Every finding on record at St. Helena Parish Nursing Home

Based on record review and interview, the facility failed to electronically submit payroll based staffing information for direct care staff as required. The deficient practice had the potential to affect the 57 residents residing in the facility.Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1 2026 (October 1, 2025 through December 31, 2025) revealed, in part, the facility failed to submit staffing data for the quarter. On 05/04/2026 at 10:00 a.m., an interview was conducted with S1ADM. A request was made for the provider's PBJ Final Validation report for Quarter 1 of fiscal year 2026 (10/01/2025 through 12/31/2025). On 05/05/2026 at 10:45 a.m., an interview was conducted with S1ADM. S1ADM stated he was responsible for entering the facility's PBJ data each quarter. S1ADM confirmed he did not have documentation the facility submitted PBJ data for Quarter 1 of fiscal year 2026 (October 1, 2025 through December 31, 2025) and should have. As of 05/05/2026 at 4:15 p.m., the provider failed to submit its PBJ Validation report for Quarter 1 of fiscal year 2026 (10/01/2025 through 12/31/2025) for review.

Based on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status contained accurate documentation for 1 (#18) of 24 residents reviewed for advanced directives in the initial screening process.Findings:Review of Resident #18's clinical record revealed she was admitted to the facility on [DATE].Review of Resident #18's Physician's Orders in the Electronic Health Record revealed the following:Order date: [DATE] - Code Status: DNR.Review of Resident #18's Physical Chart revealed a LaPost, dated [DATE], with CPR checked and signed by Resident #18, which indicated she did want to be resuscitated if found with no pulse or respirations.On [DATE] at 3:15 p.m., an interview was conducted with S5LPN. She stated all residents had a LaPost which determined their end of life wishes. S5LPN stated physical copies of all residents' LaPost forms were kept in a red binder and also in their individual physical charts. Upon review of the red binder with S5LPN, she confirmed there was an updated LaPost form dated [DATE] which indicated Resident #18 was a DNR and matched the [DATE] Physician's Order. S5LPN further confirmed the LaPost on Resident #18's physical chart indicated she wished to be resuscitated if found with no pulse or respirations was dated [DATE], and did not contain the updated LaPost form dated [DATE]. She confirmed all of Resident #18's medical records should contain accurate documentation and Resident #18's physical chart did not.On [DATE] at 3:34 p.m., an interview was conducted with S2DON. She stated residents' most current LaPost was kept on their physical charts and in a red binder, which should match the current Code Status order in the Electronic Health Record. She stated all medical records should contain accurate and updated documentation.

Based on interviews and record review, the facility failed to ensure services provided by the facility met professional standards by failing to ensure nursing staff did not borrow medications from one resident to administer to another resident for 1 (#11) of 17 residents reviewed in the final sample.Review of Resident #11's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Rash and Other Nonspecific Skin Eruption. Review of Resident #11's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/2026 revealed that the resident had a Brief Interview for Mental Status (BIMS) of 15, indicating the resident was cognitively intact. Review of Resident #11's current Physician Orders revealed the following, in part: Order date: 01/10/2025 - Vistaril Oral Capsule 25 mg (Hydroxyzine Pamoate) Give 25 mg by mouth four times a day related to Rash and Other Nonspecific Skin Eruption. Review of Resident #11's MAR dated May 2026 revealed Vistaril was administered daily as ordered at the scheduled times of 8:00 a.m., 1:00 p.m., 5:00 p.m., and 8:00 p.m. with the exception of the two following occasions:05/02/2026 at 8:00 p.m. - 9 was documented by S4LPN05/04/2026 at 8:00 a.m. - 9 was documented by S6LPNReview of the MAR Chart Codes Key revealed 9 = other/see progress notes.Further review revealed Vistaril was administered daily as ordered on 05/01/2026-05/03/2026 at the scheduled times of 8:00 a.m., 1:00 p.m., 5:00 p.m. by S3LPN and on 05/03/2026 at 8:00 p.m. by S4LPN. Review of the May 2026 Nurses Administration Notes revealed the following in part: 05/02/2026 at 8:57 p.m., Orders - Administration Note: Note Text: Vistaril Oral Capsule 25 MGGive 25 mg by mouth four times a day related to rash and other nonspecific skin eruption. Awaiting pharmacy. Signed by: S4LPN.05/04/2026 at 8:06 a.m., Orders - Administration Note: Note Text: Vistaril Oral Capsule 25 MGGive 25 mg by mouth four times a day related to rash and other nonspecific skin eruption.Out will order. Signed by: S6LPN. On 05/05/2026 at 11:45 a.m., an interview was conducted with Resident #11. He stated he takes Vistaril four times a day for itching. He stated, on Saturday 05/02/2026, his day shift nurse told him he was out of his Vistaril and that she was going to order it from pharmacy. He stated he was told by his night shift nurse on Saturday 05/02/2026 that he was out of his Vistaril, so he did not receive his 8:00 p.m. dose. He stated the nurses administered all four doses of Vistaril to him on Sunday, 05/03/2026, and they told him they borrowed the Vistaril from another resident's medication while they waited on his to be delivered. On 05/05/2026 at 12:23 p.m., an interview was conducted with S6LPN. She stated she was assigned to Resident #11 on day shift yesterday, 05/04/2026, and when she went to administer Resident #11's morning dose of medications, he was out of his Vistaril. She stated the night nurse she relieved on 05/04/2026 told her that Resident #11 was out of the Vistaril, they ordered it, and it hadn't come in. She stated Resident #11 told her he was given all his Vistaril doses on Sunday, 05/03/2026, and that his Sunday nurses told him they had borrowed Vistaril from another resident to administer to him. On 05/06/2026 at 10:30 a.m., an interview was conducted with S3LPN. She confirmed she was the nurse assigned to Resident #11 on 05/01/2026 through 05/03/2026 from 6:00 a.m. to 6:00 p.m. She stated Resident #11was ordered to receive Vistaril 25 mg one capsule four times a day at 8:00 a.m., 1:00 p.m., and 5:00 p.m. and on night shift at 8:00 p.m. She stated 3 of those 4 administrations were scheduled on her shift. She stated, on Saturday 05/02/2026, she administered Resident #11's 1:00 p.m. dose of Vistaril and realized there was one pill left. She stated there were no other Vistaril blister pill packs available for Resident #11. She stated once she realized this, she faxed over a request to the pharmacy to have a refill for Resident #11's Vistaril to be delivered on Saturday 05/02/2026. She was able to provide surveyor with documented evidence of the fax sent to the pharmacy on 05/02/2026 at 4:30 p.m., requesting Resident #11's Vistaril refill. She stated she returned to work on Sunday, 05/03/2026, and realized the Vistaril had not been delivered for Resident #11. She stated she did not call the pharmacy or on call pharmacist to follow up on the medication. She stated, instead of Resident #11 missing his doses for the day, she borrowed 3 Vistaril pills from Resident #36. She confirmed she borrowed 3 doses of Vistaril from Resident #36, on 05/03/2026 at 8:00 a.m., 1:00 p.m., and 5:00 p.m., and administered it to Resident #11, and should not have. She confirmed it was not the facility's process to borrow medications from one resident and administer it to another. On 05/06/2026 at 2:31 p.m., a telephone interview was conducted with S4LPN. She stated she was the nurse assigned to Resident #11 on 05/02/2026 and 05/03/2026 from 6:00 p.m. to 6:00 a.m. She stated Resident #11 was ordered to receive Vistaril four times a day, which was once on her shift at 8:00 p.m. She stated on Saturday 05/02/2026 she was told by the day shift nurse that Resident #11 was out of his Vistaril but that she had ordered it from the pharmacy. She stated Resident #11's Vistaril was not available on 05/02/2026 at 8:00 p.m. so she did not administer it and charted it as awaiting pharmacy. She stated, on 05/03/2026, she was told by the same day shift nurse that Resident #11's Vistaril had not been delivered but that she had borrowed Vistaril from Resident #36 to administer to Resident #11. She stated she did not contact the pharmacy or on call pharmacist to try to obtain or follow up on the status of Resident #11's Vistaril. She confirmed, on 05/03/2026, Resident #11 was out of Vistaril and she borrowed Vistaril from another resident to administer to Resident #11. She confirmed medications should not have been borrowed from one resident to give to another resident. On 05/06/2025 at 1:45 p.m., an interview was conducted with S2DON. She stated the process for refilling medications was for the nurse to send a fax or call the pharmacy to request a refill from the pharmacy prior to the medication running out. She stated if the resident was out of medication, and it was outside of regular pharmacy hours of operation, the nurse should have called the on call pharmacist and notified them of the medication needed. She stated the on call pharmacist would deliver the medication to the facility. She stated she was made aware on 05/04/2026 by the day shift nurse of Resident #11's Vistaril being out and another resident's medication was used for Resident #11. She stated nurses should not have borrowed medications from one resident to give to another resident. She confirmed it was not the facility's process nor was it acceptable for nurses to borrow medications from one resident to administer to another resident. She stated she expected nurses to follow the facility's protocol to obtain medication refills.

Based on record review and interviews, the facility failed to:Ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening Resident Review (PASRR) Level II evaluation as required for 2 (#1 and #3) of 3 sampled residents' records reviewed for PASRR.Ensure a resident with a new psychiatric diagnosis and/or admitted to inpatient psychiatric facility was referred for a Preadmission Screening Resident Review (PASRR) Level II evaluation as required for 2 (#1 and #3) of 3 sampled residents' records reviewed for PASRR.1. Resident #1 Review of Clinical Record revealed Resident #1 was admitted on [DATE] with diagnoses as follows: Traumatic Subdural Hemorrhage, Anxiety Disorder, Irritability and Anger, and Major Depressive Disorder. Review of Resident #1's PASRR Level I Form dated 09/12/2024 revealed no mental health diagnoses. Review of Resident #1's MAR for the month of January 2026 revealed the resident was prescribed Seroquel and Sertraline for Major Depressive Disorder. Review of resident record titled, Summary of Episode revealed in part: Resident #1 had a diagnosis of Major Depressive Disorder onset date 10/21/2024. Resident #1 was prescribed Sertraline for Major Depressive Disorder start date 10/22/2024. An interview was conducted on 02/18/2026 at 3:22 p.m. with S3SW. S3SW confirmed she does not have a process to review PASRR forms for residents transferring from another facility. An interview was conducted with S4MDS on 02/18/2026 at 3:44 p.m. She verified the date of approval for the 142 form was 09/12/2024. An interview was conducted with S2DON on 02/19/2026 at 10:58 a.m. She verified that Resident #1's admitting diagnoses included Major Depressive Disorder. Resident #3 Review of the Clinical Record revealed Resident #3 was admitted to the facility on [DATE] with no psychiatric diagnoses upon admit. Further review revealed a diagnosis of Major Depressive Disorder dated 11/17/2021. Review of Resident #3's Level I PASRR Form dated 04/05/2021 and completed by the local hospital revealed Section III: Mental Illness did not have any psychiatric diagnoses selected. An interview was conducted on 02/19/2026 at 4:30 p.m. with S3SW. S3SW reviewed Resident #3's Major Depressive Disorder diagnosis and confirmed the Level I PASRR dated 04/05/2021 did not reflect his mental illness status. S3DSW confirmed there was no process for identifying residents with new mental illness diagnosis who needed a Level 1 PASRR resubmitted. She confirmed she was unaware Level 1 PASRR required resubmission after a new mental illness diagnosis. An interview was conducted on 02/19/2026 at 3:55 p.m. with S2DON. S2DON stated she did not know who was responsible for reviewing the resident's Level I PASRR for accuracy when a new psychiatric diagnosis was identified and/or who was responsible for conducting the resubmission of a Level I PASRR for Level II evaluation when required. An interview was conducted on 02/19/2026 at 2:30 p.m. with S1ADM. S1ADM stated he was not aware a Level I PASRR needed to be resubmitted for Level II PASRR evaluation when a resident had a newly identified psychiatric diagnosis. 2. Resident #1 An interview was conducted on 02/18/2026 at 2:06 p.m. with S1ADM. He confirmed the date of initial PASRR was 09/12/2024 to meet the 30day criteria Resident #1 would have had to be admitted by 10/12/2024. Review of care plan conference summary dated 12/18/2025 section Mood / Behaviors revealed Resident #1 had irritability, anger, major depression, and anxiety. Review of IOP assessment dated [DATE] revealed in part, patient reports: depression, anxiety, hallucination, delusions, withdrawal and mood swings. An interview was conducted on 02/18/2026 at 3:22 p.m. with S3SW. She confirmed Resident #1 was not admitted within 30 days of the 142 assessment. S3SW confirmed that if a resident is discharged for more than 30 days then a new PASRR would need to be completed. She confirmed Resident #1 was discharged [DATE] and returned on 04/03/2025, and a new PASRR was not completed. An interview was conducted with S4MDS on 02/18/2026 at 3:44 p.m. S4MDS stated to be a complete discharge the resident would have to be gone more than 30 days. She confirmed that according to the MDS records Resident #1 had been gone more than 30days between 02/25/2025 and 4/23/2025. An interview was conducted with S2DON on 02/19/2026 at 10:58 a.m. She confirmed that Resident #1's date of admission was 10/21/2025, she acknowledged the date of approval on the 142 PASRR form 09/12/2025 to be more than 30 days prior to Resident #1's admission date. She acknowledged that a new PASRR assessment should be done if the admission is not within 30 days, if a significant change occurs, and if a resident is discharged and returns to the facility, and Resident #1's PASRR was not. An interview was conducted with S2DON on 02/19/2026 at 3:45 p.m. She confirmed Resident #1 was PEC'd in October and was not reassessed for PASRR on his return. She also confirmed that Resident #1's medications were increased after that event indicating a significant change. An interview was conducted on 02/19/2026 At 4:04 p.m. with S1ADMN and S2DON. They verified that due to PEC there should have been another PASRR assessment completed. Both stated the Resident Review Form is not something they were aware of. They stated they were not aware that adding IOP services qualified as a significant change thus requiring a new Resident Review Form and PASRR review. Resident #3 Review of Resident #3's Discharge MDS with an ARD of 10/10/2025 revealed an unplanned admission to an inpatient psychiatric facility with acute onset of a mental status change from Resident #3's baseline. Review of Resident #3's Inpatient Psychiatric Facility's History and Physical Examination dated 10/11/2025 through 10/24/2025 revealed the following, in part: Resident #3 was referred from the Nursing home facility under a Physician's Emergency Certificate (PEC) due to escalating agitation and threatening behaviors, including an alleged incident in which he kicked a staff member; Diagnosis of Major Depressive disorder, severe; and Increased Abilify 5 mg for mood/behavior dated 10/16/2025 due to symptoms uncontrolled. Review of Resident #3's Level 1 PASRR form from admit to current for Level II evaluation revealed no other Level 1 PASRR resubmitted after admission for Resident #3. An interview was conducted on 02/19/2026 at 4:30 p.m. with S3SW. S3SW stated she did not review the residents' admission Level 1 PASRR for accuracy when Resident #3 was sent to the inpatient psychiatric facility for behaviors. She reviewed Resident #3's Major Depressive Disorder diagnosis and confirmed the level 1 PASRR dated 04/05/2021 did not reflect his diagnosis status or inpatient psychiatric admission as mentioned above. She stated she was not aware a level 1 PASRR resubmission for level II PASRR evaluation was required for residents who are admitted to inpatient psychiatric facilities. An interview was conducted on 02/19/2026 at 3:55 p.m. with S2DON. S2DON stated she did not review residents' Level 1 PASRR's upon inpatient psychiatric facility admissions to ensure mental illness diagnoses were accurate. S2DON stated there was no process for the facility to review Level 1 PASRR's to ensure accuracy of the mental illness section. She reviewed Resident #3's Level 1 PASRR and confirmed it indicated the resident did not have a mental illness, which was not accurate. She confirmed Resident #3's PASRR Level 1 had not been resubmitted to the appropriate authority with the accurate mental illness diagnoses selected for Level II evaluation.

Based on interviews and record reviews, the facility failed to ensure a resident's discharge assessment was completed and transmitted for 1 (#3) of 5 (#1, #2, #3, #4, and #5) residents reviewed for Resident Assessment.Review of Resident #3's Clinical Record revealed he admitted to the facility on [DATE] and was discharged to a local hospital on [DATE]. Review of Resident #3's Minimum Data Set (MDS) Assessments revealed no discharge MDS was opened and/or completed. On 10/01/2025 at 1:52 p.m., an interview was conducted with S5MDS. She stated she was one of the facility's MDS nurses. She confirmed Resident #3 had discharged from the facility on 08/11/2025 and a discharge MDS had not been opened, completed, nor transmitted, and should have been.On 10/01/2025 at 1:56 p.m., an interview was conducted with S6ADON. She stated an MDS assessment should be completed upon a resident's discharge from the facility. She confirmed Resident #3 discharged from the facility on 08/11/2025 and there was no discharge assessment opened, completed, or transmitted, and there should have been.

Based on record reviews and interviews, the facility failed to send a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (#4) of 4 (#1, #3, #4, #5) residents reviewed for admission, transfer and discharge requirements.Review of Resident #4's Medical record revealed he was admitted to the facility on [DATE] and was transferred from the facility to a local hospital emergency room on [DATE]. Further review revealed Resident #4 returned to the facility on [DATE]. Review of the facility's Ombudsman Emergency Transfer Log for August 2025 revealed no documentation of Resident #4's transfer to a hospital emergency room on [DATE].Review of the facility's Census Change Sheet for August 2025 revealed no documentation of Resident #4's transfer to the hospital emergency room on [DATE].On 10/01/2025 at 7:48 a.m., an interview was conducted with S1ADM. He stated S3BOM was responsible for updating the Emergency Transfer Log that provides written notice to the Ombudsman for all resident transfers.On 10/01/2025 at 8:18 a.m., an interview was conducted with S3BOM. She stated she was responsible for updating the Ombudsman Emergency Transfer log and to document any resident transfers to the hospital and/or emergency room. She stated she was notified daily of all resident transfers through the Census Change Sheet. She reviewed the facility's Census Change Sheet for August 2025 and confirmed Resident #4's transfer to the hospital emergency room on [DATE] was not documented. On 10/01/2025 at 8:43 a.m., an interview was conducted with S1ADM. He stated the resident's assigned nurse was responsible for updating the Census Change Sheet at time of the transfer. He reviewed the facility's Census Change Sheet and the facility's Ombudsman Emergency Transfer Log for August 2025. He confirmed Resident #4's transfer to the hospital emergency room on [DATE] was not documented and should have been. On 10/01/2025 at 12:05 p.m., an interview was conducted with S4LPN. She confirmed she did not fill out the Census Change Sheet when Resident #4 was transferred to the hospital emergency room on [DATE]. She stated she did not know she was required to complete the Census Change Sheet with each resident transfer to the hospital and/or emergency room. On 10/01/2025 at 1:22 p.m., an interview was conducted with S2DON. She stated she expected all resident transfers to be documented on the Census Change Sheet by their assigned nurse to allow for the Ombudsman Transfer Log to be accurate.

