied O2 with a mask at 5 lpm until first responders arrived. A phone interview was conducted with Nurse #3 on [DATE] at 4:32 PM. The incident report and her written statement related to Resident #89's [DATE] incident of substance ingestion were reviewed with Nurse #3. Nurse #3 confirmed the information documented in her written statement. Nurse #3 stated that Resident #89 had no loss of consciousness at any point while at the facility. She reported Resident #89 continued with audible wheezing throughout the time period they were waiting for first responders. A written statement dated [DATE] completed by Nurse #4 was reviewed. Nurse #4 indicated on [DATE] at approximately 1:30 PM NA #1 brought Resident #89 out of the dining room and stated that she thought the resident was choking. Nurse #4 wrote that Resident #89's mouth and cheeks were full of food and she was still chewing on the food. Resident #89 was asked to spit out the food and the resident just kept chewing and would not spit it out. Nurse #4 indicated Nurse #1 and Nurse #2 removed all visible food from Resident #89's mouth by hand. A phone interview was conducted with Nurse #4 on [DATE] at 1:45 PM. She stated she was unable to recall any specifics about the incident of substance ingestion on [DATE] for Resident #89. A phone interview was conducted with Resident #89's physician on [DATE] at 2:36 PM. The physician reported that he expected the recommendations of ST as well as his orders to be followed. He indicated aspiration precautions were expected to be implemented for any resident noted to be an aspiration risk. An interview was conducted with the Director of Nursing (DON) on [DATE] at 4:20 PM. The DON revealed that when she investigated the [DATE] incident of substance ingestion for Resident #89 she determined the resident likely aspirated. She stated that her expectations were for staff to provide supervision and cueing as recommended by ST, as ordered by the physician, and as indicated in the care plan. She additionally stated that she expected aspiration precautions to be implemented for all residents identified as at risk for aspiration. The Administrator and DON were notified of the Immediate Jeopardy on [DATE] at 3:03 PM. On [DATE] at 7:06 PM the facility provided the following credible allegation of Immediate Jeopardy removal: Address how corrective action will be accomplished for the resident found to have been affected by the deficient practice: On [DATE] at approximately 1:30pm, Resident was escorted from the dining room and was noted making a vomiting noise. The Certified Nursing Assistant immediately took the resident to the nurse ' s station where the nurse assessed resident having difficulty swallowing and showing signs of aspiration with audible wheezing. The nurse attempted to remove food particles from resident ' s mouth but was unsuccessful in removing all food particles and therefore dentures were removed to perform a mouth sweep. During this process the resident continued to try to chew and swallow. At this time resident ' s lips became cyanotic and showing signs of difficulty breathing so the [MEDICATION NAME] maneuver was initiated by the nurse without success. Resident remained conscious and was moving air. The resident was taken from the nurse ' s station to her room in wheelchair by the Nurse supervisor, Nurse and Certified Nursing Assistant. Nurse supervisor suctioned resident to attempt to remove remaining food particles unsuccessfully. Resident ' s oxygen saturation was 79 percent, oxygen at 5 liters was applied via non-rebreather face mask. Physician Assistant and Responsible Party were notified at 1:40pm. The Physician Assistant stated to call Emergency Management Services. Emergency Services was called at 1:45pm and arrived at 2:00pm. First Responders took over care of the resident. Facility Nurse staff remained in room for support. First Responders applied oxygen with their regulator at fifteen liters per minute. At 2:10pm, the Emergency Management Technicians (EMT) arrived. They discussed with first responders and facility staff resident ' s condition and decision to suction resident in ambulance. First Responders and Emergency Management Technicians assisted the resident to the hall in her wheelchair, placed her on the gurney and proceeded to the ambulance. The EMTs remained in the ambulance for a few minutes and left the facility at 2:15pm. At 2:48pm the EMTs called to get next of kin contact information and informed the staff that the resident had died prior to reaching the hospital. On [DATE] an investigation was initiated immediately by the Director of Nursing and the Administrator and statements received from staff present in the dining room, at the nurse ' s station. At the conclusion of the investigation it was determined that the Certified Nursing Assistance was at the table providing assistance to another resident. According to the Certified nursing assistant ' s statement she followed aspiration precautions by setting up her tray, the chicken was in small pieces and saw her eating while helping another resident. Upon interview with C.N.A. on [DATE] by Director of Nursing and Administrator, she would not admit to not providing supervision and cueing. