Every finding on record at Westminster Commons

Based on observations, staff interviews, and review of the Facility Policy, Hand Washing the facility failed to prepare puree foods under sanitary conditions for three of three residents (R) receiving a puree diet. This deficient practice had the potential to cause foodborne illness to residents receiving a puree diet. Findings include:Review of the facility's policy titled, Hand Washing, undated, documented the following Procedure instructions: 1. When to Wash Hands. After handling soiled equipment or utensils. During food preparations, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, and before donning gloves for working with food.Observation on 08/12/2026 at 11:10 AM revealed Dietary [NAME] GG removed his gloves and wiped down the kitchen counter with a wet dishcloth. He placed the dishcloth into soapy water and then wiped his hands on his pants. Dietary [NAME] GG donned a new pair of gloves without washing his hands and began preparing the first puree item of beef burgundy. After the Dietary Manager washed the food processor bowl and lid, Dietary [NAME] GG again removed his gloves, wiped the counter with the wet dishcloth, placed the cloth back into soapy water, and wiped his hands on his pants. He repeated this same process during preparation of the next two puree items-sweet peas and buttered egg noodles-each time wiping his hands on his pants and donning clean gloves without washing his hands. At no time during the puree process did Dietary [NAME] GG wash his hands.An interview with Dietary [NAME] GG on 08/12/2026 at 11:55 AM acknowledged that he should have washed his hands appropriately after contact with the used dishcloth and his uniform and before donning a new pair of gloves. He confirmed he should have sanitized his hands after removing and donning gloves throughout the puree process.An Interview on 08/12/2026 at 11:55 AM with the Dietary Manager confirmed that Dietary [NAME] GG should have washed his hands after contact with the used dishcloth and his uniform, and before donning a new pair of gloves during the puree preparation process.

Based on record review and staff interviews, the facility failed to ensure one of three Certified Medication Aides (CMA) had the required competencies needed to provide safe resident care. This deficient practice had the potential to result in an unqualified staff member performing medication administration tasks without verified competency.Findings include:A review of the employee file for CMA HH revealed a CMA registry date of 11/12/2022. The file revealed CMA HH did not have a skills checklist.An interview on 08/13/2026 at 3:00 PM with the DON revealed that skills checks were completed annually and as needed. She stated that when nurses were training on the floor, she received feedback from the staff providing the training. She stated that the time frame for completing a skills check after hire depended on the nurse, but typically the time frame was three days. She stated that CMA HH should have had a skills check completed. The DON stated she could not provide a reason as to why CMA HH did not have one. She stated that skills checks did not take long since they could be completed by observing a single med pass. An interview on 08/13/2026 at 3:09 PM with the Administrator revealed that his expectation was that all staff received their skills check upon completing orientation. He stated that if staff were not receiving their skills check, the facility ran the risk of having an unqualified person on the floor. He stated that this was not the process of the facility.