Based on interviews, observations, and record reviews, the facility failed to protect the residents' right to be free from sexual abuse, psychosocial abuse, and neglect for 1 (#1) of 6 (#1, #2, #3, #R4, #R5, and #R6) sampled residents reviewed for abuse. The facility failed to protect Resident #1 from being sexually and psychosocially abused by Resident #2. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 08/01/2025 at 7:59 p.m., when Resident #2, a cognitively intact resident with a history of sexually inappropriate behaviors and a convicted sex offender, put his hand between Resident #1's upper thighs and touched her vaginal area. Resident #1 had a BIMS of 2, which indicated she was severely cognitively impaired. From 7:59 p.m. to 8:43 p.m. At 8:13 p.m., S9CNA witnessed the sexual abuse and failed to separate the residents. Resident #2 was observed in video footage to sexually abuse Resident #1 intermittently while Resident #1 attempted to stop the abuse. At 8:43 p.m., S7LPN and S11CNA witnessed the touching and intervened. After the incident, Resident #1 stated she told Resident #2 no. Interviews revealed the facility failed to monitor any of the remaining 28 female residents who could have been affected by the deficient practice after the sexual abuse occurred. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Resident #1, it could be determined a reasonable person would be likely to experience severe psychosocial harm as a result of the sexual abuse since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. S1ADM was notified of the Immediate Jeopardy situation on 08/27/2025 at 4:15 p.m. This deficient practice continued at a potential for more than minimal harm for any of the 28 female residents residing in the facility who were not assessed after the incident. Review of the facility's policy dated 01/14/1999 and titled, Adult, Disabled Person, or Elderly Abuse-Recognition and Reporting revealed the following, in part:Sexual abuse: Includes any non-consensual sexual contact of any type with a resident including:Unwanted intimate touching of any kind especially of breast or perineal area.Procedure: To protect the resident from real or suspected.sexual abuse, staff shall safeguard the resident from the offending individual. Resident #1Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Alzheimer's Disease, Mood (Affective) Disorder, and Major Depressive Disorder. Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/12/2025 revealed a Brief Interview for Mental Status (BIMS) of 2, which indicated Resident #1 was severely cognitively impaired. Review of the facility's Incident Log revealed, Resident #1 was involved in a Physical Aggression Received incident. Resident #1's Incident Report revealed the following, in part:Date: 08/01/2025 at 8:43 p.m. Person Preparing Report: S7LPNNursing Description: When S7LPN was walking up with S11CNA, S11CNA got her attention and pointed toward two residents in the front lobby in front of the nurse's station. S7LPN noticed Resident #2 had his hand between Resident #1's legs. S7LPN removed Resident #2's hand and separated the two residents. When S7LPN was speaking with Resident #1, she informed her Resident #2 said, Don't let no one see this. When Resident #1 was asked if she told Resident #2 no, she said, yes. S7LPN talked further with Resident #1, she asked if she could check her out and make sure that everything was ok. Resident #1 refused and put her right fist in the air saying she can handle anything that needs to be handled. At 10:12 p.m., local police arrived at the facility and spoke to Resident #1 and #2 regarding the incident. Information regarding both residents, as well as a typed statement, was given to the officers by S7LPN. Resident #1 remained at the nurse's station until she was ready to go to bed and at that time, she was assisted to the room and assisted to bed. S1ADM was notified. S2DON was made aware by S1ADM. Further review of Resident #1's Clinical Record revealed no new interventions or services to address the sexual abuse after the incident occurred. Resident #2Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder and Depression. Further review revealed Resident #2 had documentation showing he was a convicted sex offender. Review of Resident #2's admission Paperwork from a local hospital dated 11/24/2023 revealed the following, in part: Resident #2 was recently released from jail for not registering as a sex offender. Review of Resident #2's Quarterly MDS with an ARD of 07/23/2025 revealed a BIMS of 14, which indicated Resident #2 was cognitively intact. Review of Resident #2's current Care Plan revealed the following, in part:Created 02/26/2025Problem: The resident has a behavior problem: excessive masturbating and staying completely naked at all times when in room/makes sexual comments towards staff at times. Interventions: Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; intervene as necessary to protect the rights and safety of others; 05/15/2025: Intensive Outpatient Program (IOP) to be notified of increase in inappropriate sexual behavior. Further review of Resident #2's Clinical Record revealed the resident had not received psychiatric services to address the sexual behaviors since January of 2025. Review the facility's Incident Log revealed, Resident #2 was involved in a Physical Aggression Initiated incident. Resident #2's Incident Report revealed the following, in part: Date: 08/01/2025 at 8:43 p.m.Person Preparing Report: S2DONNursing Description: S7LPN informed me of the incident between Resident #2 and Resident #1. S11CNA and S7LPN noticed Resident #2 had his hand between Resident #1's legs. S7LPN removed Resident #2's hand and separated the two residents. I informed Resident #2 he was not allowed to touch the other residents. Resident #2 verbalized understanding. S7LPN notified S1ADM and doctor. Review of Resident #2's Police Incident Report revealed the following, in part:On 08/01/2025 at approximately 10:00 p.m., two officers were dispatched to the facility in regards to a sexual battery that had just taken place. Upon our arrival, we met with S7LPN. S7LPN began to tell us earlier in the night, she came upon Resident #2 fondling Resident #1 in the common area located in front of the nurse's desk. S7LPN stated as soon as she saw this, she removed Resident #2's hand. S7LPN said Resident #2 went to his room and she contacted both her boss and the police. S7LPN stated she saw Resident #2 with his hand buried between Resident #1's legs and he was using his thumb as if he was massaging Resident #1's vaginal area in a circular motion. I then spoke with Resident #1. Resident #1 stated Resident #2 was rubbing on her leg and she told him to leave her alone. Resident #1 seemed a little confused at the time, the longer we spoke, however she insisted Resident #2 was her friend, but that she had told him no when he began rubbing on her. After speaking with Resident #1, we were then taken to speak to Resident #2. Upon speaking with Resident #2, he stated he knew why we were there and that he had indeed touched Resident #1 in an inappropriate way and he was sorry, and he knew he had done wrong. It was at this time Resident #2 was told to have no further contact with Resident #1 and the matter was going to be investigated further, and it was possible he could be facing criminal charges because of the incident. On 08/25/2025 at 3:20 p.m., video footage of the incident was reviewed with S1ADM. S1ADM confirmed the following:08/01/2025 at 7:56 p.m., Resident #2 wheeled himself beside Resident #1, who was sitting directly in front of the nurse's station in her wheelchair. 7:58 p.m., Resident #2 was observed touching Resident #1's right shin.7:59 p.m., Resident #2's left hand moved from Resident #1's shin to between her upper thigh and vaginal area, outside of her pants. Resident #1 immediately put her hands on Resident #2's left arm.8:01 p.m., Resident #1 attempted to remove Resident #2's hand but was unsuccessful. Resident #2's hand remained between Resident #1's upper thighs until 8:12 p.m., when Resident #1 stood up. Resident #2's hand was observed going behind Resident #1's buttocks. 8:13 p.m., S9CNA was observed to walk within approximately 6 feet from where Residents #1 and #2 were and Resident #1 sat back down. S9CNA pointed at Resident #2, and was observed to say something, then S9CNA walked away. Resident #2's hand remained in between Resident #1's upper thighs when she sat down. 8:18 p.m., Resident #2 removed his hand from between Resident #1's thighs. 8:22 p.m., Resident #2 put his right hand between Resident #1's upper thighs and Resident #1 started tapping on the top Resident #2's hand. Resident #2 removed his hand at 8:23 p.m. when S8LPN and S17LPN was observed walking back to the nurse's station with their medication carts. 8:25 p.m., S8LPN was observed administering Resident #2 his medications and S17LPN was observed administering Resident #1 her medications, then both nurses walked away. 8:29 p.m., Resident #2 placed his left hand between Resident #1's upper thighs again and Resident #1 attempted to remove it. After attempting to remove it, it could not be determined where Resident #2's hand was until 8:42 p.m., when Resident #2's left hand was observed coming from behind the left wheel of his wheelchair. 8:43:37, Resident #2 was observed putting his left hand back between Resident #1's upper thighs and Resident #1 was observed slapping at his hand. 8:43:47, S11CNA was observed walking up the hall back to the nurse's station. S11CNA grabbed at S7LPN, who was walking beside her, and pointed towards Residents #1 and #2. S7LPN immediately removed Resident #2's hand from between Resident #1's thighs and separated the residents. S7LPN was observed talking to Resident #1 then she picked up the phone and called someone. 8:48 p.m., Resident #2 was brought to his room. On 08/26/2025 at 1:47 p.m., an interview was attempted with Resident #1. She was unable to be interviewed due to her cognitive status. On 08/26/2025 at 11:58 a.m., an interview was conducted with Resident #1's family member. He stated Resident #1 had been residing at the facility for a little over a month. He stated the facility notified him of the incident between Resident #1 and #2 on 08/01/2025. He stated he was told there was a gentleman resident in the common area with Resident #1, and he rubbed her between her legs. He stated he was told it was not skin to skin, but it was still inappropriate touching. He stated Resident #1 was confused. He stated if Resident #1 was cognitive, she would have been very upset that someone touched her inappropriately. On 08/25/2025 at 4:32 p.m., an interview was conducted with S9CNA. She said Resident #1 was not cognitively intact and Resident #2 was. She stated knew Resident #2 was a sex offender and explained when children came into the facility, the resident had to be moved to his room. S9CNA stated she worked the night of 08/01/2025, when Residents #2 sexually abused Resident #1. She stated Resident #1 was at the front of the nurse's station in her wheelchair. S9CNA stated she was sitting in the dining room charting, and she saw Resident #1 stand up. She stated Resident #2 was sitting to the right of Resident #1. She stated as Resident #1 was standing up, she was telling Resident #1 to sit down while simultaneously walking towards Resident #1. She stated as she got closer, she saw Resident #2 take his hand and touch Resident #1's vagina from the backside. She stated she told Resident #2 he could not touch her. She stated Resident #2 knew what he was doing and that it was sexual abuse. She stated she did not separate Resident #1 from Resident #2. She stated her first instinct was to report the incident to the nurse and she did not think to separate the residents. She stated she went to find a nurse to report it to and when she came back, staff were in the front lobby talking about Resident #2 sexually touching Resident #1. She stated she then notified S7LPN what she saw earlier. She stated she notified S1ADM. She stated after S7LPN and S11CNA saw Resident #2 touching Resident #1, the residents were separated, and Resident #2 was sent to a behavioral hospital. She stated Resident #2 had not been back to the facility since the incident occurred. On 08/26/2025 at 6:37 a.m., an interview was conducted with S7LPN. She stated Resident #2 was fully cognitive. She stated Resident #1 was not cognitive. She stated she was aware Resident #2 was a sex offender. She stated she worked the night of 08/01/2025, when Residents #2 sexually abused Resident #1. She stated after she completed her medication pass, S11CNA got her attention and pointed at Residents #1 and #2. She stated she saw Resident #2 with his hand in between Resident #1's legs rubbing her vagina violently. S7LPN stated Resident #2 had his fingers toward Resident #1's buttocks and his thumb was rubbing Resident #1's front vaginal area. S7LPN stated she physically removed Resident #2's hand and separated the residents immediately. She stated she asked Resident #1 what happened and Resident #1 said I told him no. S7LPN stated she called S1ADM immediately to report it. She stated S1ADM told her to call the police and file a report. S7LPN stated she heard Resident #2 tell the officers he was not in his right mind and stated he just wanted to feel her. She stated Resident #2 said he didn't want to get caught. She stated Resident #1 refused to be assessed afterwards for any injuries. She stated after the incident took place, S9CNA told her she had seen Resident #2 touch Resident #1's vagina earlier in the night. She stated the incident was sexual abuse because Resident #2 was cognitive and knew what he was doing and Resident #1 said no, and was not cognitive. She stated Resident #2 was sent to a behavior hospital after the incident and had not been back to the facility. On 08/25/2025 at 2:33 p.m., 08/26/2025 at 10:05 a.m. and 12:30 p.m., and 08/27/2025 at 6:37 a.m., attempts were made to contact S11CNA for interview with no answer. On 08/25/2025 at 2:41 p.m., an interview was conducted with a local Police Officer. He stated he could not remember the date, but he responded to a call at the facility regarding sexual battery at the beginning of the month. He stated when he arrived to the facility, S7LPN told him she witnessed Resident #2 inappropriately touching Resident #1 between her legs, in her vaginal area. He stated S7LPN told him she had to physically remove Resident #2's hands from Resident #1's vaginal area, then she stated she separated them. He stated he spoke to Resident #1 first. He stated Resident #1 told him Resident #2 had been rubbing her between the legs and she told Resident #2 to stop and he didn't. He stated Resident #1 had some confusion but was able to recall what happened. He stated he then spoke to Resident #2. He stated Resident #2 admitted he touched Resident #1 between the legs and Resident #2 said he was sorry. The officer stated after interviews, statements, and camera footage, he put charges on Resident #2. He stated the facility sent Resident #2 to a behavioral hospital the next day. The officer stated the incident between Resident #1 and Resident #2 was sexual battery. He stated Resident #1 did not consent and probably could not consent to the touching due to her mental status. He stated Resident #1 told Resident #2, no, and he still proceeded to touch her inappropriately. On 08/27/2025 at 8:10 a.m., an interview was conducted with S12NP. He stated he was familiar with Resident #2. He stated at the beginning of the year, Resident #2 was in the IOP program and received group therapy and individual counseling for bipolar and depression. He stated Resident #2 responded well to the program and his symptoms of bipolar and depression improved with medication changes. He stated Resident #2 completed his treatment at the beginning of the year and was discharged from the program. He stated he was not notified Resident #2 was having increased inappropriate sexual behaviors in May. He stated if Resident #2's behaviors had become a problem, he would have expected staff to notify him to address the behaviors. He stated he was not notified by the facility Resident #2 sexually abused Resident #1 on 08/01/2025. He stated he had not evaluated Resident #1 or #2 since the incident, and stated he needed to. On 08/26/2025 at 2:25 p.m., an interview was conducted with S2DON. She stated Resident #2 was cognitive and Resident #1 was not. She stated on 08/01/2025, she was notified of the incident between Resident #1 and #2 by S1ADM. She stated she was told Residents #1 and #2 were in front of the nurse's station and Resident #2 had his hand between Resident #1's legs, touching her inappropriately. She stated S7LPN separated the residents then notified S1ADM. She stated Resident #1 would not allow the nurse to assess her. She stated later on, while the CNA was changing her, the nurse assessed for scratches, bruises, discoloration, and injury. She stated the resident had no physical injuries. She stated Resident #2 remained in his room until he was sent to a behavioral hospital the next day. She stated Resident #1 was able to tell S7LPN she told Resident #2 no when he was touching her. S2DON stated Resident #1 was touched without her consent and it was wrong. S2DON stated since the incident, Resident #1 did not receive a formal mental status or psychiatric evaluation to assess for psychosocial abuse. She stated S12NP had not been notified of the incident. She further confirmed S12NP was not notified of Resident #2's increase in sexually inappropriate behaviors in May per his care plan intervention. She stated she was unaware Resident #2 was a sex offender until after the incident between Resident #1 and #2. She stated prior to the incident, there was no facility policy for the admission of sex offenders and there was no interventions in place to protect other residents from Resident #2. She verified she watched the video footage and confirmed S9CNA should have separated Residents #1 and #2 after she witnessed Resident #2 touch Resident #1's vaginal area to prevent the abuse from continuing. She stated to her knowledge, none of the cognitive female resident's had been asked if they had been touched inappropriately by another resident. She stated there had been no monitoring related to abuse since the incident. She stated since the incident, staff had been in-serviced on separating the resident's for safety first, then reporting, but there was no monitoring in place. On 08/26/2025 at 3:14 p.m., an interview was conducted with S1ADM. He stated on 08/01/2025 at 8:45 p.m., S7LPN reported the abuse of Resident #1 by Resident #2. S1ADM stated S7LPN saw Resident #2 rubbing Resident #1's vaginal area. He stated he notified S2DON and told S7LPN to call the police and complete a physical assessment on Resident #1. He stated Resident #1 refused the assessment. He stated a psychiatric evaluation was not completed for Resident #1 after the incident to assess for psychosocial abuse. He stated after watching the video footage, the incident was sexual abuse. He further confirmed S9CNA should have separated Residents #1 and #2 after she saw Resident #2 touch Resident #1's vagina to prevent the abuse from continuing. He confirmed it was 30 minutes from the time S9CNA witnessed the sexual abuse to the time S7LPN stopped the sexual abuse. He stated he found out Resident #2 was a sex offender on 08/04/2025, when a staff member notified him. He stated on 08/04/2025, he was also notified Resident #3 was a sex offender as well. He stated since the incident, staff had been in-serviced to separate the residents for safety first then report the abuse immediately. He stated none of the cognitive female residents had been asked if they had been touched inappropriately by another resident. He stated no monitoring related to abuse had occurred since the incident. He stated prior to the incident, there was no facility policy for the admission of sex offenders. He stated going forward, no sex offenders will be admitted to the facility. The Immediate Jeopardy was removed on 08/28/2025 at 5:20 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Plan of RemovalF600: The facility failed to ensure Resident #1, a cognitively impaired resident, was free from sexual and psychosocial abuse by Resident #2, a cognitively intact resident who had a history of sexually inappropriate behaviors. Resident #2 was a convicted sex offender prior to admission to the facility.Plan of Correction-All residents have the potential to be affected-Effective 08/27/2025, S2DON and Designee will conduct Life Rounds on all female residents and body assessments on BIMS > 9 to make sure residents feel safe and are not being abused by another resident.-Effective 08/27/2025 and ongoing until completed, S1ADM will educate/train staff through in-service before the start of their shift on Adult, Disabled Person, or Elderly Abuse Recognition and Reporting. This will be monitored by S1ADM/Designee for all shifts for the next 30 days, utilizing the audit tool and employee roster.-08/04/2025 admission Policy developed for the acceptance of sex offenders by the S18CEO. -08/04/2025 Per Policy, current residents' sex offender status have been checked, and all potential residents will be checked before admission by the S6SW/Designee. This will be monitored by S1ADM/Designee for the next 30 days and ongoing upon notification of potential residents.-08/06/2025 S6SW notified residents, families, and responsible parties of sex offenders being housed in the facility and will continue to be monitored by S1ADM/Designee. -08/04/2025 The remaining sex offender in the building was educated through in-service by S1ADM on the appropriate protocols of the facility and will be monitored closely by S1ADM/Designee through observation daily, as long as the resident resides in the facility.-08/05/2025 Staff educated through in-service by S1ADM on protocols and actions to take for the remaining sex offender. This will be monitored closely S1ADM/Designee through observation daily, as long as the resident resides in the facility.-The facility will ascertain substantial compliance by 08/28/2025.