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: A 100% audit of Residents [DIAGNOSES REDACTED]. An information sheet, Swallowing Guidelines sheet, was implemented on [DATE] with current recommendations for those 26 identified with swallowing guidelines requiring supervision. The Swallowing Guidelines sheets (name, room number, diet, and recommendation from physician and speech therapist) are located in an aspiration precaution binder located in each dining room and each resident care kiosk. The swallowing guideline sheets and the kiosk are reconciled by the Assistant Director of Nurses and changes are updated when indicated by the physician or speech therapist. All 43 residents with [DIAGNOSES REDACTED]. CNAs will be assigned to residents identified requiring cueing and aspiration precautions by the charge nurse at the beginning each shift. Training of licensed and certified staff provided by SDC and DON on cueing and aspiration precautions and responsibilities initiated on [DATE]. All licensed and certified nursing staff will receive this training prior to working next shift. This training will be included in new licensed and certified nursing staff orientation process. Address what measure will be put into place or systemic changes made to ensure that the deficient practice will not recur: On [DATE] an implementation of a dining room staff sign-in sheet to include sign in times/sign out times as well as aspiration precaution and supervision to be provided. This information is located in a binder in each dining room and resident care kiosk. Management, Licensed Nursing or Department Head will monitor meal supervision, utilizing Dining Supervision Manager Observation sheet. Supervision is being provided to ensure aspiration and safety precautions are being followed during meals in the dining rooms and for residents that eat in their rooms. The Director of Nursing will assign managers to the dining rooms to include resident rooms. Effective [DATE], on-site licensed staff, certified staff and department heads were trained by SDC on the information provided on aspiration precautions and residents requiring supervision to ensure that safety precautions are being followed. This information is located in a binder in each dining room and resident care kiosk. Training on the [MEDICATION NAME] maneuver with return demonstration and proper use of suction machine was conducted as well. This education was provided by the Registered Nurse, Staff Development Coordinator (SDC) to Licensed staff and other licensed staff will be trained prior to next shift worked. Emergency equipment (suction machine) was placed [DATE] in the dining rooms, set-up was completed and instructions were given to Licensed Staff by the SDC. On [DATE] education was also provided by the SDC for nursing staff to ensure supervision is being provided during meals and ensure aspiration precautions and safety is being provided. Licensed and Certified Nursing staff were also educated on the signs and symptoms of aspiration. Effective [DATE], re-education on the facility abuse and neglect policy was initiated for all staff and completed. The facility Abuse and neglect policy reflects that not providing care in accordance with the resident care plan maybe constitute neglect. This education was provided by RN Staff Development Coordinator. Staff not educated by [DATE] will not be allowed to work until educated. Effective [DATE], education on providing supervision during meals to ensure aspiration precautions and safety is added to all new employee orientation. This education will also be conducted annually by SDC for all staff. CNAs will be assigned to residents identified requiring cueing and aspiration precautions by the charge nurse at the beginning each shift. Training of licensed and certified

Based on record review, observation, and interviews with Speech Therapist, Registered Dietician, physician, and staff, the facility failed to supervise residents with aspiration precautions during meals for 3 of 3 residents (Residents #89, #33, and #57) reviewed for aspiration precautions. Resident #89 was observed by nursing staff with a mouth full of food making a vomiting noise after meal time. She was transferred to the emergency room by Emergency Medical Services and died in the ambulance on the way to the hospital. Immediate Jeopardy began on [DATE] at approximately 1:30 PM when Nursing Assistant #1 observed Resident #89 making a vomiting sound following the lunch meal that she had eaten in the dining room. She was assessed by nursing staff to have a large amount of ground/chewed food, estimated at 4 ounces, in her mouth. Emergency Medical Services (EMS) were contacted by facility staff to evaluate Resident #89 for the chief complaint of choking. Resident #89 was en route to the hospital with EMS when she went into [MEDICAL CONDITION] and [MEDICAL CONDITION] and was pronounced dead on [DATE] at 2:29 PM. Immediate Jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated and no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. The findings included: 1. Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#1. The order indicated, (change) diet to (mechanical soft) finger foods. (Resident #89) needs (one on one) supervision or dining room supervision to cue (resident) to take small bites, eat slow and swallow between bites, and to alternate solids (and) liquids. This [DATE] order remained in place throughout the remainder of Resident #89's stay at the facility. The Nutrition/Dehydration Risk assessment dated [DATE] indicated Resident #89 had severely impaired decision making, she was rarely/never understood, and she had impairment on one side of her upper extremities. She was assessed as dependent on staff for assistance with eating. Resident #89 was noted to have no swallowing disorders and she was on mechanically altered diet. Resident #89's plan of care indicated she needed monitoring of nutritional status and weight status related to a [DIAGNOSES REDACTED]. This care plan, initiated on [DATE] and most recently reviewed/revised on [DATE], indicated Resident #89's diet was mechanical soft with finger foods. The interventions included, in part: - Provide Resident #89 with assist at meals to ensure optimal and safe oral intake. - Remind Resident #89 of swallowing precautions. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #89's cognition was severely impaired. She had short-term and long-term memory problems and severely impaired decision making. Resident #89 was assessed as requiring the extensive assistance of 1 for eating. She was on a mechanically altered diet and had no swallowing disorders. Resident #89 had not received Speech Therapy during this MDS period. The Nutrition Quarterly assessment dated [DATE] completed by the Registered Dietician (RD) indicated Resident #89's diet was, (mechanical) soft, finger foods and she was noted with no swallowing issues. Her [DIAGNOSES REDACTED]. Resident #89's Nursing Assistant (NA) Kardex (care guide), undated, indicated Resident #89's diet was mechanical soft with finger food and she required one to one (1:1) supervision or dining room supervision. A review of the NA documentation of Resident #89's eating assistance for (MONTH) (YEAR) indicated: - 8 meals were documented as independent with no set up - 8 meals were documented as supervision with set up only - 10 meals were documented as limited assistance of 1 - 1 meal was documented as extensive assistance of 1 - 28 meals were documented as dependent of 1 A review of the NA documentation of Resident #89's eating assistance for [DATE] through [DATE] indicated: - [DATE]: 2 meals were documented with 1 noted as limited assistance of 1 and 1 noted as dependent of 1 - [DATE] 1 meal was documented, and it was noted as limited assistance of 1 An incident report dated [DATE] completed by Nurse #1 indicated Resident #89 had an incident of substance ingestion on [DATE] at 1:30 PM. The incident was initially reported by NA #1. The narrative of the incident read, (NA #1) brought (Resident #89) out of dining room to nurses station, stating ' I think she needs some help ' . Nurse assessment completed with food noted in oral cavity. Another nurse (Nurse #2) removed some food particles from mouth and dentures. There was a large amount of well ground food and (Nurse #2) continued to remove food until no longer visible. As (Resident #89) began to wheeze, [MEDICATION NAME] maneuver was performed on resident. Mouth check repeatedly with no food noted. Resident #89's vital signs (VS) were noted as temperature 95.7, pulse 75, respirations 28, blood pressure (B/P) ,[DATE], and pain scale 0. The physician was notified at 1:40 PM. The immediate actions taken were noted as a mouth sweep, [MEDICATION NAME], VS, oxygen (O2), 911 called, and Emergency Medical Services (EMS) transported Resident #89. The immediate post-incident actions indicated Resident #89 was sent to the emergency room (ER). A nursing note dated [DATE] completed by Nurse #1 indicated the following: 1:30 PM - (Resident #89) was brought into hallway by (NA #1) out of the dining room and stated resident was choking. Upon assessment (Resident #89) had a mouth full of food and was trying to chew and swallow the food. Encouraged resident to spit out food and resident refused to do so and clamped teeth together while still trying to swallow the food. At this time writer attempted the [MEDICATION NAME] maneuver with no results. Able to remove dentures and resident had large amount of food in mouth and pockets of food in cheek as well as food stuck to the top denture. (Resident #89) began to have audible wheezing noted, oxygen saturation was 79% on (room air), heart rate 75, respirations 28, lips were cyanotic ((bluish discoloration indicating poor oxygen circulation)). (Resident #89) taken to room and oxygen applied at 5 (liters per minute) via mask. 1:40 PM - Notified (Physician's Assistant) and (Responsible Party) of incident. New order given to send to ER. 1:45 PM - Called EMS for transport services. 