Based on record reviews and interview, the facility failed to ensure staff was provided Quality Assurance and Performance Improvement (QAPI) training for 5 (S7LPN, S8LPN, S9CNA, S10CNA, and S11CNA) of 5 (S7LPN, S8LPN, S9CNA, S10CNA, and S11CNA) personnel files reviewed. Review of S7LPN's personnel file revealed a hire date of 07/26/2024. Further review of S7LPN's personnel file revealed no documented evidence, and the facility presented no documented evidence, S7LPN received QAPI training as required. Review of S8LPN's personnel file revealed a hire date of 12/01/2023. Further review of S8LPN's personnel file revealed no documented evidence, and the facility presented no documented evidence, S8LPN received QAPI training as required. Review of S9CNA's personnel file revealed a hire date of 04/16/2025. Further review of S9CNA's personnel file revealed no documented evidence, and the facility presented no documented evidence, S9CNA received QAPI training as required. Review of S10CNA's personnel file revealed a hire date of 03/29/2022. Further review of S10CNA's personnel file revealed no documented evidence, and the facility presented no documented evidence, S10CNA received QAPI training as required. Review of S11CNA's personnel file revealed a hire date of 12/11/2024. Further review of S11CNA's personnel file revealed no documented evidence, and the facility presented no documented evidence, S11CNA received QAPI training as required. On 08/28/2025 at 10:20 a.m., an interview was conducted with S1ADM. He stated there was no documentation any staff had completed QAPI training.

Based on observation, record reviews and interviews, the facility failed to ensure notifications of changes in residents' conditions were made for 2 (#1 and #2) of 4 (#1, #2, #3, and #R6) residents reviewed for behavioral services. The facility failed to ensure:1. S12NP was notified Resident #2 had an increase in inappropriate sexual behaviors; and 2. S12NP was notified Resident #2 sexually and psychosocially abused Resident #1.1.Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder and Depression. Further review revealed Resident #2 was a convicted sex offender. Review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/2025 revealed a Brief Interview for Mental Status (BIMS) of 14, which indicated Resident #2 was cognitively intact. Review of Resident #2's Nurse's Notes revealed the following, in part:03/04/2025 at 2:34 p.m. - Resident #2 constantly pulls off all of his clothing after the Certified Nursing Assistants (CNAs) have dressed him. He doesn't call for help with changing his brief. This morning and this afternoon, I knocked on the door to give Resident #2 his medications, he told me to come in and he was lying in bed with no brief or clothing on. I had to tell him to cover up so I could come in and give him his medication. Signed, S19LPN04/27/2025 at 6:07 a.m. - CNA reported to me that while she was changing Resident #2, he made some very crude comments to her. CNA stated Resident #2 said he wanted to touch her all over and continued making sexual comments to her. CNA told Resident #2 he was being very disrespectful and inappropriate. CNA finished up with Resident #2 as soon as possible and reported to S8LPN. Signed, S8LPN Review of Resident #2's current Care Plan revealed the following, in part:Created 02/26/2025Problem: The resident has a behavior problem: excessive masturbating and staying completely naked at all times when in room/makes sexual comments towards staff at times. Interventions: Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; intervene as necessary to protect the rights and safety of others; 05/15/2025: Intensive Outpatient Program (IOP) to be notified of increase in inappropriate sexual behavior. Review of an email dated 05/16/2025 at 10:34 a.m. from S4CP to S6SW revealed the following, in part:I couldn't remember if you were in the meeting when S2DON said it or not, but S2DON said she wants S12NP to look at Resident #2 because the CNAs are saying he's progressively getting worse and worse about making inappropriate sexual comments towards them. Review of Resident #2's Psychiatric Evaluation Notes revealed the last time he was evaluated by S12NP was on 01/16/2025. On 08/26/2025 at 1:10 p.m., an interview was conducted with S4CP. She stated the intervention initiated on Resident #2's care plan on 05/15/2025 for IOP to be notified of his increased inappropriate sexual behaviors was S6SW's responsibility to arrange. S4CP stated she did not know if it was done. On 08/26/2025 at 1:11 p.m., an interview was conducted with S1ADM. He stated S6SW was on vacation and unable to be reached. 2.Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Alzheimer's Disease, Mood (Affective) Disorder, and Major Depressive Disorder. Review of Resident #1's admission MDS with an ARD of 07/12/2025 revealed a BIMS of 2, which indicated Resident #1 was severely cognitively impaired. Review of the facility's Incident Log revealed, Resident #1 was involved in a Physical Aggression Received incident. Resident #1's Incident Report revealed the following, in part:Date: 08/01/2025 at 8:43 p.m. Person Preparing Report: S7LPNNursing Description: When S7LPN was walking up with S11CNA, S11CNA got her attention and pointed toward two residents in the front lobby in front of the nurse's station. S7LPN noticed Resident #2 had his hand between Resident #1's legs. S7LPN removed Resident #2's hand and separated the two residents. When S7LPN was speaking with Resident #1, she informed her Resident #2 said, Don't let no one see this. When Resident #1 was asked if she told Resident #2 no, she said, yes. S7LPN talked further with Resident #1, she asked if she could check her out and make sure that everything was ok. Resident #1 refused and put her right fist in the air saying she can handle anything that needs to be handled. At 10:12 p.m., local police arrived at the facility and spoke to Resident #1 and #2 regarding the incident. Information regarding both residents, as well as a typed statement, was given to the officers by S7LPN. Resident #1 remained at the nurse's station until she was ready to go to bed and at that time, she was assisted to the room and assisted to bed. S1ADM was notified. S2DON was made aware by S1ADM. On 08/25/2025 at 3:20 p.m., video footage of the incident was reviewed with S1ADM. S1ADM confirmed the following:08/01/2025 at 7:56 p.m., Resident #2 wheeled himself beside Resident #1, who was sitting directly in front of the nurse's station in her wheelchair. 7:58 p.m., Resident #2 was observed touching Resident #1's right shin.7:59 p.m., Resident #2's left hand moved from Resident #1's shin to between her upper thigh and vaginal area, outside of her pants. Resident #1 immediately put her hands on Resident #2's left arm.8:01 p.m., Resident #1 attempted to remove Resident #2's hand but was unsuccessful. Resident #2's hand remained between Resident #1's upper thighs until 8:12 p.m., when Resident #1 stood up. Resident #2's hand was observed going behind Resident #1's buttocks. 8:13 p.m., S9CNA was observed to walk within approximately 6 feet from where Residents #1 and #2 were and Resident #1 sat back down. S9CNA pointed at Resident #2, and was observed to say something, then S9CNA walked away. Resident #2's hand remained in between Resident #1's upper thighs when she sat down. 8:18 p.m., Resident #2 removed his hand from between Resident #1's thighs. 8:22 p.m., Resident #2 put his right hand between Resident #1's upper thighs and Resident #1 started tapping on the top Resident #2's hand. Resident #2 removed his hand at 8:23 p.m. when S8LPN and S17LPN was observed walking back to the nurse's station with their medication carts. 8:25 p.m., S8LPN was observed administering Resident #2 his medications and S17LPN was observed administering Resident #1 her medications, then both nurses walked away. 8:29 p.m., Resident #2 placed his left hand between Resident #1's upper thighs again and Resident #1 attempted to remove it. After attempting to remove it, it could not be determined where Resident #2's hand was until 8:42 p.m., when Resident #2's left hand was observed coming from behind the left wheel of his wheelchair. 8:43:37, Resident #2 was observed putting his left hand back between Resident #1's upper thighs and Resident #1 was observed slapping at his hand. 8:43:47, S11CNA was observed walking up the hall back to the nurse's station. S11CNA grabbed at S7LPN, who was walking beside her, and pointed towards Residents #1 and #2. S7LPN immediately removed Resident #2's hand from between Resident #1's thighs and separated the residents. S7LPN was observed talking to Resident #1 then she picked up the phone and called someone. 8:48 p.m., Resident #2 was brought to his room. Review of Resident #1's Psychiatric Evaluation Notes revealed the last time she was evaluated by S12NP was on 07/31/2025, before she was sexually and psychosocially abused by Resident #2. On 08/26/2025 at 11:58 a.m., an interview was conducted with Resident #1's family member. He stated Resident #1 had been residing at the facility for a little over a month. He stated the facility notified him of the incident between Resident #1 and #2 on 08/01/2025. He stated he was told there was a gentleman resident in the common area with Resident #1, and he rubbed her between her legs. He stated he was told it was not skin to skin, but it was still inappropriate touching. He stated Resident #1 was confused. He stated if Resident #1 was cognitive, she would have been very upset that someone touched her inappropriately. On 08/27/2025 at 8:10 a.m., an interview was conducted with S12NP. He stated he was familiar with Resident #2. He stated at the beginning of the year, Resident #2 was in the IOP program and received group therapy and individual counseling for Bipolar and Depression. He stated Resident #2 responded well to the program and his symptoms of Bipolar and Depression improved with medication changes. He stated Resident #2 completed his treatment at the beginning of the year and was discharged from the program. He stated he was not notified Resident #2 was having increased inappropriate sexual behaviors in May 2025. He stated if Resident #2's behaviors had become a problem, he would have expected staff to notify him to address the behaviors. He stated he was not notified by the facility Resident #2 sexually abused Resident #1 on 08/01/2025. He stated he had not evaluated Resident #1 or #2 since the incident, and stated he needed to. On 08/26/2025 at 2:25 p.m., an interview was conducted with S2DON. She stated both she and S6SW arranged IOP for the facility residents. S2DON confirmed S12NP was not notified of Resident #2's increase in sexual behaviors in May 2025 per his care plan intervention, and should have been. She further confirmed S12NP had not been notified of the incident between Resident #1 and #2, and Resident #1 had not been assessed for psychosocial abuse.

Based on record reviews and interviews, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASRR) Level II by failing to incorporate PASRR Level II determinations and recommendations into a resident's transitions of care for 1 (#2) of 3 (#2, #3, and #R6) residents reviewed for sexual behaviors.Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE] with diagnoses including, Bipolar Disorder and Depression. Review of Resident #2's Form 142 revealed he was approved for admission by Level II authority for a temporary period of 03/04/2025 - 03/03/2026. Review of Resident #2's PASRR Level II Evaluation Summary and Determination Notice dated 03/11/2025 revealed the Level II authority had approved 365 days for nursing facility placement and the following to occur: 1. Psychiatric Evaluation for assessment and medication management. 2. Referral for Dementia Testing/Evaluation by a Neurologist or Neuropsychologist. 3. Community Based Service via Mental Health Rehab Services to be rendered at NF Community Psychiatric Supportive Services and Psychosocial Rehab Individual counseling to occur by a licensed mental health professional. Review of Resident #2's clinical record revealed the last time he received a psychiatric evaluation was on 01/16/2025. Further review revealed none of the PASRR Level II recommendations listed above had been completed since 03/11/2025. An interview was conducted with S2DON on 08/27/2025 at 12:14 p.m. S2DON reviewed Resident #2's Level II Determination Notice dated 03/11/2025 and confirmed the PASRR level II recommendations mentioned above were not implemented, and should have been.

Based on record reviews and interviews, the provider failed to develop and implement a comprehensive person centered care plan for each resident as evidenced by failing to:1. Develop a comprehensive person centered care plan for 2 of 2 (#2 and #3) residents who were registered sex offenders; and 2. Implement a care plan intervention for 1 (#2) of 3 (#2, #3, and #R6) residents reviewed for sexual behaviors. Review of the facility's policy dated 12/27/2019 and titled, Plan of Care revealed the following, in part:Policy StatementIt is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. Procedure:Developing the Comprehensive Care Plan: 3. Each discipline will check and/or add interventions/approaches to include but not limited to:b. Interventional entries reflect activities that incorporate observations, assessments, management and teaching components that will restore, maintain and/or promote the resident's well-being. 1.Resident #2Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder and Depression. Further review revealed Resident #2 was a registered sex offender. Review of Resident #2's admission Paperwork from a local hospital dated 11/24/2023 revealed the following, in part: Resident #2 was recently released from jail for not registering as a sex offender. Review the facility's Incident Log revealed, Resident #2 was involved in a Physical Aggression Initiated incident. Resident #2's Incident Report revealed the following, in part: Date: 08/01/2025 at 8:43 p.m.Person Preparing Report: S2DONNursing Description: S7LPN informed me of the incident between Resident #2 and Resident #1. S11CNA and S7LPN noticed Resident #2 had his hand between Resident #1's legs. S7LPN removed Resident #2's hand and separated the two residents. S2DON informed Resident #2 he was not allowed to touch the other residents. Resident #2 verbalized understanding. S7LPN notified S1ADM and doctor. Review of Resident #2's current Care Plan revealed the following, in part: Created 08/06/2025Problem: Documented safety concerns: Resident is a registered sex offender Interventions: Not permitted to participate in activities when children are present; two staff members shall be present at all times while providing care for resident; while interacting with others, staff will be with resident at all times; when appointments or things that cause resident to leave facility, resident will be under the supervision of staff; notification will be made to staff, residents, and family members that a sex offender is housed here, but name will not be mentioned. Resident #3Review of Resident #3' Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Major Depressive Disorder, Anxiety Disorder, and Hemiplegia and Hemiparesis Following Cerebral Infarction. Review of Resident #3's Care Plan created on 08/04/2025 revealed the following, in part: Problem: Documented safety concerns: Resident is a registered sex offender Interventions: Not permitted to participate in activities when children are present; two staff members shall be present at all times while providing care for resident; while interacting with others, staff will be with resident at all times; when appointments or things that cause resident to leave facility, resident will be under the supervision of staff; notification will be made to staff, residents, and family members that a sex offender is housed here, but name will not be mentioned; Resident counseled by administrative staff on guidelines to follow during his admission here. On 08/26/2025 at 1:10 p.m., an interview was conducted with S4CP. She stated she knew Resident #2 was a registered sex offender when he was admitted to the facility because it was in his admission paperwork. She stated she was also aware Resident #3 was a registered sex offender. She stated she was not initially trained to care plan residents for being sex offenders. She confirmed Residents #2 and #3's care plans were developed to reflect their sex offender status after the incident occurred between Residents #1 and #2. On 08/26/2025 at 2:25 p.m., an interview was conducted with S2DON. She stated she was unaware Resident #2 and Resident #3 were registered sex offenders until after the incident occurred between Resident #1 and #2 on 08/01/2025. S2DON stated if she would have known Resident #2 was a registered sex offender, she would have been more aggressive with initiating interventions for him, which could have made staff more aware of Resident #2's behaviors. She stated if S4CP was aware Residents #2 and #3 were registered sex offenders, they should have been care planned for being sex offenders prior to the incident between Residents #1 and #2 on 08/01/2025. 2. Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder and Depression. Further review revealed Resident #2 was a registered sex offender. Review of Resident #2's Care Plan created on 02/26/2025 revealed the following, in part: Problem: The resident has a behavior problem: excessive masturbating and staying completely naked at all times when in room/makes sexual comments towards staff at times. Interventions: Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; intervene as necessary to protect the rights and safety of others; 05/15/2025: Intensive Outpatient Program (IOP) to be notified of increase in inappropriate sexual behavior. Review of an email dated 05/16/2025 at 10:34 a.m. from S4CP to S6SW revealed the following, in part:I couldn't remember if you were in the meeting when S2DON said it or not, but S2DON said she wants S12NP to look at Resident #2 because the Certified Nursing Assistants (CNAs) are saying he's progressively getting worse and worse about making inappropriate sexual comments towards them. Review of Resident #2's Psychiatric Evaluation Notes revealed the last time he was evaluated by S12NP was on 01/16/2025. On 08/26/2025 at 1:10 p.m., an interview was conducted with S4CP. She stated the intervention initiated on Resident #2's care plan on 05/15/2025 for IOP to be notified of his increased inappropriate sexual behaviors was S6SW's responsibility to arrange, and she did not know if it was. On 08/26/2025 at 1:11 p.m., an interview was conducted with S1ADM. He stated S6SW was on vacation and unable to be reached. On 08/27/2025 at 8:10 a.m., an interview was conducted with S12NP. He stated he was not notified Resident #2 was having increased inappropriate sexual behaviors in May 2025. He stated if Resident #2's behaviors had become a problem, he would have expected staff to notify him. On 08/26/2025 at 2:25 p.m., an interview was conducted with S2DON. She stated both she and S6SW arranged IOP for the facility residents. S2DON further confirmed S12NP was not notified of Resident #2's increase in sexual behaviors in May 2025 per his care plan intervention and should have been.