2:00 PM - EMS arrived - VS oxygen saturation is 79%, (heart rate) 104, (respirations) 32, B/P ,[DATE]. 2:15 pm EMS transported (Resident #89) to ER at this time. A physician's orders [REDACTED].#89 indicated send to ER for evaluation per family request and (physician). A Resident Transfer Form dated [DATE] completed by Nurse #1 indicated Resident #89 was transferred to a local hospital. The reason for the transfer was noted to be choking while eating chicken. The EMS record dated [DATE] was reviewed. The record indicated the following: The chief complaint for Resident #89 was choking. While EMS were en-route to the facility the first responders on scene advised them Resident #89 was condition red (critical) with possible aspiration. Upon EMS arrival on scene Resident #89 was seated upright in a wheelchair with first responders administering high flow O2 via mask. The first responders advised EMS that Resident #89 had been reported to have placed a large amount of chicken in her mouth and began choking on it. Facility staff removed all they could from Resident #89's mouth and throat. Resident #89 was moved from wheelchair to EMS stretcher and was taken out of facility onto the transport. During transportation to the ER Resident #89 was examined and was found to have chicken in her trachea. The chicken was removed. Resident #89 was then noted with decreased respiratory effort and her heartrate was decreasing into an extremely bradycardic (slow) rhythm. Approximately 2 minutes prior to arrival at the ER Resident #89 was noted with [MEDICAL CONDITION] and [MEDICAL CONDITION]. A valid Do Not Resuscitate (DNR) was present with the resident and no resuscitative efforts were made. Resident #89's death was pronounced on [DATE] at 2:29 PM. Upon arrival at the ER the physician advised that since Resident #89 expired prior arrival that she was to be transferred to the morgue. Resident #89's physician was contacted, and he advised that since it was an un-natural death it needed to be a Medical Examiner's (ME) case. Resident #89 was transported to the morgue and was to be examined by the ME. A death certificate, signed by the Medical Examiner on [DATE], indicated Resident #89 choked on a bolus (a ball-like mixture of food and saliva) of chicken at the facility resulting in an accidental death on [DATE] with the immediate cause identified as asphyxia - occlusion of airway by bolus of food. A phone interview was conducted with ST #1 on [DATE] at 3:30 PM. ST #1 indicated she no longer worked at the facility and she was unable to recall any specifics about Resident #89 without reviewing the speech therapy records. The speech therapy plan of care, speech therapy discharge plan, and dietary order for Resident #89 were reviewed with ST #1. The speech therapy plan of care dated [DATE] completed by ST #1 indicated speech therapy was necessary for Resident #89 due to dysphagia and [MEDICAL CONDITION]. The physician's orders [REDACTED].#1, (change) diet to (mechanical soft) finger foods. (Resident #89) needs (one on one) supervision or dining room supervision to cue (resident) to take small bites, eat slow and swallow between bites, and to alternate solids (and) liquids. Resident #89's speech therapy discharge instructions dated [DATE] completed by ST #1 indicated aspiration precautions were to be continued with the provision of compensatory strategies for swallowing as well as strategies to maximize communication. ST #1 was asked about Resident #89's diet order that stated mechanical soft and finger foods. She reported that Resident #89 was able to have finger foods and/or mechanical soft foods. She stated that chicken in bite size pieces was appropriate for Resident #89 based on the diet order. ST #1 was asked about her expectations related to meal supervision for Resident #89. She stated that if Resident #89 ate in her room that 1:1 supervision was to be provided. She indicated if Resident #89 ate in the dining room she expected a staff member to be in the vicinity of her and for the staff member to provide compensatory strategy cues/aspiration precaution cues to the resident throughout the meal. She explained that these cues included reminders to take sitting up straight in her wheelchair, taking small sips, taking small bites, alternating between solids and liquids, and to swallow her food. Based on the staff schedule, the assignment schedule, and an interview with the Director of Nursing on [DATE] at 8:20 AM the NAs that were supposed to be in the dining room during lunch on [DATE] were NA #1, NA #2, and NA #3. The DON reported that NA #1 was supervising Resident #89 at the time of the incident. The DON revealed it was unknown how many residents were eating lunch in the dining room at the time of the incident ([DATE]). A written statement (incorrectly dated [DATE]) completed by NA #1 was reviewed. NA #1 indicated that between 12:15 PM and 1:30 PM on [DATE] she was in the dining room helping pass out trays and feeding residents. She noted that she set up Resident #89's tray reporting that she had grilled chicken that was cut up into small pieces. NA #1 wrote, I saw her eating while I was helping feed another resident. She indicated that around 1:30 PM lunch was over, and another NA removed Resident #89's tray. NA #1 reported she then started pushing Resident #89 in her wheelchair out of the dining room. She indicated that when she reached the dining room door with Resident #89 she heard the resident making a noise like she was trying to throw up. NA #1 wrote that she pushed Resident #89 down the hall in her wheelchair and started yelling for Nurse #4 to help her. She indicated that when she reached the nurse's station Nurse #1, Nurse #2, and Nurse #4 were there. She indicated that the nurses removed about 4 ounces of food from Resident #89's mouth. A phone interview was conducted with NA #1 on [DATE] at 5:08 PM. The incident report and her written statement related to the incident of substance ingestion on [DATE] for Resident #89 was reviewed with NA #1. NA #1 was asked to describe the seating arrangements in the dining room for herself and Resident #89 on [DATE] during the lunch meal. She reported that Resident #89 was seated at one end of a rectangular table that had seating for 6 residents. She indicated that 2 seats were on each side of the table and one seat on each end of the table. She was unable to recall if all 6 of the seats were occupied by residents on [DATE] during the lunch meal. She reported that she was assisting another resident with eating on this date ([DATE]) during lunch and she believed the resident she was assisting was seated next to Resident #89. NA #1 was unable to recall with certainty if she was seated between Resident #89 and the resident she was assisting or if she was seated on the opposite side of the resident she was assisting. She stated that she recalled setting up Resident #89's tray. She reported that Resident #89 had grilled chicken that had been cut up into small pieces as well as some vegetables. She indicated Resident #89 ate independently after set-up during lunch in the dining room on [DATE]. She stated that she looked over at Resident #89 during the meal to make sure she was eating, but that she had not observed her during the whole meal as she was helping someone else. NA #1 was asked if she noticed if Resident #89 was eating fast, if she was swallowing, if she was holding food in her mouth, or if she required any cues to ensure she was safely eating. NA #1 stated, to be honest with you I don't recall. She explained that she knows that Resident #89 was not choking or making any unusual sounds during the meal so she didn't think there was anything she needed. She reported that after Resident #89's tray had been cleared she was going to take her back to her room to lay down. She stated that she began to push Resident #89 by wheelchair out of the dining room when the resident started coughing. She indicated Resident #89 was making a noise like she was trying to throw up. She reported she called out for one of the nurses to help and that it was Nurse #1 who first realized Resident #89 had food in her mouth. NA #1 was asked if she had observed Resident #89's mouth prior to transporting her out of the dining room and she revealed she had not. She stated that she would've approached Resident #89 from the side and then from behind, so she could push her wheelchair. She revealed she had not observed Resident #89 from the front before exit the dining room. She additionally revealed she had not noticed during the lunch meal that Resident #89 was not swallowing her food. This interview with NA #1 continued. NA #1 was asked if Resident #89 required assistance with eating. She stated that most of the time Resident #89 ate independently after set-up and required no assistance. She was asked if Resident #89 had any specific dietary orders related to aspiration precautions. She stated that Resident #89 was supposed to be observed while eating but explained that this was not 1:1 observation it was just checking on her to make sure she was eating. She was asked if Resident #89 required any specific cueing and she stated that the only cueing Resident #89 required was encouragement to eat as sometimes she just sat there rather than feeding herself. The physician's orders [REDACTED].