Based on observation, record reviews, and interviews, the facility failed to ensure a resident's care plan was revised by failing to update problems, goals, and interventions after she was sexually and psychosocially abused for 1 (#1) of 4 (#1, #2, #3, and #R6) residents reviewed for care plans. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Alzheimer's Disease, Mood (Affective) Disorder, and Major Depressive Disorder. Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/12/2025 revealed a Brief Interview for Mental Status (BIMS) of 2, which indicated Resident #1 was severely cognitively impaired. Review of the facility's Incident Log revealed, Resident #1 was involved in a Physical Aggression Received incident. Resident #1's Incident Report revealed the following, in part:Date: 08/01/2025 at 8:43 p.m. Person Preparing Report: S7LPNNursing Description: When S7LPN was walking up with S11CNA, S11CNA got her attention and pointed toward two residents in the front lobby in front of the nurse's station. S7LPN noticed Resident #2 had his hand between Resident #1's legs. S7LPN removed Resident #2's hand and separated the two residents. When S7LPN was speaking with Resident #1, she informed her Resident #2 said, Don't let no one see this. When Resident #1 was asked if she told Resident #2 no, she said, yes. S7LPN talked further with Resident #1, she asked if she could check her out and make sure that everything was ok. Resident #1 refused and put her right fist in the air saying she can handle anything that needs to be handled. At 10:12 p.m., local police arrived at the facility and spoke to Resident #1 and #2 regarding the incident. Information regarding both residents, as well as a typed statement, was given to the officers by S7LPN. Resident #1 remained at the nurse's station until she was ready to go to bed and at that time, she was assisted to the room and assisted to bed. S1ADM was notified. S2DON was made aware by S1ADM. On 08/25/2025 at 3:20 p.m., video footage of the incident was reviewed with S1ADM. S1ADM confirmed the following:08/01/2025 at 7:56 p.m., Resident #2 wheeled himself beside Resident #1, who was sitting directly in front of the nurse's station in her wheelchair. 7:58 p.m., Resident #2 was observed touching Resident #1's right shin.7:59 p.m., Resident #2's left hand moved from Resident #1's shin to between her upper thigh and vaginal area, outside of her pants. Resident #1 immediately put her hands on Resident #2's left arm.8:01 p.m., Resident #1 attempted to remove Resident #2's hand but was unsuccessful. Resident #2's hand remained between Resident #1's upper thighs until 8:12 p.m., when Resident #1 stood up. Resident #2's hand was observed going behind Resident #1's buttocks. 8:13 p.m., S9CNA was observed to walk within approximately 6 feet from where Residents #1 and #2 were and Resident #1 sat back down. S9CNA pointed at Resident #2, and was observed to say something, then S9CNA walked away. Resident #2's hand remained in between Resident #1's upper thighs when she sat down. 8:18 p.m., Resident #2 removed his hand from between Resident #1's thighs. 8:22 p.m., Resident #2 put his right hand between Resident #1's upper thighs and Resident #1 started tapping on the top Resident #2's hand. Resident #2 removed his hand at 8:23 p.m. when S8LPN and S17LPN was observed walking back to the nurse's station with their medication carts. 8:25 p.m., S8LPN was observed administering Resident #2 his medications and S17LPN was observed administering Resident #1 her medications, then both nurses walked away. 8:29 p.m., Resident #2 placed his left hand between Resident #1's upper thighs again and Resident #1 attempted to remove it. After attempting to remove it, it could not be determined where Resident #2's hand was until 8:42 p.m., when Resident #2's left hand was observed coming from behind the left wheel of his wheelchair. 8:43:37, Resident #2 was observed putting his left hand back between Resident #1's upper thighs and Resident #1 was observed slapping at his hand. 8:43:47, S11CNA was observed walking up the hall back to the nurse's station. S11CNA grabbed at S7LPN, who was walking beside her, and pointed towards Residents #1 and #2. S7LPN immediately removed Resident #2's hand from between Resident #1's thighs and separated the residents. S7LPN was observed talking to Resident #1 then she picked up the phone and called someone. 8:48 p.m., Resident #2 was brought to his room. Review of Resident #1's current Care Plan revealed it was not revised after 08/01/2025 to reflect problems, goals, and interventions related to her being a victim of sexual and psychosocial abuse. On 08/26/2025 at 1:10 p.m., an interview was conducted with S4CP. She confirmed Resident #1's care plan was not revised after 08/01/2025 to reflect she was a victim of sexual and psychosocial abuse. She stated Resident #1's care plan should have been revised for staff to observe Resident #1 for any psychosocial or behavioral changes. On 08/26/2025 at 2:25 p.m., an interview was conducted with S2DON. She stated Resident #1's care plan should have been revised after 08/01/2025 to reflect she was a victim of sexual and psychosocial abuse and for staff to observe for any behavioral changes, and it was not.

Based on observation, record reviews and interviews, the facility failed to ensure each resident had the right to be free from physical abuse for 2 (#1 and #2) of 4 (#1, #2, #3, and #R1) residents reviewed for abuse. The facility failed to ensure: 1. Resident #1 was free from physical abuse by S5CNA, and 2. Resident #2 was free from physical abuse by Resident #R1. This deficient practice resulted in actual physical harm on 04/20/2025 at 4:54 a.m., when S5CNA punched Resident #1, a cognitively intact resident, twice on the left side of the face and the left upper lip resulting in Resident #1 being sent to the local emergency room . The resident was diagnosed with a 2.5 cm laceration of left face which required 4 stiches and a contusion of left orbital area. After returning to the facility, Resident #1 continued to have pain when eating and drinking. Findings: Review of the facility's policy titled, dated 01/14/1999, titled Adult, Disabled Person, or Elderly Abuse Recognition and Reporting, revealed, in part: Definitions: Abuse: The willful infliction of injury .with resulting physical harm, pain, or mental anguish. Physical abuse: Includes hitting, slapping, punching, and kicking. The following criteria may be used to assist in the identification of physical abuse: Scratches, cuts, scalp injury, contusions or lacerations inconsistent with the resident's or caregiver's explanation of the injury. 1. Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included Traumatic Subdural Hemorrhage and Stable Burst Fracture of Second Lumbar Vertebra. Review of Resident #1's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/15/2025, revealed a BIMS (Brief Interview for Mental Status) of 14, which indicated the resident was cognitively intact. Review of Resident #1's care plan revealed he has an activity of daily living self-care performance deficit related to limited mobility. Resident #1 was totally dependent on staff for dressing, eating, personal hygiene, oral care and toileting needs. Resident #1 required two staff assistance for transfers. Further review revealed Resident #1 was not care planned for making false allegations or confabulations. Review of facility's self-reported incident dated 04/20/2025 at 10:55 a.m. revealed, in part: Date of Incident: 04/20/2025 Time of Incident: 4:00 a.m. Discovered Date and Time: 04/20/2025 at 9:30 a.m. Discovered by: S4LPN Description: Resident #1 alleged that he was struck in the face by S5CNA. Resident #1 was noted by morning staff on 04/20/2025 with a bruise on the left side of his head near his hairline. A laceration was also noted on his upper left lip. Resident #1 provided a description of the staff that allegedly stuck him in the face. The description matched the staff that provided care overnight to Resident #1. S5CNA was suspended pending the outcome of the investigation. Resident #1 was transported to the local emergency room for evaluation and treatment. Review of local emergency room Physician Documentation dated 04/20/2025 at 9:57 a.m., revealed, in part: Wound #1: Location: Left face Type: Linear Wound Measurement: 2.5 centimeters Number of Sutures/Staples: 4 Discharge Diagnosis: Laceration of left face, contusion of left orbital area Review of emergency room Nurses' Note dated 04/20/2025 at 9:57 a.m. revealed Resident #1 reported to the emergency room staff he had an argument with a CNA around 4:00 a.m. and the CNA punched him in the mouth and eye. Review of diagnostic CT scan conducted on 04/20/2025 at 11:44 a.m. revealed: Exam: CT of Facial/Sinus without contrast Impression: Left orbital soft tissue swelling Review of the facility's medication administrative note for Resident #1 dated 04/20/2025 revealed: Date: 04/20/2025 Time: 11:15 p.m. Author: S3LPN Resident #1 received oxycodone-acetaminophen oral tablet 7.5-325 mg. Resident states his lip is killing him. Follow-Up Pain Scale: 9 out of 10 As Needed Administration: Ineffective On 04/28/2025 at 11:18 a.m., an interview was conducted with S6CNA. She stated on 04/20/2025 at 7:45 a.m. she entered Resident #1's room. She stated at that time she saw he had a bloody cut to his left upper lip and a bruise around his left eye. She stated she asked Resident #1 if he fell and he stated a CNA hit him twice in the face. S6CNA immediately reported this to S4LPN. On 04/28/2025 at 11:24 a.m., an interview was conducted with Resident #1. Resident #1 stated he required assistance with all activities of daily living including transfer from bed to wheelchair and eating, and bowel and bladder incontinence. He stated on 04/20/2025 between 4:00 a.m. and 5:00 a.m., S5CNA entered his room. He said he was in bed and asked S5CNA to get a snack out of his dresser drawer. He stated S5CNA told him he didn't need a snack and he cursed at S5CNA. He stated S5CNA punched him twice in the face. He stated he used his call light to call for help. He stated S3LPN entered his room and he reported S5CNA punched him in the face. He stated S3LPN said yeah right and exited his room. Resident #1 denied falling out of the bed or obtaining the injury by another source. He confirmed S6CNA entered his room and asked what happened to his face. He confirmed he reported to S6CNA he was punched in the face twice by S5CNA. Resident #1 stated he was then sent to the emergency room and had to get stitches to his left upper lip. On 04/28/2025 at 11:39 a.m., an interview was conducted with S4LPN. S4LPN stated on 04/20/2025 at 7:50 a.m., S6CNA reported she needed to see Resident #1 immediately, due to bruising and a cut to Resident #1's face. S4LPN stated upon assessment, Resident #1 had a cut to the left upper lip, which was still bleeding and a black eye on the left side. She stated Resident #1 stated S5CNA punched him in the face. S4LPN sent Resident #1 to the emergency room for an evaluation and treatment. On 04/30/2025 at 11:39 a.m., an observation was conducted of facility video surveillance from the morning of 04/20/2025 with S1DON and S2SUP present. The video surveillance revealed the following: 4:54 a.m.-S5CNA entered Resident #1's room and closed door. 5:00 a.m.-S5CNA exited Resident #1's room. 5:01 a.m.-S5CNA entered Resident #1's room a second time. 5:03 a.m.-S5CNA exited Resident #1's room. 5:05 a.m.-Resident #1's call light alarmed with flashing light. 5:06 a.m.-S5CNA entered Resident #1's room a third time, call light turned off. 5:07 a.m.-S5CNA exited Resident #1's room. 5:10 a.m.-S5CNA entered Resident #1's room a fourth time. 5:10 a.m.-S5CNA exited Resident #1's room. 5:49 a.m.-S3LPN entered Resident #1's room. 5:50 a.m.-S3LPN exited and re-entered Resident #1's room 5:51 a.m.-S3LPN exited Resident #1's room 7:49 a.m.-S6CNA entered and exited Resident #1's room 8:03 a.m.-S6CNA re-entered Resident #1's room 8:04 a.m.-S4LPN entered Resident #1's room 8:12 a.m.-S4LPN exited Resident #1's room On 04/30/2025 at 2:40 p.m., an interview was conducted with S3LPN. She stated she was the nurse taking care of Resident #1 on the night of 04/19/2025. She stated she went in Resident #1's room on 04/20/2025 at 5:30 a.m., to administer pain medication. She stated she saw a red mark to Resident #1's lower lip, but did not turn the room lights on to investigate it. She stated she asked Resident #1 about the red mark and Resident #1 replied he bit his lip so she left the room. On 05/01/2025 at 9:08 a.m., an observation was made of S7LPN administer oral medications to Resident #1. He grimaced while he swallowed medications and sucked water through a straw. On 05/01/2025 at 9:21 a.m., an interview was conducted with S7LPN. She stated Resident #1 is oriented and requires total care. She stated if Resident #1 fell he would require assistance to get off of the floor. She stated due to Resident's swollen lip, he has had difficulty eating and sucking liquids through a straw. On 05/01/2025 at 11:08 a.m., a telephone interview was conducted with S5CNA. She confirmed she was assigned to care for Resident #1 on 04/19/2025 from 6:00 p.m. to 04/20/2025 at 6:00 a.m. S5CNA stated Resident #1 required total care. S5CNA denied Resident #1 had a fall or injuring himself on the night of 04/19/2025 or the morning of 04/20/2025. She stated if Resident #1 would have fallen he would have required assistance to get off of the floor. She stated he could not get up on his own. S5CNA denied observing a laceration and bruise to Resident#1's face that night. She stated on the morning of 04/20/2025, Resident #1 cursed at her. S5CNA denied hitting Resident #1 resulting in a black eye and busted lip. On 05/01/2025 at 10:50 a.m., an interview was conducted with S1DON. S1DON stated Resident #1 was cognitive, could not get off the floor independently. S1DON confirmed on the morning of 04/20/2025, S6CNA found Resident #1 had a left black eye and laceration to his left upper lip and alleged S5CNA punched him in the face. Resident #1 was sent to the emergency room and received stitches to the lip. S1DON stated Resident #1 did not fall or have any other accident or injuries the night of 04/19/2025. S1DON stated physical abuse may have occurred. She stated the facility notified the local police and removed S5CNA from the schedule pending investigation. During the dates of the survey 04/28/2025 to 05/01/2025, attempts were made to interview the facility's administrator. The facility's administrator was on medical leave and not available for interviews. 2. Review of the Clinical Record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side. Review of Resident #2's Quarterly MDS with ARD of 02/12/2025, revealed a BIMS of 9, which indicated the resident was moderately cognitively impaired. Review of Resident #R1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis affecting Right Side. Review of Resident #R1's Quarterly MDS with ARD of 02/19/2025, a BIMS of 4, which indicated the resident was severely cognitively impaired. Review of facility's incident report revealed, in part: Date of Incident: 04/15/2025 Time of Incident: 12:55 p.m. Incident Report Completed by: S4LPN Description: Resident #R1 shouted for me to come to the smoking area. Upon going in the smoking area, Resident #2 had blood coming from his left forehead. Resident #2 was immediately sent to the local emergency room for evaluation. Review of emergency room Physician documentation dated 04/15/2025 at 1:08 p.m., revealed, in part: Chief Complaint for Resident #2: Head laceration Patient is a nursing home resident and was hit by another resident with a hand grabber causing bleeding to scalp. Wound Dimensions: 1.5 centimeter laceration to left scalp superior to forehead. Discharge Diagnosis: Scalp laceration Review of diagnostic CT scan conducted on 04/15/2025 at 1:38 p.m. revealed: Resident #2 Exam: CT of Head without contrast Impression: Suture associated with recent laceration in the left frontal scalp. Review of the local behavioral health hospital discharge instructions revealed Resident #R1 was admitted on [DATE] and discharged on [DATE]. A safety plan was initiated, which included medication adjustments. On 05/01/2025 at 12:41 p.m., an interview was conducted with Resident #2. He stated he was on the smoking patio in early April when Resident #R1 hit him in the head with a hand grabber. He stated he was sent to the hospital and had to get staples placed to left forehead. Resident #2 confirmed he was angry as a result of this incident. On 05/01/2025 at 2:50 p.m., an interview was conducted with Resident #R1. When asked about the incident in April with Resident #2, he was unable to speak clearly, but he motioned lifting his left arm up and swinging the left arm in a downward motion and shook his head in a yes motion when asked if he hit Resident #2. On 05/01/2025 at 10:50 a.m., an interview was conducted with S1DON. She stated she witnessed an incident which involved Resident #2 and Resident #R1 on the smoker's patio on 04/15/2025. She stated Resident #2 was digging for cigarette buds and Resident #R1 told Resident #2 to stop digging for cigarette buds. Resident #2 through an ashtray at Resident #R1. Resident #R1 then swung a hand grabber at Resident #2 and struck Resident #2's forehead. S1DON stated she immediately separated the two residents. She stated she observed blood oozing from Resident #2's forehead. She stated she sent Resident #2 to the emergency room for evaluation. She stated she sent Resident #R1 out for behavioral evaluation. She confirmed as a result of this incident Resident #2 sustained a head injury resulting in staples to his forehead. She confirmed Resident #R1 was admitted to a behavioral hospital on 04/15/2025 and discharged on [DATE]. S1DON stated neither resident had been involved in any other incidents.

Based on interviews and record reviews, the facility failed to ensure services were provided to meet quality professional standards. The facility failed to ensure nursing staff documented a resident's change in condition for 1 (#1) of 4 (#1, #2, #3, R1) residents sampled. This had the potential to affect 58 residents residing in the facility. Findings: Review of the facility's policy, dated 01/01/1999, titled Notification of Change in Resident's Condition, revealed, in part: Physicians, responsible family members or legal representative shall be notified as soon as possible, within 24 hours or as medically indicated, of any changes in the resident's condition. Procedure: 1. The nurse shall be responsible for notifying the attending physician and the resident's responsible family when a change occurs in the resident's condition 2. These changes shall include significant changes in physical, mental, or psychosocial status as well as any accident 3. Nurse shall document changes on the resident's medical record Review of Resident #1's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Traumatic Subdural Hemorrhage, and Chronic Pain. Further review revealed no change in Resident #1's condition documentation on 04/20/2025 by S3LPN. Review of Resident #1's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/15/2025 revealed the resident had a BIMS (Brief Interview for Mental Status) of 14, which indicated the resident was cognitively intact. Review of the Emergency Transfer Log dated 04/01/2025 to 04/28/2025 revealed, Resident #1 was transferred to local emergency department on 04/20/2025 for a lip laceration. Review of the Emergency Department Physician Documentation dated 04/20/2025 at 9:57 a.m. revealed, in part: Wound #1: Location: Left face Type: Linear Wound Measurement: 2.5 cm # Sutures/Staples: 4 Discharge Diagnosis: Laceration of left face, contusion of left orbital area On 04/28/2025 at 11:24 a.m., an interview was conducted with Resident #1. Resident #1 stated early Easter morning, S5CNA punched him in the mouth and in the left eye. Resident #1 further stated he reported this to S3LPN. On 04/28/2025 at 11:39 a.m., an interview was conducted with S4LPN. S4LPN confirmed she was the oncoming nurse on 04/20/2025 at 6:00 a.m. She stated S6CNA notified her of Resident #1's condition and asked her to evaluate Resident #1 immediately. She stated upon assessment, Resident #1 had a cut to the left upper lip, which was still bleeding and a left black eye. She stated S3LPN did not report any change of condition on Resident #1 in morning report. She confirmed she immediately notified S1DON, the physician, resident's family, and sent Resident#1 to the emergency room . Review of S3LPN's handwritten statement revealed, in part: Approximately 5:30 a.m. I entered resident's room to administer his PRN pain pill. While in his room I did observe what appeared to look like a cut on the resident's lower lip. When I asked him what happened he stated that he bit his lip. On 04/30/2025 at 9:15 a.m., an interview was conducted with S1DON. She confirmed S3LPN did not document a change in condition in Resident #1's chart. S1DON confirmed S3LPN did not report a change in condition to the oncoming nurse. On 04/30/2025 at 2:40 p.m., an interview was conducted with S3LPN. She stated she went in Resident #1's room on 04/20/2025 at 5:30 a.m., with the room lights off, to administer pain medication. She confirmed she saw a red mark to Resident #1's lip. She stated Resident #1 reported he bit his lip. She further stated she did not document a change in condition in Resident #1's chart. She confirmed she did not report a change in condition to the oncoming nurse or anyone else.