#89 needed cueing to take small bites, eat slow, swallow between bites, and to alternate solids liquids was reviewed with NA #1. NA #1 revealed she was not aware of this order and she had not provided any of these cues to Resident #89 on [DATE] or on any prior date. A written statement dated [DATE] completed by NA #2 was reviewed. This indicated NA #2 walked into the dining room around 1:15 PM ([DATE]) and saw Resident #89 eating with her fingers. The resident was noted to be putting pieces of chicken in her mouth. NA #2 indicated that NA #1 told her she would stay in the dining room. NA #2 then left the dining room. An interview was conducted with NA #2 on [DATE] at 10:37 AM. The incident report and her written statement related to incident of substance ingestion on [DATE] for Resident #89 was reviewed with NA #2. She stated that she was in and out of the dining room during the lunch meal on [DATE] and that she had not assisted Resident #89 with eating. She reported she saw Resident #89 in the dining room and that she was eating independently. This interview with NA #2 continued. NA #2 was asked if Resident #89 required assistance with eating. She stated that some days Resident #89 ate independently after set-up and required no assistance, but other days she would just sit there and not eat so she needed some verbal encouragement. She was asked if Resident #89 had any specific dietary orders related to aspiration precautions. NA #2 stated that the NAs were just supposed to watch Resident #89 to ensure she was eating. She indicated that this was not 1:1 observation it was just checking on her throughout the meal. NA #2 was asked if Resident #89 required any specific cueing and she stated that the only cueing Resident #89 required was encouragement to eat on some days. The physician's orders [REDACTED].#89 needed cueing to take small bites, eat slow, swallow between bites, and to alternate solids liquids was reviewed with NA #2. NA #2 revealed she was not aware of this order and she had not provided any of these cues to Resident #89 when she assisted her with meals. An interview was conducted with NA #3 on [DATE] at 2:45 PM. She stated that she recalled being in the dining room during lunch on [DATE]. She reported that she was helping another resident eat and that she had not observed Resident #89. NA #3 was asked if Resident #89 required assistance with eating. She indicated that sometimes she fed herself and sometimes she needed assistance in the form of encouragement. She was asked if Resident #89 had and specific dietary orders, care plan interventions, or cues related to aspiration precautions. NA #3 reported she recalled that Resident #89 was on a finger food diet and that she needed checked up on while she was eating just to make sure she was feeding herself because sometimes she just sat there with her food in front of her and had not fed herself. A written statement dated [DATE] completed by Nurse #1 was reviewed. Nurse #1 indicated at approximately 1:30 PM NA #1 brought Resident #89 out of the dining room stating that I think she needs some help. She indicated Resident #89 was assessed with [REDACTED]. Nurse #1 wrote that she encouraged Resident #89 to spit out the food, but the resident had not done so. Nurse #2 was noted to also tell Resident #89 to spit out the food, but the resident had clamped her mouth shut and was still chewing the food in her mouth. Nurse #2 removed the dentures from Resident #89's mouth and performed a mouth sweep. There was a large amount estimated at 4 ounces of well ground food removed from Resident #89's mouth. Nurse #2 continue to sweep Resident #89's mouth until no visible food was seen in her mouth. Resident #89 was then noted to begin wheezing and her lips had a change in color. Nurse #1 indicated she performed the [MEDICATION NAME] on Resident #89 with no more food expelled from her mouth. Resident #89's oxygen saturation (O2 sat) was noted as 79 % on room air and her lips were blue. NA #1 and Nurse #3 took Resident #89 to her room as Nurse #1 contacted the Physician ' s Assistant (PA) and the Responsible Party (RP) at approximately 1:40 PM. The PA gave the order for transfer to the ER. A phone interview was conducted with Nurse #1 on [DATE] at 12:20 PM. The incident report, nursing note, and her written statement related to Resident #89's [DATE] incident of substance ingestion were reviewed with Nurse #1. She verified that she had completed all of these documents and confirmed the information as written. Nurse #1 stated that when NA #1 brought Resident #89 as brought out to the nurse's station that she visibly could see (Resident #89) had a mouth full of food and that she wouldn't spit the food out. Nurse #1 was asked if Resident #89 required any assistance with eating. She revealed she believed Resident #89 had an order