Based on interview and record review, the facility failed to ensure all alleged allegations involving physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency, for 1 (#2) of 4 (#1, #2, #3 and R1) residents investigated for abuse. Findings: Review of the facility's policy, dated 01/14/1999, titled Adult, Disabled Person, or Elderly Abuse Recognition and Reporting, revealed, in part: Procedure: 1. All cases of suspected abuse must be reported to authorities. 2. All reports received by the administrator or director of nursing shall be referred as appropriate to local or state law enforcement agency and/or shall be referred to the appropriate department providing protective regulatory services. Review of Resident #2's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #2's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/12/2025 revealed the resident had a BIMS (Brief Interview for Mental Status) of 9, which indicated the resident was moderately, cognitively intact. Review of the Emergency Transfer Log dated 04/01/2025 to 04/28/2025 revealed, in part: Resident #2 was transferred to local emergency department on 04/15/2025 for a forehead laceration. Review of Emergency Department Physician Documentation dated 04/15/2025 at 1:08 p.m., revealed, in part: Chief Complaint: Head laceration Patient is a nursing home resident and was hit by another resident with a hand grabber causing bleeding to scalp. Review of the facility's self-reported incident dated April 2025 revealed, there were no reports filed for Resident #2. On 05/01/2025 at 10:50 a.m., an interview was conducted with S1DON. She stated she witnessed Resident #2 and Resident #R1 have an encounter on the smoker's patio outside on 04/15/2025. She stated Resident #R1 swung a hand grabber at Resident #2 and struck Resident #2's forehead. She stated the Administrator was responsible for reporting incidents of alleged abuse to the state survey agency. She stated the Administrator was on administrative medical leave and was not available for interview. She confirmed a report of alleged physical abuse was not submitted to the state survey agency and should have.

Based on record review and interview, the facility failed to ensure its facility assessment was updated annually and included staffing level(s) needed for emergencies, weekends and specific shifts, such as day, evening, and night. The deficient practice had the potential to affect the 56 residents residing in the facility. Findings: Review of the facility's assessment dated [DATE] revealed the following, in part: 1. It was not updated at least annually; 2. It did not include needed staffing level(s) for emergencies, weekends or specific shifts, such as day, evening, and night. On 04/07/2025 at 2:54 p.m., an interview was conducted with S1DON. S1DON confirmed the facility's assessment was not updated annually and it did not include needed staffing levels for weekends or day, evening, and night shifts.

46981 Based on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status for 3 (#14, #52, and #56) of 17 sampled residents reviewed for PASRR. Findings: Resident #14 Review of Resident #14's Clinical Record revealed an admitted [DATE] with diagnoses which included Bipolar, Depression, and Dementia. Review of Resident #14's current Care Plan revealed in part, the following: Onset date: 10/02/2024 Problem: Level II PASRR Review of Resident #14's Annual MDS with an Assessment Reference Date (ARD) of 11/13/2024 revealed in part, the following: Section A1500: Preadmission Screening and Resident Review (PASRR) was coded No. Resident #52 Review of Resident #52's Clinical Record revealed an admitted [DATE] with diagnoses, which included Schizophrenia and Dementia. Further review of the clinical record revealed Resident #52 was issued a Level II PASRR with a temporary period effective 08/16/2023 through 08/14/2024. Review of Resident #52's current Care Plan revealed in part, the following: Onset date: 02/20/2025 Problem: Level II PASRR Review of Resident #52's Annual MDS with an Assessment Reference Date (ARD) of 07/10/2024 revealed in part, the following: Section A1500: Preadmission Screening and Resident Review (PASRR) was coded No. Resident #56 Review of Resident #56's Clinical Record revealed an admitted [DATE] with diagnoses, which included Paranoid Schizophrenia, Unspecified Psychosis, and Major Depressive Disorder. Further review of the clinical record revealed Resident #56 was issued a Level II PASRR with a temporary period effective 04/09/2024 through 04/08/2025. Review of Resident #56's current Care Plan revealed in part, the following: Onset date: 10/16/2024 Problem: Level II PASRR Review of Resident #56's Annual MDS with an Assessment Reference Date (ARD) of 12/11/2024 revealed in part, the following: Section A1500: Preadmission Screening and Resident Review (PASRR) was coded No. On 04/09/2025 at 3:30 p.m., an interview was conducted with S1DON. S1DON reviewed Residents #52 and #56's above mentioned MDS Assessments and Level II PASRRs. S1DON stated the facility was unable to locate Resident #14's PASRR form, and she confirmed Resident #14 had a current Level II PASRR. S1DON confirmed Residents #14, #52, and #56's Section A1500 should have been coded Yes for PASRR, and they were not. 48912

48912 Based on record reviews and interviews, the facility failed to ensure a Significant Change Minimum Data Set (MDS) Assessment was completed within 14 days for residents who transferred hospice services for 2 of 2 (#19 and #42) sampled residents receiving hospice services. Findings: Resident #19 Review of Resident #19's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Multiple Myeloma. Review of Resident #19's Hospice Admission documents revealed he transferred hospice companies on 03/18/2025. Review of Resident #19's MDS assessments failed to reveal a significant change assessment was submitted when Resident #19 transferred hospice services on 03/18/2025. Resident #42 Review of Resident #42's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Dysphagia Following Cerebral Infarction. Review of Resident #42's Hospice Admission documents revealed he transferred hospice companies on 03/18/2025. Review of Resident #42's MDS assessments failed to reveal a significant change assessment was submitted when Resident #42 transferred hospice services on 03/18/2025. On 04/09/2025 at 9:28 a.m., a telephone interview was conducted with Resident #19's hospice nurse. She stated Resident #42 received care from this hospice company as of 03/18/2025. On 04/09/2025 at 1:25 p.m., an interview was conducted with Resident #42's hospice nurse. She stated Resident #42 received care from this hospice company as of 03/18/2025. On 04/09/2025 at 1:50 p.m., an interview was conducted with S1DON. She reviewed Resident #19 and #42's MDS assessments and confirmed both residents did not have a Significant Change MDS Assessment completed on 03/18/2025 and should have.

Based on observation and interviews, the facility failed to implement and maintain an infection prevention control program to help prevent the development and transmission of infection for 1 (#24) out of 2 (#24 and #8) residents reviewed for wound care. The facility failed to ensure personnel consistently removed soiled PPE and preformed proper hand hygiene during wound care. Findings: Review of Resident #24's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses including Pressure Ulcer of Left Hip, Stage 4. Review of Resident #24's current Physician Orders revealed the following, in part: Start date 11/13/2024 - cleanse pressure ulcer, stage 4 to left hip with wound cleanser, apply silver alginate, cover with border foam dressing every Tuesday, Thursday, Saturday, and PRN until resolved. On 04/08/2025 at 11:54 a.m., an observation was made of wound care performed by S2LPN on Resident #24. S2LPN applied gloves and cleaned wound with wound cleanser. Then using soiled gloves and without preforming hand hygiene, S2LPN applied apply silver alginate and covered wound with border foam dressing. S2LPN then removed soiled gloves and performed hand hygiene. On 04/08/2025 at 11:48 a.m., an interview was conducted with S2LPN. S2LPN stated she was the facility's wound care nurse. S2LPN confirmed her gloves were soiled after cleaning Resident #24's wound. S2LPN confirmed she should have removed her soiled gloves and preformed hand hygiene prior to applying ointment and bandage and did not. On 04/09/2025 at 1:50 p.m., an interview was conducted with S1DON. S1DON confirmed during wound care, nurses should change their gloves and perform hand hygiene after cleaning a wound and place on new gloves before redressing the wound.

Based on observation, record review, and interview, the facility failed to ensure the results from the most recent recertification survey was readily available for resident review. This deficient practice had the potential to affect the 56 residents who currently resided in the facility. Findings: Review of the facility's undated policy titled Posting of Survey Results, revealed in part, the following: The facility shall post in a place readily accessible to residents the most recent survey of the facility. Review of the facility's Survey History revealed the most recent recertification survey was on 02/29/2024. An observation was made on 04/07/2025 at 9:30 a.m. of the facility's Survey Results folder located near the nurses' station of the facility. Review of the Survey Results folder revealed the last survey posted in the binder was dated 01/20/2023. Further review revealed no documented evidence of the survey results from the recertification survey dated 02/29/2024. An interview was conducted on 04/07/2025 at 9:35 a.m. with S1DON. She reviewed the facility's Survey Results folder. She confirmed the survey results from the recertification survey dated 02/29/2024 were not located in the folder.

Based on observations, interviews, and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident residing in the facility. The facility failed to ensure: 1. Residents received adequate supervision for 1 (#18) of 3 (#18, #23, and #46) residents care planned for hourly rounding to prevent falls; 2. A functional call light system was in place for 1 (#18) of 23 resident's reviewed in the initial pool. This deficient practice resulted in an immediate jeopardy situation for Resident #18, on 02/27/2024 at 12:00 a.m. when staff failed to perform hourly rounding on Resident #18. The facility's video footage revealed no staff entered Resident #18's room from 12:00 a.m. until 3:17 a.m. then did not enter again until 4:24 a.m. Resident #18 was found on the floor of her room by staff on 02/27/2024 at 4:24 a.m. after Resident #18's roommate verbally called out for staff to come help Resident #18. Resident #18 was transferred to the emergency room and diagnosed with a Right Humerus Fracture. Nursing and CNA staff interviews revealed staff did not know Resident #18 should have been rounded on hourly to decrease falls. This deficient practice resulted in an immediate jeopardy situation for Resident #18, a resident who required staff assistance with toileting and transfers, on 02/27/2024 at 3:39 a.m., when CNA staff did not have pager's to receive notification that Resident #18 pushed her call light and required assistance. Resident #18 was left unassisted by staff from 3:39 a.m. to 4:24 a.m., when the resident's roommate verbally called for help and staff entered the resident's room. Staff found Resident #18 on the floor. Resident #18 was transferred to the emergency room and diagnosed with a Right Humerus Fracture. This deficient practice had the potential to affect any of the 54 residents residing in the facility who utilized the call light system. S1ADM was notified of the Immediate Jeopardy on 02/28/2024 at 7:25 p.m. The Immediate Jeopardy was removed on 02/29/2024 at 12:04 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Cross Reference F689 Cross Reference F919 Findings: 1. Review of the facility's policy titled, Fall Assessment revealed the following, in part: Policy: All falls are reviewed in the morning meetings to determine possible interventions for each resident with a fall on an individualistic basis. Residents' who have been determined as a frequent faller will have increased observation in order to prevent falls. Review of Resident #18's Clinical Record revealed a facility admitted [DATE] and diagnoses which included Repeated Falls, Altered Mental Status and Dementia Unspecified Severity with Agitation. Review of Resident #18's current Care Plan revealed the following, in part: Problem onset of 10/01/2020 Problem: Falls Interventions: Start date 02/05/2024-Hourly checks An interview was conducted with S4CNAS on 02/27/2024 at 2:08 p.m. She stated Resident #18 was a fall risk and required staff assistance with transfers and toileting. She stated on 02/27/2024 around 4:30 a.m., Resident #18 was found on the floor in her room lying on her back. She stated the CNAs were scheduled a fall intervention tasks in the computer to document fall monitoring for Resident #18 every two hours. She reviewed Resident #18's electronic record and confirmed the fall monitoring interventions assigned to the CNAs were scheduled for every one hour not two hours. She stated she did not know Resident #18 required hourly rounds beginning on 02/05/2024. An interview was conducted with S3ADON on 02/27/2024 at 3:50 p.m. She stated after a resident had a fall, the CNAs were scheduled fall intervention tasks in the computer to complete and document on. She reviewed the electronic record for Resident #18 and verified the CNAs were assigned an hourly rounding task after a fall on 02/05/2024. She stated Resident #18 was a fall risk, and to prevent falls, the CNAs were to monitor her hourly. An interview was conducted with S4CNAS on 02/28/2024 at 11:09 a.m. She stated Resident #18 had frequent falls. She stated she and the nurses were responsible for notifying the CNAs of any new interventions to prevent resident falls. She stated after Resident #18's fall on 02/05/2024, the CNAs were scheduled fall intervention tasks in the computer to complete and document on. She stated she and the CNA's documented the task was completed, but were unaware it had to be completed hourly. She stated she was not aware of a rounding schedule for the nurse and CNAs. An interview was conducted with S3ADON on 02/29/2024 at 2:40 p.m. She stated she was unaware the CNAs were documenting Resident #18's fall monitoring tasks for hourly rounding as completed, but were unaware Resident #18 should be rounded on hourly. She stated she would expect staff to document only care and interventions provided. She stated she expected staff to know what interventions were in place to prevent resident falls. An interview was conducted with S2DON on 02/29/2024 at 2:45 p.m. She stated she was unaware the CNAs were documenting Resident #18's fall monitoring tasks for hourly rounding as completed, but were unaware Resident #18 should be rounded on hourly. She stated she would expect staff to document only care and interventions provided. She stated all staff had access to the resident's care plans and interventions in the computer. She stated she expected staff to know what interventions were in place to prevent resident falls. She stated there had been no specific monitoring to ensure the CNAs implemented and documented interventions initiated for resident falls accurately and there should have been. Review of video footage without audio was conducted with S1ADM on 02/28/2024 at 12:23 p.m. and revealed the following: Location: Hall B 02/27/2024 from 12:00 a.m. until 4:55 a.m. No staff were observed entering Resident #18's room from 12:00 a.m. - 3:17 a.m. and from 3:23 a.m. - 4:24 a.m. An interview was conducted with S1ADM on 02/28/2024 at 1:20 p.m. He reviewed Resident #18's care plan and confirmed an intervention for hourly rounding was added on 02/05/2024 after the resident had a fall. He confirmed Resident #18 was not rounded on hourly by staff on 02/27/2024 from 12:00 a.m. to 3:17 a.m., and should have been. 2. Review of the facility's policy titled, Resident Call System revealed the following, in part: Policy: The facility shall provide a functional communication system in which residents can contact staff for assistance. Each resident room . shall be equipped with a communication system that connect directly to a staff member or to a nurse's station that is appropriately staffed to respond to resident calls. The resident call system shall be checked at the beginning of each shift for appropriate function. Review of Resident #18's Nurses' Notes dated February 2024 revealed the following, in part: 02/27/2024 at 12:47 p.m. -Late Entry-Patient was found lying on her back in her room on the floor stating that she had got up and attempted to go to the bathroom on her own. 02/27/2024 at 10:14 a.m. - At 9:38 a.m., received report that resident had an Acute Right Humerus Fracture. Review of video footage without audio was conducted with S1ADM on 02/28/2024 at 12:23 p.m. and revealed the following: Location: Hall B 02/27/2024 from 12:00 a.m. until 4:55 a.m. No staff were observed entering Resident #18's room from 3:23 a.m. - 4:24 a.m. Review of Resident #18's Call Light Event Report dated 02/27/2024 revealed the following, in part: Occurred: 03:39 a.m. Responded: 04:47 a.m. Response Time: 67 minutes An interview was conducted with S1ADM on 02/28/2024 at 1:20 p.m. He stated each CNA was assigned a pager at the beginning of their shift. He explained when a resident pressed their call light, an automatic page was sent to the CNA's pager, to the monitor at the nurses' station, and to the scroll board on the wall outside of the nurses' station. He stated at night there was no one assigned to monitor the scroll board and the nurses were responsible for monitoring the call light system and ensuring call lights were answered. S1ADM reviewed Resident #18's call light log and confirmed Resident #18 pressed her call light on 02/27/2024 at 3:39 a.m. S1ADM confirmed the above video footage revealed staff did not enter the resident's room until 4:24 a.m. and the call light was turned off by S4CNAS at 4:47 a.m. He stated call lights should be answered within 6 minutes. He confirmed Resident #18 waited over 40 minutes for assistance. An interview was conducted with S4CNAS on 02/27/2024 at 2:08 p.m. She stated Resident #18 was a fall risk, was able to use her call light, and required staff assistance with transfers and toileting. She stated on 02/27/2024 around 4:30 a.m. she saw Resident #18's roommate's call light was lit up on the scroll board. She stated when she entered the room, Resident #18 was on the floor lying on her back. She stated she turned off Resident #18 and her roommate's call lights. Further review of video footage without audio was conducted with S1ADM and S4CNAS on 02/28/2024 at 3:00 p.m. and revealed the following: Location: Nurses' station 02/27/2024 from 3:39 a.m. - 4:12 a.m. S7LPN and S23LPN were observed walking in and out of the nurse's station from 3:39 a.m. - 4:00 a.m. No staff were observed in the nurse's station from 4:10 a.m. - 4:12 a.m. An interview was conducted with S4CNAS on 02/28/2024 at 3:00 p.m. She confirmed when a message was illuminated on the scroll board, it indicated the call light was pressed. She explained if the call light was answered the message would disappear, but if it was unanswered the message would repeat every 6 minutes until answered. She confirmed when a CNA staff was unavailable to answer the call light system, the nurse at the nurse's station was responsible for ensuring the resident's needs were tended to. She stated from 8:00 p.m. to 8:00 a.m. there was no one assigned to monitor the scroll board and the nurses were responsible for monitoring the call light system. She confirmed S7LPN and S23LPN were walking in and out of the nurse's station between 3:39 a.m. - 4:12 a.m. and should have responded to the illuminated message on the scroll board. She stated the CNA staff do not always have enough pagers available because the staff on the prior shift took the pagers home. S4CNAS confirmed 3 of the 6 CNAs working today, 02/28/2024, did not have a pager. She stated it was the CNA's with pager's responsibility to inform the CNAs without pagers if a resident called for assistance. If the CNA with a pager was providing care to a resident, they would not notify the other CNA until care was completed. She also said that if no CNA's had pagers it would be up to the nurse to monitor the scroll board and alert the CNA. She confirmed this would delay care and it happened often. An interview was conducted with S1ADM on 02/28/2024 at 3:00 p.m. S1ADM confirmed he was not aware there had been an issue with not having enough pagers for the CNA staff. He stated S4CNAS never informed him the staff were taking the pagers home with them and leaving the facility short. He stated it was the responsibility of S4CNAS to ensure the staff left the pagers in the facility. He stated S7LPN and S23LPN were both at the nurses' station the night Resident #18's call night was activated. He stated the scroll board outside of the nurses' station should be monitored at all times by the nursing staff. He stated the night Resident #18 fell , the nurses should have been monitoring the scroll board since the CNA staff were out on the hall. He confirmed on 02/27/2024 when Resident #18 fell , the call light system was not effective to ensure the safety of the resident. An interview was conducted with S3ADON on 02/29/2024 at 10:00 a.m. She stated she was not aware the CNAs did not have pagers for their shifts. She stated at night there was no one assigned to monitor the scroll board and the nurses were responsible for monitoring the call light system and ensuring call lights were answered. She confirmed on 02/27/2024 when Resident #18 fell , the present call light system was not effective to ensure the safety of the residents. An interview was conducted with S2DON on 02/29/2024 at 10:05 a.m. She stated she was not aware the CNAs did not have a pager for their shifts. She stated at night there was no one assigned to monitor the scroll board and the nurses were responsible for monitoring the call light system and ensuring call lights were answered. She confirmed on 02/27/2024 when Resident #18 fell , the present call light system was not effective to ensure the safety of the residents.

Based on observations, interviews, and record review, the facility failed to maintain an adequately equipped call system by failing to ensure: 1. CNA staff had sufficient functioning devices to respond to resident call lights for 1 (#18) of 23 resident's reviewed in the initial pool for call lights. 2. A staff member was assigned to monitor the scroll board for unanswered call lights from 8:00 p.m. to 8:00 a.m. This deficient practice had the potential to affect any of the 54 residents residing in the facility who utilized the call light system. This deficient practice resulted in an immediate jeopardy situation for Resident #18, a resident who required staff assistance with toileting and transfers, on 02/27/2024 at 3:39 a.m., when CNA staff did not have pager's to receive notification that Resident #18 pushed her call light and required assistance. Resident #18 was left unassisted by staff from 3:39 a.m. to 4:24 a.m., when the resident's roommate verbally called for help and staff entered the resident's room. Staff found Resident #18 on the floor. Resident #18 was transferred to the emergency room and diagnosed with a Right Humerus Fracture. S1ADM was notified of the Immediate Jeopardy on 02/28/2024 at 7:25 p.m. The Immediate Jeopardy was removed on 02/29/2024 at 12:04 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Review of the facility's policy titled, Resident Call System revealed the following, in part: Policy: The facility shall provide a functional communication system in which residents can contact staff for assistance. Each resident room . shall be equipped with a communication system that connect directly to a staff member or to a nurse's station that is appropriately staffed to respond to resident calls. The resident call system shall be checked at the beginning of each shift for appropriate function. Review of Resident #18's Clinical Record revealed a facility admitted [DATE] and diagnoses which included Repeated Falls, Altered Mental Status and Dementia Unspecified Severity with Agitation. Review of Resident #18's Quarterly MDS with an ARD of 12/29/2023 revealed a BIMS of 13, which indicated she was cognitively intact. Further review revealed Resident #18 required staff assistance with toileting and transfers. Review of Resident #18's current Care Plan revealed the following, in part: Problem onset of 10/01/2020 Problem: Falls Interventions: Educate resident on calling for assistance; Re-educated resident on staying in bed and calling for assistance. An interview was conducted with Resident #18 on 02/28/2024 at 2:57 p.m. She stated when she fell on [DATE] she was trying to go to the bathroom. An interview was conducted with Resident #18's roommate on 02/28/2024 at 2:23 p.m. She stated she pressed her call light in the early morning of 02/27/2024 after her roommate fell and stated she needed help. Review of Resident #18's Nurses' Notes dated February 2024 revealed the following, in part: 02/27/2024 at 12:47 p.m. -Late Entry-Patient was found lying on her back in her room on the floor stating that she had got up and attempted to go to the bathroom on her own. Signed by S7LPN 02/27/2024 at 10:14 a.m. - At 9:38 a.m., received report that resident had an Acute Right Humerus Fracture. Signed by S22LPN Review of Resident #18's Emergency Department Nurse's Note dated 02/27/2024 at 5:02 a.m. revealed the following, in part: Presenting complaint: Patient reports that she fell walking to the bathroom. Patient also reports pain in her right arm from her shoulder to right wrist. Quality of pain: Throbbing Severity of pain: Mild to Moderate Pain scale: 6/10 Review of Resident #18's Right Humerus X-ray dated 02/27/2024 revealed the following, in part: Indications: Pain with trauma Impression: Proximal Humeral abnormalities with total shoulder arthroplasty device and intramedullary rod across the proximal Humerus and possibly Mid Humerus Fractures. The Mid Humerus fracture is new from the 2023 exam but the Proximal Humeral abnormalities appear stable. Review of Resident #18's Right Shoulder X-ray dated 02/27/2024 revealed the following, in part: Impression: There is a non-displaced fracture in the distal diaphyseal portion of the Right Humerus. An intramedullary nail crosses fracture. Review of video footage without audio was conducted with S1ADM on 02/28/2024 at 12:23 p.m. and revealed the following: Location: Hall B 02/27/2024 from 12:00 a.m. until 4:55 a.m. No staff were observed entering Resident #18's room from 3:23 a.m. - 4:24 a.m. Review of Resident #18's Call Light Event Report dated 02/27/2024 revealed the following, in part: Occurred: 03:39 a.m. Responded: 04:47 a.m. Response Time: 67 minutes An interview was conducted with S1ADM on 02/28/2024 at 1:20 p.m. He stated each CNA was assigned a pager at the beginning of their shift. He explained when a resident pressed their call light, an automatic page was sent to the CNAs pager, to the monitor at the nurses' station, and to the scroll board on the wall outside of the nurses' station. He stated at night there was no one assigned to monitor the scroll board and the nurses were responsible for monitoring the call light system and ensuring call lights were answered. S1ADM reviewed Resident #18's call light log and confirmed Resident #18 pressed her call light on 02/27/2024 at 3:39 a.m. S1ADM confirmed the above video footage revealed staff did not enter the resident's room until 4:24 a.m. and the call light was turned off by S4CNAS at 4:47 a.m. He stated call lights should be answered within 6 minutes. He confirmed Resident #18 waited over 40 minutes for assistance. An interview was conducted with S4CNAS on 02/27/2024 at 2:08 p.m. She stated Resident #18 was a fall risk, was able to use her call light, and required staff assistance with transfers and toileting. She stated on 02/27/2024 around 4:30 a.m. she saw Resident #18's roommate's call light was lit up on the scroll board. She stated when she entered the room, Resident #18 was on the floor lying on her back. She stated she turned off Resident #18 and her roommate's call lights. An interview was conducted with S24CNA on 02/28/2024 at 2:15 p.m. She stated CNAs should be given a pager at the beginning of their shift. She stated when a resident pressed the call light, the pager would alarm with a message with the resident's room and bed number. She stated there was also a scroll board at the nurse's station that would show the room and bed number of the resident who called for assistance. She said the message would stay on the screen until the call light was answered in the resident's room. She stated staff were to answer the call lights within 6 minutes. She stated during her shift on 02/26/2024 from 6:00 p.m. to 6:00 a.m. she did not have her pager because there were not enough. She stated if staff were not at the nurses' station watching the scroll board and she did not have a pager, she would not know if a resident pressed their call light for assistance. She stated on 02/27/2024, Resident #18 waited over 40 minutes for the call light to be answered. She confirmed she should have had a pager during her shift to ensure residents call lights were answered timely. An interview was conducted with S25CNA on 02/28/2024 at 3:57 p.m. She stated she worked on 02/26/2024 from 6:00 p.m. to 6:00 a.m. and was assigned to Hall A. She stated there was not always enough pagers for the CNA staff. She stated if she did not have a pager, she would not know if a resident pressed their call light unless a staff member was monitoring the scroll board and notified her. She confirmed she did not have a pager on 02/26/2024. An interview was conducted with S26CNA on 02/28/2024 at 4:18 p.m. She stated she worked on 02/26/2024 from 6:00 p.m. to 6:00 a.m. on Hall A. She stated she did not have a pager during that shift. She said CNAs were supposed to have pagers, but sometimes the day shift CNAs took the pagers home and the night shift would not have any. She stated if she did not have a pager, she would not know if a resident pressed their call light unless a staff member was monitoring the scroll board and notified her. She stated she never reported that the night shift CNA staff did not have enough pagers. An interview was conducted with S27CNA on 02/28/2024 at 4:29 p.m. She stated she worked on 02/26/2024 from 6:00 p.m. to 6:00 a.m. on Hall B. She stated she and the other CNA on Hall B that night did not have a pager. She stated it was common for the CNAs not to have a pagers during their shift. She stated if staff were not at the nurses' station and she did not have a pager, she would not know if a resident pressed their call light. She stated she was expected to answer call lights within 3-5 minutes. An interview was conducted with S28CNA on 02/28/2024 at 2:17 p.m. She stated when a call light was pressed, the alert went to all pagers. She stated call lights should be answered within 5 minutes of being initiated. She stated if she did not have a pager, she would not know if a resident pressed their call light unless a staff member was monitoring the scroll board and notified her. Further review of video footage without audio was conducted with S1ADM and S4CNAS on 02/28/2024 at 3:00 p.m. and revealed the following: Location: Nurses' station 02/27/2024 from 3:39 a.m. - 4:12 a.m. S7LPN and S23LPN were observed walking in and out of the nurse's station from 3:39 a.m. - 4:00 a.m. No staff were observed in the nurse's station from 4:10 a.m. - 4:12 a.m. An interview was conducted with S4CNAS on 02/28/2024 at 3:00 p.m. She confirmed when a message was illuminated on the scroll board, it indicated the call light was pressed. She explained if the call light was answered the message would disappear, but if it was unanswered the message would repeat every 6 minutes until answered. She confirmed when a CNA staff was unavailable to answer the call light system, the nurse at the nurse's station was responsible for ensuring the resident's needs were tended to. She stated from 8:00 p.m. to 8:00 a.m. there was no one assigned to monitor the scroll board and the nurses were responsible for monitoring the call light system. She confirmed S7LPN and S23LPN were walking in and out of the nurse's station between 3:39 a.m. - 4:12 a.m. and should have responded to the illuminated message on the scroll board. She stated the CNA staff do not always have enough pagers available because the staff on the prior shift took the pagers home. S4CNAS confirmed 3 of the 6 CNAs working today, 02/28/2024, did not have a pager. She stated it was the CNA's with pager's responsibility to inform the CNAs without pagers if a resident called for assistance. If the CNA with a pager was providing care to a resident, they would not notify the other CNA until care was completed. She also said that if no CNA's had pagers it would be up to the nurse to monitor the scroll board and alert the CNA. She confirmed this would delay care and it happened often. An interview was conducted with S1ADM on 02/28/2024 at 3:00 p.m. S1ADM confirmed he was not aware there had been an issue with not having enough pagers for the CNA staff. He stated S4CNAS never informed him the staff were taking the pagers home with them and leaving the facility short. He stated it was the responsibility of S4CNAS to ensure the staff left the pagers in the facility. He stated S7LPN and S23LPN were both at the nurses' station the night Resident #18's call night was activated. He stated the scroll board outside of the nurses' station should be monitored at all times by the nursing staff. He stated the night Resident #18 fell , the nurses should have been monitoring the scroll board since the CNA staff were out on the hall. An interview was conducted with S21CNA on 02/28/2024 at 3:30 p.m. He stated he did not have a pager today because there was none available for use. He confirmed he worked 6:00 a.m. - 6:00 p.m. An interview was conducted with S23LPN on 02/28/2024 at 3:42 p.m. She stated when a resident pressed the call light, a message was sent to the CNAs pagers, to a monitor at the nurses' station and on a scroll board. She stated when a call light was pressed, the scroll board listed the room number, but did not list how long the call light had been initiated. She stated the CNAs should have pagers. She stated all staff in the facility were responsible for monitoring the call light system. She stated if the call light was going off for three minutes, the nurse should respond. An interview was conducted with S28CNA on 02/28/2024 at 3:45 p.m. She stated she did not have a pager today. She confirmed she worked 6:00 a.m. - 6:00 p.m. and was responsible for Hall B. An interview was conducted with S29CNA on 02/28/2024 at 3:50 p.m. She stated she did not have a pager today. She confirmed she worked 6:00 a.m. - 6:00 p.m. and was responsible for Hall B. An interview was conducted with S7LPN on 02/28/2024 at 7:18 p.m. He stated the only way the CNAs would know a resident called for assistance was if the pagers alerted them. He stated the nurses' were responsible for monitoring the call light system while at the desk. He stated there were times when there was not a staff member at the nurses' station. He stated on the morning of 02/27/2024, he did not see Resident #18's call light going off. He stated he was not aware the CNAs did not had pagers that night. He stated call lights should be answered within five minutes and if not, he should answer the light. He stated he found Resident #18 on the floor because her roommate was yelling out for help. He stated Resident #18 was continent and let the staff know when she needed to go to the bathroom. An interview was conducted with S3ADON on 02/29/2024 at 10:00 a.m. She stated staff should answer the call light within 6 minutes. She stated the pager alert repeated every 3-6 minutes, stayed on the kiosk and scroll board until answered and if not answered the ward clerk would enter a message into the CNAs pager with more specific details. She stated she was not aware the CNAs did not have pagers for their shifts. She stated at night there was no one assigned to monitor the scroll board and, the nurses were responsible for monitoring the call light system and ensuring call lights were answered. She stated if the nurses were busy the pagers made a beep noise at the nurse's station to alert them. She confirmed on 02/27/2024 when Resident #18 fell , the present call light system was not effective to ensure the safety of the residents. An interview was conducted with S2DON on 02/29/2024 at 10:05 a.m. She staff should answer the call light within 6 minutes. She stated the pager alert repeated every few minutes, the message stayed on kiosk and scroll board until answered and if not answered the staff at the nurses' station could enter a message into the CNAs pager with more specific details. She stated she was not aware the CNAs did not have a pager for their shifts. She stated at night there was no one assigned to monitor the scroll board and the nurses were responsible for monitoring the call light system and ensuring call lights were answered. She stated if the nurses were busy the pager made a beep noise at nurses' station to alert them. She confirmed on 02/27/2024 when Resident #18 fell , the present call light system was not effective to ensure the safety of the residents. An interview was conducted with S1ADM on 02/29/2024 at 10:28 a.m. He stated the expectation was for staff to answer resident call lights within 6 minutes. He stated he would have not have expected staff to wait over 30 minutes to answer Resident #18's call light on 02/27/2024. He stated all CNAs assigned to residents were supposed to have pagers on them during their shift. He confirmed on 02/27/2024 when Resident #18 fell , the present call light system was not effective to ensure the safety of the resident.

Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision by failing to ensure 1 (#18) of 3 (#18, #23, and #46) residents care planned for hourly rounding received adequate supervision to prevent falls. This deficient practice resulted in an immediate jeopardy situation for Resident #18, on 02/27/2024 at 12:00 a.m. when staff failed to perform hourly rounding on Resident #18. The facility's video footage revealed no staff entered Resident #18's room from 12:00 a.m. until 3:17 a.m. then did not enter again until 4:24 a.m. Resident #18 was found on the floor of her room by staff on 02/27/2024 at 4:24 a.m. after Resident #18's roommate verbally called out for staff to come help Resident #18. Resident #18 was transferred to the emergency room and diagnosed with a Right Humerus Fracture. Nursing and CNA staff interviews revealed staff did not know Resident #18 should have been rounded on hourly to decrease falls. S1ADM was notified of the Immediate Jeopardy on 02/29/2024 at 1:53 p.m. The Immediate Jeopardy was removed on 02/29/2024 at 4:38 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Review of the facility's policy titled, Fall Assessment revealed the following, in part: Policy: All falls are reviewed in the morning meetings to determine possible interventions for each resident with a fall on an individualistic basis. Residents' who have been determined as a frequent faller will have increased observation in order to prevent falls. Review of Resident #18's Clinical Record revealed a facility admitted [DATE] and diagnoses which included Repeated Falls, Altered Mental Status and Dementia Unspecified Severity with Agitation. Review of Resident #18's Quarterly MDS with an ARD of 12/29/2023 revealed she required staff assistance with toileting and transfers. Review of Resident #18's current Care Plan revealed the following, in part: Problem onset of 10/01/2020 Problem: Falls Interventions: Start date 02/05/2024-Hourly checks Review of Resident #18's fall intervention task for hourly rounding revealed S24CNA documented the task as complete on 02/26/2024 at 8:32 p.m. Further review revealed no documentation the task was documented as completed on 02/27/2024 by S24CNA. Review of the facility's Incident Log dated February 2024 revealed the following, in part: Resident #18 had falls on the following dates: 02/05/2024 and 02/27/2024. Review of Resident #18's Incident Reports revealed the following, in part: 02/05/2024 at 1:56 p.m. Incident Type: Non-Witnessed Fall Immediate Actions Taken: Staff to check on resident hourly. 02/27/2024 at 5:00 a.m. Incident Type: Non-Witnessed Fall Review of Resident #18's Nurses' Notes dated February 2024 revealed the following, in part: 02/05/2024 at 2:31 p.m. Staff to check on resident hourly. Review of Resident #18's Emergency Department Nurse's Note dated 02/27/2024 at 5:02 a.m. revealed the following, in part: Presenting complaint: Patient reports that she fell walking to the bathroom. Patient also reports pain in her right arm from her shoulder to right wrist. Review of Resident #18's Right Humerus X-ray dated 02/27/2024 revealed the following, in part: Impression: Proximal Humeral abnormalities with total shoulder arthroplasty device and intramedullary rod across the proximal Humerus and possibly Mid Humerus Fractures. The Mid Humerus fracture is new from the 2023 exam but the Proximal Humeral abnormalities appear stable. Review of Resident #18's Right Shoulder X-ray dated 02/27/2024 revealed the following, in part: Impression: There is a non-displaced fracture in the distal diaphyseal portion of the Right Humerus. An intramedullary nail crosses fracture. An interview was conducted with S4CNAS on 02/27/2024 at 2:08 p.m. She stated Resident #18 was a fall risk and required staff assistance with transfers and toileting. She stated on 02/27/2024 around 4:30 a.m., Resident #18 was found on the floor in her room lying on her back. She stated the CNAs were scheduled a fall intervention tasks in the computer to document fall monitoring for Resident #18 every two hours. She reviewed Resident #18's electronic record and confirmed the fall monitoring interventions assigned to the CNAs were scheduled for every one hour not two hours. She stated she did not know Resident #18 required hourly rounds beginning on 02/05/2024. An interview was conducted with S31CNA on 02/27/2024 at 2:32 p.m. She stated she was assigned to Resident #18 today, who was a fall risk and required staff assistance with transfers and toileting. She stated there was a fall monitoring task assigned to the CNAs in the computer to monitor Resident #18 every two hours to prevent falls. She stated she documented the task was completed, but did not know Resident #18 should have been checked on hourly to prevent falls. An interview was conducted with S22LPN on 02/27/2024 at 3:03 p.m. She stated she was assigned to Resident #18 today, who was a fall risk and required staff assistance with transfers and toileting. She stated after a resident had a fall, the CNAs were scheduled fall intervention tasks in the computer to document on every two hours. She reviewed the electronic record for Resident #18 and confirmed she was care planned for hourly checks initiated on 02/05/2024. She stated she did not know Resident #18 should have been checked on every hour to prevent falls. An interview was conducted with S3ADON on 02/27/2024 at 3:50 p.m. She stated after a resident had a fall, the CNAs were scheduled fall intervention tasks in the computer to complete and document on. She reviewed the electronic record for Resident #18 and verified the CNAs were assigned an hourly rounding task after a fall on 02/05/2024. She stated Resident #18 was a fall risk, and to prevent falls, the CNAs were to monitor her hourly. An interview was conducted with S24CNA on 02/27/2024 at 4:13 p.m. She stated Resident #18 was a fall risk and required staff assistance with transfers and toileting. She stated she worked on 02/26/2024 from 6:00 p.m. to 6:00 a.m. and was assigned to Resident #18. She stated she transferred Resident #18 into bed around 12:00 a.m. and did not know when she rounded on Resident #18 after that. She stated Resident #18 fell around 4:00 a.m. to 4:30 a.m. She stated there was a task assigned in the computer for the CNAs to monitor Resident #18 every two hours to prevent falls. She stated she documented the task was completed, but was unaware it had to be completed hourly. She stated had she known she would have checked on Resident #18 more often. She stated the nurses rounded on Resident #18, but not sure when or how often as there was no set rounding schedule. An interview was conducted with S7LPN on 02/27/2024 at 4:30 p.m. He verified he worked on 02/26/2024 from 6:00 p.m. to 6:00 a.m. and was assigned to Resident #18, who was a fall risk. He stated sometime after 4:00 a.m., he found Resident #18 on the floor in her room and S23LPN brought the resident to the emergency room . He stated after a resident had a fall, the CNAs were scheduled fall intervention tasks in the computer to complete and document on every two hours. He stated interventions to prevent Resident #18 from falling were rounding every two hours. He stated he was not aware Resident #18 was care planned for hourly rounding to prevent falls. An interview was conducted with S4CNAS on 02/28/2024 at 11:09 a.m. She stated Resident #18 had frequent falls. She stated she and the nurses were responsible for notifying the CNAs of any new interventions to prevent resident falls. She stated after Resident #18's fall on 02/05/2024, the CNAs were scheduled fall intervention tasks in the computer to complete and document on. She stated she and the CNA's documented the task was completed, but were unaware it had to be completed hourly. She stated she was not aware of a rounding schedule for the nurse and CNAs. An interview was conducted with S6LPN on 02/28/2024 at 12:02 p.m. She stated she was assigned to Resident #18 who was a fall risk. She stated after a resident had a fall, the CNAs were scheduled fall intervention tasks in the computer to complete and document on. She stated she was not aware an hourly rounding fall intervention was assigned to the CNAs for Resident #18. She stated staff not rounding hourly could contribute to Resident #18's falls. An interview was conducted with S32CNA on 02/28/2024 at 1:42 p.m. She stated Resident #18 was a fall risk and required staff assistance with transfers and toileting. She stated there was a task assigned in the computer for the CNAs to monitor Resident #18 every two hours to prevent falls. She stated she documented the task was completed, but was unaware it had to be completed hourly. She stated she did not recall any staff notifying her to round on Resident #18 hourly to prevent falls. An interview was conducted with S30LPN on 02/28/2024 at 1:57 p.m. She stated Resident #18 was a fall risk and required assistance with toileting and transfers. She stated Resident #18 had frequent falls. She stated after a resident had a fall, the CNAs were scheduled fall intervention tasks in the computer to complete and document on. She stated staff rounded every two hours on the residents. She stated she was not aware Resident #18 should have been rounded on hourly to prevent falls. An interview was conducted with S3ADON on 02/29/2024 at 2:40 p.m. She stated she was unaware the CNAs were documenting Resident #18's fall monitoring tasks for hourly rounding as completed, but were unaware Resident #18 should be rounded on hourly. She stated she would expect staff to document only care and interventions provided. She stated she expected staff to know what interventions were in place to prevent resident falls. An interview was conducted with S2DON on 02/29/2024 at 2:45 p.m. She stated she was unaware the CNAs were documenting Resident #18's fall monitoring tasks for hourly rounding as completed, but were unaware Resident #18 should be rounded on hourly. She stated she would expect staff to document only care and interventions provided. She stated all staff had access to the resident's care plans and interventions in the computer. She stated she expected staff to know what interventions were in place to prevent resident falls. She stated there had been no specific monitoring to ensure the CNAs implemented and documented interventions initiated for resident falls accurately and there should have been. Review of video footage without audio was conducted with S1ADM on 02/28/2024 at 12:23 p.m. and revealed the following: Location: Hall B 02/27/2024 from 12:00 a.m. until 4:55 a.m. No staff were observed entering Resident #18's room from 12:00 a.m. - 3:17 a.m. and from 3:23 a.m. - 4:24 a.m. An interview was conducted with S4CNAS on 02/28/2024 at 1:15 p.m. She stated S24CNA was assigned to Resident #18 on 02/26/2024 from 6:00 p.m. - 6:00 a.m. An interview was conducted with S1ADM on 02/28/2024 at 1:20 p.m. He reviewed Resident #18's care plan and confirmed an intervention for hourly rounding was added on 02/05/2024 after the resident had a fall. He confirmed Resident #18 was not rounded on hourly by staff on 02/27/2024 from 12:00 a.m. to 3:17 a.m., and should have been.

Based on interviews and record review, the facility failed to ensure each resident was given the appropriate treatment and services to maintain his or her ability to carry out activities of daily living for 1 (#18) of 6 (#17, #18, #19, #28, #51 and #109) residents reviewed for ADLs. This deficient practice had the potential to affect any of the 50 residents residing in the facility who required staff assistance with ADLs. This deficient practice resulted in an actual harm for Resident #18, a resident who required staff assistance with toileting and transfers, on 02/27/2024 at 3:39 a.m., when Resident #18 pushed her call light and required assistance with toileting. CNA staff did not provide ADL care to Resident #18 in a timely manner which lead to her getting out of bed unassisted and falling. Staff found Resident #18 on the floor at 4:24 a.m. Resident #18 was transferred to the emergency room and diagnosed with a Right Humerus Fracture. Resident #18 required increased assistance with ADL's, a Hoyer lift for transfers, and became incontinent at all times after the fall on 02/27/2024. Findings: Review of Resident #18's Clinical Record revealed a facility admitted [DATE] with diagnoses, which included Repeated Falls, Altered Mental Status, and Dementia Unspecified Severity with Agitation. Review of Resident #18's Quarterly MDS with an ARD of 12/29/2023 revealed a BIMS of 13, which indicated she was cognitively intact. Further review revealed Resident #18 required staff assistance with toileting, transfers, and was frequently incontinent of bowel and bladder. Review of Resident #18's current Care Plan revealed the following, in part: Problem onset of 10/01/2020 Problem: ADL's: Requires assistance with ADL's Interventions: Start date 02/29/2024 - Transfers: Total two person assist/lift; Toileting: Total/two person assist. Problem onset of 02/29/2024 Problem: Total bowel and bladder incontinence Interventions: Start date 02/29/2024 - Incontinence care every 2 hours and as needed Review of Resident #18's Incident Reports revealed the following, in part: 02/27/2024 at 5:00 a.m. Incident Type: Non-Witnessed Fall Location: Resident Room Review of Resident #18's Nurses' Notes dated February 2024 revealed the following, in part: 02/27/2024 at 12:47 p.m. -Late Entry-Patient was found lying on her back in her room on the floor stating she had got up, and attempted to go to the bathroom on her own. Review of Resident #18's Emergency Department Nurse's Note dated 02/27/2024 at 5:02 a.m. revealed the following, in part: Presenting complaint: Patient reported she fell walking to the bathroom. Patient also reported pain in her right arm from her shoulder to right wrist. Review of Resident #18's Right Humerus X-ray dated 02/27/2024 revealed the following, in part: Impression: Proximal Humeral abnormalities with total shoulder arthroplasty device and intramedullary rod across the proximal Humerus and possibly Mid Humerus Fractures. The Mid Humerus fracture is new from the 2023 exam but the Proximal Humeral abnormalities appear stable. Review of Resident #18's Right Shoulder X-ray dated 02/27/2024 revealed the following, in part: Impression: There is a non-displaced fracture in the distal diaphyseal portion of the Right Humerus. An intramedullary nail crosses fracture. An interview was conducted with Resident #18 on 02/28/2024 at 2:57 p.m. She stated when she fell on [DATE], she was trying to go to the bathroom. She stated she required more staff assistance and hurt really badly when she had to move to get dressed, go to the bathroom, and transfer in and out of bed. She stated she had not requested to transfer to the toilet since her fall because it was too painful. She stated she had been incontinent since she fell . Review of facility's video footage without audio was conducted with S1ADM on 02/28/2024 at 12:23 p.m. and revealed the following: Location: Hall B 02/27/2024 from 12:00 a.m. until 4:55 a.m. No staff were observed entering Resident #18's room from 3:23 a.m. - 4:24 a.m. Review of Resident #18's Call Light Event Report dated 02/27/2024 revealed the following, in part: Occurred: 03:39 a.m. Responded: 04:47 a.m. An interview was conducted with S1ADM on 02/28/2024 at 1:20 p.m. S1ADM reviewed Resident #18's call light log, and confirmed Resident #18 pressed her call light on 02/27/2024 at 3:39 a.m. S1ADM confirmed the above video footage revealed staff did not enter the resident's room until 4:24 a.m. and the call light was turned off by S4CNAS at 4:47 a.m. He confirmed Resident #18 waited over 40 minutes for assistance and had a fall. An interview was conducted with S32CNA on 02/28/2024 at 1:42 p.m. She stated Resident #18 was a fall risk and required staff assistance with transfers and toileting. She stated prior to Resident #18's fall on 02/27/2024, she required one to two staff assistance with transfers, toileting, and dressing. She also said the resident told staff when she needed to go to bathroom and asked to use the toilet. She stated since Resident #18's fall on 02/27/2024, she had been incontinent and required more assistance with all ADL's. An interview was conducted with S28CNA on 02/29/2024 at 9:34 a.m. She stated Resident #18 was a fall risk and required staff assistance with transfers and toileting. She stated prior to Resident #18's fall on 02/27/2024, she required one to two staff assistance with transfers, toileting, and dressing and told staff when she needed to go to bathroom and asked to use the toilet. She stated since Resident #18's fall on 02/27/2024, she required total assistance with two to three staff for Hoyer lift transfers, bathing and dressing and was always incontinent and no longer asked staff to use the toilet. An interview was conducted with S6LPN on 02/29/2024 at 9:40 a.m. She stated prior to Resident #18's fall on 02/27/2024, she required one person transfer assist to stand and pivot and would ask staff to go to bathroom and use the toilet. She stated since Resident #18's fall on 02/27/2024, she required total assistance with two staff for Hoyer lift transfers, was always incontinent and no longer asked staff to use the toilet. An interview was conducted with S3ADON on 02/29/2024 at 10:00 a.m. She stated since Resident #18's fall on 02/27/2024, she had an ADL decline, required two staff assistance with ADL's, and Hoyer lift transfers due to her decreased mobility and right arm fracture. An interview was conducted with S2DON on 02/29/2024 at 10:05 a.m. She stated since Resident #18's fall on 02/27/2024, she had an ADL decline, required two staff assistance with ADL's, and Hoyer lift transfers due to her decreased mobility and right arm fracture.

Based on interviews and record review, the facility failed to ensure the governing body established and implemented policies/procedures regarding the management and operation of the facility. This deficient practice was evidenced by the facility's failure to have policies and procedures to address how 6 (S10LPNTx, S15CNA, S17CNA, S21CNA, S22CNA, S23CNA) of 14 (S5QA, S6LPN, S7LPN, S10LPNTx, S13CNASup, S14CNA, S15CNA, S16CNA, S17CNA, S18CNA, S21CNA, S22CNA, S23CNA, S25CNA) direct care staff would readily identify the code status of all residents in the facility, and/or the appropriate actions direct care staff should implement in the event a resident was found unresponsive. This failed practice had the potential to effect all 62 residents who currently resided in the facility. This resulted in an Immediate Jeopardy situation, which was identified upon entrance to the facility on [DATE] at 8:30 a.m., when the facility failed to have an effective system in place to ensure direct care staff were knowledgeable of how to identify a resident's code status. On [DATE] at 7:05 a.m., Resident #4 who was a full code, did not receive CPR when he was found unresponsive. Multiple current staff members were unable to correctly state how to identify a resident's code status and/or the appropriate actions to implement if a resident was found unresponsive. S1ADM and S2DON were notified of the Immediate Jeopardy on [DATE] at 3:05 p.m. The IJ was removed on [DATE] at 12:28 p.m. when the facility presented an acceptable plan of removal. Through interview and record review, the surveyor confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. The plan of removal included the following: 1. All charts were reviewed to make sure each resident's code status matched the resident's door and were corrected in the chart/EMR on [DATE]. All residents' nametags on the outside of their doors were replaced on [DATE] to reflect the new policy. 2. Meetings will be held with all full time and PRN staff before they will be allowed to work their next shift, but no later than [DATE], educating them on the new policies about a resident's Code Status and checking their email before each shift. 3. The administrator sent out an email to all staff, Full time and PRN, explaining that there will only be a Red Dot on the outside of the room if a resident is a NO CODE. This is the ONLY dot that will be on the door. If there is not a dot, the resident is a full code and you are to do CPR all the way to the ER. CNAs and Nurses are responsible to do CPR. 4. New policies were developed and implemented immediately. Policy 5341.1 Identification of Code Status at room level, Policy 5341.3 Admission Code Status, Policy 5341.4 Change of Code Status, and Revised Policy 5341.2 Code of Nursing Home Resident. 5. The DON began educating staff on the new policies and procedures [DATE]. The remainder of the staff, full time and PRN, will be educated by the DON/Designee before they work the hall for their next shift, but no later than [DATE]. The DON/Designee will randomly select staff members every day for the next 7 days to assess their knowledge of the policy, then twice a week for the next 3 months. If any problems arise, they will be immediately re-educated. All staff will be educated on hire and quarterly on these new policies. This will be monitored in the QAPI meeting at least quarterly. The deficient practice continued at a potential for more than minimal harm for all 62 residents currently residing in the facility. Findings: Review of Resident #4's Hospital Records, dated [DATE], revealed the following: Emergency Department Physician Medical Record Assumption of Care [DATE] at 7:09 a.m. Chief Compliant: Unresponsive History of Present Illness: [AGE] year old sent to ER from nursing home is full cardiorespiratory arrest with no CPR in progress. Patient reportedly not breathing for ,[DATE] minutes. Patient was admitted to nursing home yesterday from hospice. Review of Systems: loss of consciousness, cardiorespiratory arrest. Physical Exam: unresponsive, pupils fixed and dilated, no heart sounds noted, respiratory arrest. Medical Decision Making: Patient was DOA from nursing. Pronounced at 7:09 a.m. on [DATE]. Emergency Department Nursing Medical Record Arrival [DATE] at 7:08 a.m. Chief Complaint: Unresponsive History of Present Illness: Unresponsive Triage Assessment: Patient arrived to ER at 7:09 a.m. unresponsive. No respirations noted, no chest rise noted, no breath sounds noted on listening to patient. No breathing noted on arrival to ER from nursing home. Triage Location, Acuity, Interventions: Patient arrived via stretcher from nursing home with (S4RN) and assistant. No CPR in progress on arrival. (S4RN) stated when she started her shift she believed night shift nurse had started compressions but was not being performed when she arrived to patient room. It had been about 8 minutes after she arrived at nursing home before patient was brought to ER. Checked carotid pulse (no pulse noted), no chest rise noted, no breath sounds heard. Review of the facility's policy for Code of Nursing Home Resident, revised [DATE], revealed the following: Policy Statement: It is the policy of the facility that any patient who does not have a written DNR order will be coded. Procedure: Any patient that is found to have no pulse or respirations and does not have a written Do Not Resuscitate order: 1. CPR will be started in the Nursing Home. 2. The hospital will be notified. 3. The patient will be transported to the hospital for further Advanced Cardiac Life Support as soon as possible. An interview was conducted with S17CNA on [DATE] at 10:00 a.m. She was asked how she would identify a resident's code status. She was unable to state how she identified each resident's code status. She stated, in the past, there was a sheet in each resident's room, but not anymore. An interview was conducted with S10LPNTx on [DATE] at 10:10 a.m. She was asked how she would identify a resident's code status. She stated she knew a resident's code status by the colored dots on the door beside their names. She stated the blue dots meant DNR and the red dots meant full code. An interview was conducted with S15CNA on [DATE] at 11:07 a.m. She was asked how she would identify a resident's code status. She stated she knew a resident's code status by the colored dots on the door beside their names. She stated the blue dots meant DNR and the red dots meant full code. She then stated red meant stop and blue meant go. She stated if she walked in the room and the resident was not breathing, she would stop and go get the nurse. She stated she would start CPR if there was a red sticker on the door. She stated she had not been told if she could initiate CPR on anyone. An interview was conducted with S22CNA on [DATE] at 11:16 a.m. She was asked how she would identify a resident's code status. She stated the facility told her that if she found someone unresponsive, she had to look at the colored dot on the door and would then tell the nurse. She stated then she may have to take the resident to the emergency room . She was asked if she would continue CPR if a resident had to be transferred to the emergency room . She stated she would not perform CPR on the resident during the transfer. She stated the facility had not told her that she should perform CPR on any resident. She said her instinct would tell her to do it, but she was not 100% sure if she was supposed to. An interview was conducted with S23CNA on [DATE] at 11:27 a.m. She was asked if she would initiate CPR on a resident that was found unresponsive and was a full code. She stated the facility has never told her that she should perform CPR or what she should do if she found someone unresponsive. An interview was conducted with S21CNA on [DATE] at 11:46 a.m. She was asked if she would continue CPR on a resident if she started CPR on a resident that was a full code and needed to be transferred to the emergency room . She stated she has not been told by any supervisor that she needed to continue CPR while transferring a resident to the ER. An interview was conducted with S2DON on [DATE] at 9:15 a.m. She was asked how the direct care staff would know the code status of a resident. She stated there was usually DNR stickers on the paper record and the nurses could see the code status on the electronic face sheet and eMAR. She stated, We also have stickers on the residents' names on their room doors. S2DON was asked if the facility had a policy on how to determine the code status of a resident and/or a policy on the use of the color-coded stickers for code status. She stated, We don't have a policy on it, but we're using the stickers as part of the system. Red dots mean stop, or DNR. Blue means continue, or full code. She was asked if staff have been in-serviced on how to know the code status of residents and use of the color-coded stickers. She stated staff had not been in-serviced on it. She stated she did not know there was a problem with the system until last week. She was asked how a newly hired CNA would be expected to know a resident's code status. She stated they go through a training with an existing CNA and the existing CNA explained the process to the new CNA. She was asked if anyone was designated to follow-up with CNAs to make sure they understood how to know the code status of a resident. She stated no one was designated to follow-up with CNAs to make sure they understood the process.