to be supervised while eating and that she, needed to be reminded to chew and swallow. A written statement, undated, completed by Nurse #2 indicated that she was standing at the medication cart on [DATE] at approximately 1:30 PM when NA #1 brought Resident #89 up to the nurse's station and stated that something was wrong and that she thought the resident was choking. Nurse #2 indicated Resident #89 had a large amount of food in her mouth and that she was still chewing on the food. She wrote that she asked Resident #89 to spit the food out, but she had not done so. She reported that she had been able to do a mouth sweep and removed a large amount of well ground food and continued to remove food until no visible food was seen. She indicated that Resident #89 then began wheezing and had a noted change in color. Nurse #2 reported that Nurse #1 performed the [MEDICATION NAME] on Resident #89. The resident's O2 sat was 79% on room air and she was then taken to her room by Nurse #3 and Nurse #4. She indicated she went with Nurse #1 to prepare the paperwork to send Resident #89 to the ER. A phone interview was conducted with Nurse #2 on [DATE] at 4:11 PM. The incident report and her handwritten statement were reviewed with Nurse #2. She verified that when Resident #89 was brought out to the nurse's station by NA #1 that it was apparent on visual observation alone that the resident had a mouth full of food. She stated that Resident #89 would not spit the food out and that she completed a mouth sweep resulting in a large amount of ground/chewed food being removed the resident's mouth. A written statement dated [DATE] completed by Nurse #3 was reviewed. Nurse #3 indicated that around 1:30 PM on [DATE] she was walking toward the nurse's station when Nurse #1 and Nurse #2 called her over. They were surrounding Resident #89 who was seated in her wheelchair and were removing chewed food from her mouth. Nurse #3 wrote that Nurse #1 and Nurse #2 told her that Resident #89 had too much food in her mouth to allow her to swallow. Resident #89 had audible wheezing and her lips and fingertips were discolored. Nurse #3 wrote that she and Nurse #4 took Resident #89 to her room and applied O2 with a mask at 5 lpm and she was noted to audibly moving air. Around 1:50 PM first responders arrived, and they applied O2 at 15 lpm via mask. EMS arrived at approximately 2:00 PM and they transported Resident #89 from her wheelchair to the EMS stretcher and left the facility. A phone interview was conducted with Nurse #3 on [DATE] at 4:32 PM. The incident report and her written statement related to Resident #89's [DATE] incident of substance ingestion were reviewed with Nurse #3. Nurse #3 confirmed the information documented in her written statement. Nurse #3 stated that Resident #89 had no loss of consciousness at any point while at the facility. She reported Resident #89 continued with audible wheezing throughout the time period they were waiting for first responders. A written statement dated [DATE] completed by Nurse #4 was reviewed. Nurse #4 indicated NA #1 brought Resident #89 out of the dining room at approximately 1:30 PM stating, Something is wrong with (Resident #89). I think she might be choking. Nurse #4 wrote that Resident #89's mouth and cheeks were full of food and she was still chewing on the food. Resident #89 was asked to spit out the food and the resident just kept chewing and would not spit it out. Nurse #4 indicated Nurse #1 and Nurse #2 removed all visible food from Resident #89's mouth by hand. A phone interview was conducted with Nurse #4 on [DATE] at 1:45 PM. She stated she was unable to recall any specifics about the incident of substance ingestion on [DATE] for Resident #89. An interview was conducted with the RD on [DATE] at 11:55 AM. The Nutrition Quarterly assessment dated [DATE] completed by the RD for Resident #89 that indicated her diet was mechanical soft, finger foods was reviewed. The RD indicated that if a resident had an order for [REDACTED]. She explained that dietary orders, such as the order for Resident #89 that stated, mechanical soft, finger foods, appeared to be contradictory orders as mechanical soft was a different texture than finger foods. She further explained that mechanical soft was normally ground food and finger foods were cut up into small/bite size pieces. She stated that at the time of her [DATE] note the facility was still regularly utilizing orders that contained more than one food texture/consistency. The RD was asked if this change with diet orders was related to the [DATE] incident of substance ingestion for Resident #89. She stated that she was unable to say because she was not involved in the facility's investigation of the incident. A phone interview was conducted with Resident #89's physician on [DATE] at 2:36 PM. The physician reported that he expected the recommendations of ST as well as his orders to be followed. He indicated aspiration precautions were expected to be implemented for any resident noted to be an aspiration risk. An interview was conducted with the Director of Nursing (DON) on [DATE] at 4:20 PM. The DON revealed that when she investigated the [DATE] incident of substance ingestion for Resident #89 she determined the resident likely aspirated. She stated that her expectations were for staff to provide supervision and cueing as recommended by ST and as ordered by the physician. She additionally stated that she expected aspiration precautions to be implemented for all residents identified as at risk for aspiration. The Administrator and DON were notified of the Immediate Jeopardy on [DATE] at 3:03 PM. On [DATE] at 7:06 PM the facility provided the following credible allegation of Immediate Jeopardy removal: Address how corrective action will be accomplished for the resident found to have been affected by the deficient practice: On [DATE] at approximately 1:30pm, Resident was escorted from the dining room and was noted making a vomiting noise. The Certified Nursing Assistant immediately took the resident to the nurse's station where the nurse assessed resident having difficulty swallowing and showing signs of aspiration with audible wheezing. The nurse attempted to remove food particles from resident's mouth but was unsuccessful in removing all food particles and therefore dentures were removed to perform a mouth sweep. During this process the resident continued to try to chew and swallow. At this time resident's lips became cyanotic and showing signs of difficulty breathing so the [MEDICATION NAME] maneuver was initiated by the nurse without success. Resident remained conscious and was moving air. The resident was taken from the nurse's station to her room in wheelchair by the Nurse supervisor, Nurse and Certified Nursing Assistant. Nurse supervisor suctioned resident to attempt to remove remaining food particles unsuccessfully. Resident's oxygen saturation was 79 percent, oxygen at 5 liters was applied via non-rebreather face mask. Physician Assistant and Responsible Party were notified at 1:40pm. The Physician Assistant stated to call Emergency Management Services. Emergency Services was called at 1:45pm and arrived at 2:00pm. First Responders took over care of the resident. Facility Nurse staff remained in room for support. First Responders applied oxygen with their regulator at fifteen liters per minute. At 2:10pm the Emergency Management Technicians (EMT) arrived. They discussed with first responders and facility staff resident's condition and decision to suction resident in ambulance. First Responders and Emergency Management Technicians assisted the resident to the hall in her wheelchair, placed her on the gurney and proceeded to the ambulance. The EMTs remained in the ambulance for a few minutes and left the facility at 2:15pm. At 2:48pm the EMTs called to get next of kin contact information and informed the staff that the resident had died prior to reaching the hospital. On [DATE] an investigation was initiated immediately by the Director of Nursing and the Administrator and statements received from staff present in the dining room, at the nurse's station. At the conclusion of the investigation it was determined that the Certified Nursing Assistant was at the table providing assistance to another resident. According to the Certified nursing assistant's statement she followed aspiration precautions by setting up her tray, the chicken was in small pieces and saw her eating while helping another resident. Upon interview with C.N.A. on [DATE] by Director of Nursing and Administrator, she would not admit to not providing supervision and cueing. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: A 100% audit of Residents [DIAGNOSES REDACTED]. An information sheet, Swallowing Guidelines sheet, was implemented on [DATE] with current recommendations for those 26 identified with swallowing guidelines requiring supervision. The Swallowing Guidelines sheets (name, room number, diet, and recommendation from physician and speech therapist) are located in an aspiration precaution binder located in each dining room and each resident care kiosk. The swallowing guideline sheets and the kiosk are reconciled by the Assistant Director of Nurses and changes are updated when indicated by the physician or speech therapist All 43 residents with [DIAGNOSES REDACTED]. CNAs will be assigned to residents identified requiring cueing and aspiration precautions by the charge nurse at the beginning each shift. Training of licensed and certified staff provided by SDC and DON on cueing and aspiration precautions and responsibilities initiated on [DATE]. All licensed and certified nursing staff will receive this training prior to working next shift. This training will be included in new licensed and certified nursing staff orientation process.