Based on record reviews and interviews, the facility failed to ensure direct care staff provided basic life support, including CPR, to a resident requiring emergency care according to the resident's advance directive and physician's orders [REDACTED].#4) of 5 (Residents #1, #2, #4, #6, #7) residents reviewed for death in the facility. This failed practice had the potential to effect all 62 residents who currently resided in the facility. This resulted in an Immediate Jeopardy situation, which was identified upon entrance to the facility on [DATE] at 8:30 a.m when the facility failed to have an effective system in place to ensure direct care staff were knowledgeable of how to identify a resident's code status. On [DATE] at 7:05 a.m., Resident #4 who was a full code, did not receive CPR when he was found unresponsive. Multiple current staff members were unable to correctly state how to identify a resident's code status and/or the appropriate actions to implement if a resident was found unresponsive. S1ADM and S2DON were notified of the Immediate Jeopardy on [DATE] at 3:05 p.m. The IJ was removed on [DATE] at 12:28 p.m. when the facility presented an acceptable plan of removal. Through interview and record review, the surveyor confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. The plan of removal included the following: 1. All charts were reviewed to make sure each resident's code status matched the resident's door and were corrected in the chart/EMR on [DATE]. All residents' nametags on the outside of their doors were replaced on [DATE] to reflect the new policy. 2. Meetings will be held with all full time and PRN staff before they will be allowed to work their next shift, but no later than [DATE], educating them on the new policies about a resident's Code Status and checking their email before each shift. 3. The administrator sent out an email to all staff, Full time and PRN, explaining that there will only be a Red Dot on the outside of the room if a resident is a NO CODE. This is the ONLY dot that will be on the door. If there is not a dot, the resident is a full code and you are to do CPR all the way to the ER. CNAs and Nurses are responsible to do CPR. 4. New policies were developed and implemented immediately. Policy 5341.1 Identification of Code Status at room level, Policy 5341.3 Admission Code Status, Policy 5341.4 Change of Code Status, and Revised Policy 5341.2 Code of Nursing Home Resident. 5. The DON began educating staff on the new policies and procedures [DATE]. The remainder of the staff, full time and PRN, will be educated by the DON/Designee before they work the hall for their next shift, but no later than [DATE]. The DON/Designee will randomly select staff members every day for the next 7 days to assess their knowledge of the policy, then twice a week for the next 3 months. If any problems arise, they will be immediately re-educated. All staff will be educated on hire and quarterly on these new policies. This will be monitored in the QAPI meeting at least quarterly. The deficient practice continued at a potential for harm for all 62 residents currently residing in the facility. Findings: Review of facility's policy for Code of Nursing Home Resident, revised [DATE], revealed the following: Policy Statement: It is the policy of the facility that any patient who does not have a written DNR order will be coded. Procedure: Any patient that is found to have no pulse or respirations and does not have a written Do Not Resuscitate order: 1. CPR will be started in the Nursing Home. 2. The hospital will be notified. 3. The patient will be transported to the hospital for further Advanced Cardiac Life Support as soon as possible. Review of an Advanced Directive for Resident #4, dated [DATE], revealed the following directives were checked: Yes to CPR Maximum Effort will be made including emergency transportation to the Hospital and if necessary, full life-support measures in the hospital including Ventilator support when appropriate and intensive care unit. The document was initialed by the resident's daughter and was signed by S12SSD. S12SSD verified during her interview on [DATE] at 10:33 a.m. that the resident's daughter, who had POA, signed and initialed the Advanced Directive and LaPOST on [DATE]. Review of a LaPOST in Resident #4's chart revealed the following: A. Cardiopulmonary Resuscitation (CPR): Person is unresponsive, pulseless and is not breathing _X_ CPR/Attempt Resuscitation (requires full treatment in section B) B. Medical Interventions: Person has pulse or is breathing _X_ Full treatment (primary goal of prolonging life by all medically effective means) Use treatments in Selective Treatment and Comfort Focused treatment. Use mechanical ventilation, advanced airway interventions and cardioversion if indicated. D. Summary The basis for these orders is: Patient's Personal Health Care Representative (Qualified Patient without capacity) Signed by the following: ER physician on [DATE] Resident #4's daughter on [DATE] Review of Resident #4's electronic health record revealed the following on the facesheet: admitted - [DATE] DNR Review of the Resident #4's Care Plan revealed, in part, the following: Date admitted : [DATE] Category: Advance Directives Problem Onset: [DATE] Advanced Directives - FULL CODE Created By: S11MDS Created On: [DATE] 11:19 AM Goal - Advanced Directives will be followed per resident/Family request Approaches - ADVANCED DIRECTIVES: FULL CODE Roles: All Employees Keep Advanced Directives on resident's chart. Roles: LPN Mark resident's chart appropriately. Roles: LPN Send copy of resident's Advanced Directives when resident is transferred to another facility. Roles: LPN Honor resident's/family wishes in regards to Advanced Directives. Roles: All employees Review of a hospice RN Initial Assessment, dated [DATE], revealed the following: Preferences: Treatment Preferences Was the patient/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? 1. Yes, and discussion occurred Please explain: Discussion with spouse and daughter. They wish patient to be full code. Need more education Date the patient/responsible party was first asked about preference regarding the use of CPR: [DATE] Was the patient/responsible party asked about preferences regarding life-sustaining treatment other than CPR? 1. Yes, and discussion occurred Please explain: Family wants life sustaining treatment, continued discussions Date the patient/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR: [DATE] Summary/Comments . SN reviewed hospice services and consents with spouse and she states that he was a DNR but we rescinded it at the hospital. Daughter states that they want patient to be a full code for now. SN reviewed patient status, poc (plan of care), expectations of decline, and explained full code vs. DNR. Daughter verbalized understanding and signed consents making patient a full code. Digitally signed by hospice RN. Review of the Nurses Notes for Resident #4 revealed, in part, the following: [DATE] at 7:05 a.m. - Transfer notes: Resident not breathing. Unable to obtain a pulse and BP. Home Health aware of transfer and resident current code status of full code. Sent resident to ER for code status of full code. Documented by S8LPN. [DATE] at 7:24 a.m. - Went in resident's room to administer morning medication. Resident noted to have shallow breaths at a rate of 8, medication administered as order. Oxygen in place at 2 LPM via NC. As I the nurse was leaving room, resident noted to no longer be breathing. Unable to obtain pulse or blood pressure. Called second nurse in to room to verify. Code status checked per Hospice. Resident noted to be a DNR per hospice, per facility advanced directive resident a full code. Chest compressions started, resident transferred to ER per code status. Documented by S8LPN. Review of Resident #4's Hospital Records, dated [DATE], revealed the following: Emergency Department Physician Medical Record Assumption of Care [DATE] at 7:09 a.m. Chief Compliant: Unresponsive History of Present Illness: [AGE] year old sent to ER from nursing home is full cardiorespiratory arrest with no CPR in progress. Patient reportedly not breathing for ,[DATE] minutes. Patient was admitted to nursing home yesterday from hospice. Review of Systems: loss of consciousness, cardiorespiratory arrest. Physical Exam: unresponsive, pupils fixed and dilated, no heart sounds noted, respiratory arrest. Medical Decision Making: Patient was DOA from nursing. Pronounced at 7:09 a.m. on [DATE]. Emergency Department Nursing Medical Record Arrival [DATE] at 7:08 a.m. Chief Complaint: Unresponsive History of Present Illness: Unresponsive Triage Assessment: Patient arrived to ER at 7:09 a.m. unresponsive. No respirations noted, no chest rise noted, no breath sounds noted on listening to patient. No breathing noted on arrival to ER from nursing home. Triage Location, Acuity, Interventions: Patient arrived via stretcher from nursing home with (S4RN) and assistant. No CPR in progress on arrival. (S4RN) stated when she started her shift she believed night shift nurse had started compressions but was not being performed when she arrived to patient room. It had been about 8 minutes after she arrived at nursing home before patient was brought to ER. Checked carotid pulse (no pulse noted), no chest rise noted, no breath sounds heard. An interview was conducted with S2DON on [DATE] at 1:15 p.m. She was asked to explain the process when CPR has to be initiated on a resident. She explained when CPR was initiated on a resident, it should be continued all the way until the resident's care was taken over by the ER personnel. An interview was conducted with S20CNA on [DATE] at 1:37 p.m. She verified she was on duty on the morning of [DATE] and was called to Resident #4's room after he became unresponsive. She stated when she walked into the room, the nurse that was on duty, S8LPN, said his chest wasn't rising or falling, he wasn't breathing and the nurse didn't find a pulse. She stated S8LPN asked another nurse, S9LPN, to check Resident #4's vitals. S20CNA stated S9LPN said she couldn't find any vitals either. S20CNA stated S4RN then came in and listened to Resident #4 and couldn't find a pulse or breathing either. S20CNA stated she helped transfer Resident #4 out of his bed onto a stretcher. S20CNA was asked if CPR was initiated on Resident #4. She stated CPR was not being performed when she entered the room and assisted to transfer the resident onto the stretcher and was not performed from that time until the resident was transferred to the adjoining hospital's ER. S20CNA was asked if she had been trained and certified in CPR. She stated she was. When asked to explain what she would be expected to do if a resident was a full code and required CPR, she stated she had been trained to call for help. She stated if a resident is a full code, you would have to start CPR and continue it until the resident is turned over to the hospital ER staff. S20CNA stated S4RN went with her to transfer the resident to the ER. An interview was conducted with S8LPN on [DATE] at 1:57 p.m. She verified she was on duty and assigned to Resident #4 when he was found unresponsive on the morning of [DATE]. She stated she got report from the night nurse who said Resident #4 wasn't doing well. S8LPN stated she gave him his medications and as she was walking out the door, she heard him take a deep breath. S8LPN stated S9LPN checked Resident #4's code status on his electronic record and said he was a DNR. S8LPN stated she knew he was a hospice patient, but felt like something was off so she went and checked the LaPOST and Advanced Directive on Resident #4's paper chart, which stated the resident was a full code. S8LPN stated she then went back down to the resident's room, started CPR, and started going into labor and had to physically stop CPR because she couldn't breathe. She stated she was 9 months pregnant at the time. S8LPN stated she called for S4RN who went to Resident #4's room. S8LPN stated she then went to the desk to call hospice to verify the resident's code status while S4RN was in the resident's room. S8LPN stated she was not aware if S4RN did CPR or not. S8LPN stated she was at the desk when Resident #4 was transferred to the ER. She stated she could not remember if CPR was done while resident was being transferred or not. S8LPN stated she had been instructed to initiate CPR if a resident was a full code and to continue until you get relief. She stated she would continue CPR until the ER staff took over if a resident was transferred to the ER. S8LPN was asked how she would know the code status of a resident. She stated she initially goes by the color-coded sticker on the door. She stated she could not remember if Resident #4 had a colored sticker on his door or not. An interview was conducted with S4RN on [DATE] at 2:28 p.m. She stated she worked part-time as a treatment nurse during the week when needed and ,[DATE] weekends a month as the RN supervisor. S4RN was asked if she was working the morning of [DATE] when Resident #4 became unresponsive and had to be transferred to the ER. She stated she remembered the incident. S4RN stated Resident #4 had just been admitted to the facility the day before on a Friday. She stated she had just walked in the door that morning and someone told her she was needed in Resident #4's room. S4RN stated she went to Resident #4's room and S8LPN and S20CNA were in the process of transferring him onto a stretcher. S4RN stated she walked in the resident's room, looked at him and assessed no vital signs, no respirations or heart rate. She stated S8LPN had started CPR and was getting off the bed and then he was transferred to the ER. She stated she did not accompany the resident to the ER. She was not sure who accompanied him. S4RN stated she did not specifically recall anybody doing CPR but could not be sure. S4RN verified that she did not perform CPR on the resident. S4RN was asked how she would know the code status of a resident. She stated the resident's code status was in the electronic health record in the clinical section on the eMAR where all the treatments and patient demographics are located. S4RN stated she doesn't look in a paper record. She stated she did not know if the code status was located anywhere else. She stated if there was an issue or occurrence then she would talk with the floor nurse because she should know and could tell her what the resident's code status was. S4RN was asked what she would do if a resident was found unresponsive with no vital signs and was a full code status. S4RN stated she would initiate CPR and would continue CPR until the resident was received in the ER. An interview was conducted with S17CNA on [DATE] at 10:00 a.m. She was asked how she would identify a resident's code status. She was unable to state how she identified each resident's code status. She stated, in the past, there was a sheet in each resident's room, but not anymore. An interview was conducted with S10LPNTx on [DATE] at 10:10 a.m. She was asked how she would identify a resident's code status. She stated she knew a resident's code status by the colored dots on the door beside their names. She stated the blue dots meant DNR and the red dots meant full code. An interview was conducted with S15CNA on [DATE] at 11:07 a.m. She was asked how she would identify a resident's code status. She stated she knew a resident's code status by the colored dots on the door beside their names. She stated the blue dots meant DNR and the red dots meant full code. She then stated red meant stop and blue meant go. She stated if she walked in the room and the resident was not breathing, she would stop and go get the nurse. She stated she would start CPR if there was a red sticker on the door. She stated she had not been told if she could initiate CPR on anyone. An interview was conducted with S22CNA on [DATE] at 11:16 a.m. She was asked how she would identify a resident's code status. She stated the facility told her that if she found someone unresponsive, she had to look at the colored dot on the door and would then tell the nurse. She stated then she may have to take the resident to the emergency room . She was asked if she would continue CPR if a resident had to be transferred to the emergency room . She stated she would not perform CPR on the resident during the transfer. She stated the facility had not told her that she should perform CPR on any resident. She said her instinct would tell her to do it, but she was not 100% sure if she was supposed to. An interview was conducted with S23CNA on [DATE] at 11:27 a.m. She was asked if she would initiate CPR on a resident that was found unresponsive and was a full code. She stated the facility has never told her that she should perform CPR or what she should do if she found someone unresponsive. An interview was conducted with S21CNA on [DATE] at 11:46 a.m. She was asked if she would continue CPR on a resident if she started CPR on a resident that was a full code and needed to be transferred to the emergency room . She stated she has not been told by any supervisor that she needed to continue CPR while transferring a resident to the ER. An interview was conducted with S2DON on [DATE] at 9:15 a.m. She was asked if she was familiar with the incident that occurred with Resident #4 on [DATE]. She stated, The only thing I know is what I'm told and what I've read. We had an order for [REDACTED]. She stated the floor nurse usually enters the initial orders when a resident is admitted . S2DON stated she was not sure where she got the DNR status. S2DON stated she spoke with S26LPN who stated she did not remember where she got the DNR status from, but she had to have had orders for it. S2DON verified that S26LPN no longer worked at the facility. S2DON stated she contacted hospice and they did not have an order for [REDACTED].#4 was a full code. S2DON stated upon interviewing S4RN, she stated she came in after chest compressions were started. She stated S4RN said she assessed the resident and S8LPN told S4RN the resident had to be transported. She stated S8LPN told her that S9LPN looked for the resident's code status on the computer and found that he was supposed to be a DNR. S2DON stated they were looking for the advanced directive and found it was initialed. They also found the LaPOST in the doctor's tray to be signed and saw documentation that the resident was to be a full code. S2DON was asked how they knew the code status of the resident. She stated there was conflicting information in the chart so they were supposed to go with the advanced directive. She stated, when in question, you should go with CPR and go forward. S2DON stated the staff started CPR and then transferred him. She stated she was not sure who the last person was that did chest compressions. S2DON stated S8LPN stopped CPR when S4RN and S20CNA transferred the resident. S2DON verified that she was aware when the staff arrived at ER, CPR was not being done. She stated the staff did not continue chest compressions during transfer. S2DON stated someone should have been on the stretcher doing CPR until the resident was received by the ER staff. She further stated she would expect all records to match in relation to a resident's code status when a resident was admitted .