Based on resident and staff interviews, record review, and review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, the facility failed to protect two of 41 sampled residents (R) (R74 and R67) in their right to be free from physical and verbal abuse from each other. This deficient practice had the potential to cause ongoing physical or psychological abuse to the residents. Findings include:Review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment or misappropriation of Property with a date of January 2026 documented under the section Policy It is the policy of this Center that each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind, exploitation, and misappropriation of property. In addition, each resident will also be protected from those practices and omissions, which if left unchecked, could lead to abuse. Further, each resident will be treated with respect and dignity at all times. The Center will foster an environment that recognizes the worth and uniqueness of all individuals with regards to person-centered care and to promote respect and set standards of care.Residents will not be subject to abuse by anyone, including but not limited to, Center staff, other residents, consultants, volunteer staff, contract residents, consultants, volunteer staff, contract staff, family members, friends or others.1. Review of the electronic medical record (EMR) for R74 revealed he was admitted to the facility on [DATE] with a diagnosis of, but not limited to, depression unspecified.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that R74 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment.Review of the Admissions Records for R74 revealed he resided in room [ROOM NUMBER] bed A.2. Review of the electronic medical record (EMR) for R67 revealed he was admitted to the facility on [DATE] with diagnoses of, but not limited to, depression unspecified, anxiety disorder unspecified, and insomnia unspecified.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that R67 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment.Review of the Admissions Records for R67 revealed he resided in room [ROOM NUMBER] bed C.Review of the care plan for R67 documented R67 has a psychosocial well-being problem related to mood disturbance as evidenced by a (Patient Health Questionnaire-9) PHQ-9 score of 13 with interventions to monitor for changes in mood, withdrawal, hopelessness, or worsening depressive symptoms and report concerns to the interdisciplinary (IDT) team.Review of the care plan for R67 documented R67 has a behavior problem related to verbal aggression towards staff members with an intervention to monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes.During an interview on 08/12/2026 at 9:20 AM with R74 in his bedroom, he stated he had continuous concerns with his roommate, R67, since R67 was admitted to the room they both occupied. R74 stated that on 08/06/2026, he encountered verbal and physical abuse from his roommate, R67, when he was leaving the room, and his wheelchair hit the footboard of his bed. He stated that his wheelchair hitting the bed was an ongoing issue between him and R67.Continuing with the interview, R74 stated that as R67 was wheeling himself out of the bedroom door, R74 attempted to close the door using a reacher device (assistive mobility aid) because he was non ambulatory. When R74 attempted to close the door, R67 was still in the doorway and hit him with the door. R67 then began to yell and curse at R74, proceeded to snatch the reacher device, pulled it apart, and shoved it back toward him. R74 stated he became fearful because of R67's verbal and physical aggression and pressed his call light for staff assistance. R74 further confirmed that Receptionist AA, followed by the Director of Nursing (DON), responded to the incident between him and R67.During an interview on 08/12/2026 at 9:31 AM, Receptionist AA stated she witnessed a verbal altercation between R74 and R67 in their bedroom doorway. She confirmed R67 was yelling and cursing at R74, and she went to the room to de escalate the situation. She stated she proceeded to inform the DON of the situation between R74 and R67 and requested her assistance.During an interview on 08/12/2026 at 1:07 PM, the DON confirmed that when she went to address the concern between R74 and R67, she witnessed R74 using the reacher device to hit R67 with the door. She stated she was unsure how many times R74 hit R67 with the door prior to her arrival and stated she offered R74 a room change.During an interview on 08/12/2026 at 2:44 PM, R67 revealed that on 08/06/2026, his wheelchair did hit the footboard of R74's bed, which led to a verbal exchange of him yelling and cursing at R74 because R74 kept using his reacher device to close the door on him. R67 continued to state he snapped and grabbed the reacher device, pulled it apart, and shoved it back at R74. He stated Receptionist AA came in at that moment and went to inform the DON of the incident. Continuing with the interview, R67 confirmed that when the DON arrived at the room, he told her he did yell, curse, and pull apart R74's reacher device.During an interview on 08/12/2026 at 4:41 PM, the Administrator stated he was not aware of the suspected verbal and physical abuse between R74 and R67 that took place on 08/06/2026. The Administrator stated it was expected for the DON and all staff to report any suspected abuse to him because he was the Abuse Coordinator. Further, the Administrator stated that all staff were responsible for keeping the residents safe.

Based on staff interviews, record review, and review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, the facility failed to report suspected verbal and physical abuse for two of 41 sampled residents (R) (R74 and R67) to the Sate Survey Agency (SSA) within the required timeframe. This deficient practice could diminish and affect the residents' quality of life. Findings include:Review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment or misappropriation of Property dated January 2026 documented under the section titled. Prevention prevention of abuse will be accomplished by the timely reporting of the suspected abuse and a thorough investigation of these instances. Under the section titled Reporting/Documentation Requirements states ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator od the center and to other officials (including to the SSA and adult protective services where state law provides for jurisdiction in long-term care Centers) in accordance with State law through established procedures in these timeframes. If the event that causes the allegations involved abuse or results in serious bodily injury, the event must be reported immediately, but no later than two hours after the allegation is made.Upon suspected abuse, neglect, or exploitation of a resident, the following procedures is to be followed: (1) Immediately notify the (a) Administrator and (b) Director of Nursing (DON).Review of the facility State Reportable binder revealed there were no reports for R74 and R67 related to verbal and physical abuse.During an interview on 08/12/2026 at 9:31 AM, Receptionist AA stated she was not familiar with the reporting requirements.During an interview on 08/12/2026 at 1:07 PM, the DON confirmed she was aware the Administrator was the Abuse Coordinator and stated abuse should be reported to him within a two hour timeframe. The DON continued to state all staff should know what to report and who to report abuse to.During an interview on 08/12/2026 at 4:41 PM, the Administrator stated he was not aware of the suspected verbal and physical abuse between R74 and R67 that took place on 08/06/2026. The Administrator stated it was expected for the DON and all staff to report any suspected abuse to him because he was the Abuse Coordinator. It was confirmed that the incident was not reported in a timely manner.

Based on and staff and interviews, record review, and review of the facility's policy titled, 'Prevention of Resident Abuse, Neglect, Mistreatment or misappropriation of Property, the facility failed to identify and investigation suspected verbal and physical abuse of resident-to-resident for two of 41 sampled residents (R) (R74 and R67). The deficient practice has the potential to allow abuse to continue. Findings include:Review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment or misappropriation of Property dated January 2026 documented under the section titled Investigation all suspected cases of abuse or misappropriation of resident's property will be fully investigated by the Administrator, Abuse Coordinator, or designee. The findings should be reported to the appropriate governing agencies: (1) interview person reporting the allegation, (2) ensure residents safety is not jeopardized, physically assessed resident, (3) secure area, if indicated, (4) Notify Medical Director (MD), resident representative, Administrator and DON immediately, (5) Interview all associates, residents and family members involved, (6) file a report to governing agency.1. Review of the electronic medical record (EMR) for R74 revealed he was admitted to the facility on [DATE] with a diagnoses of, but not limited to, depression unspecified.Review of the Progress Notes in the EMR for R74 revealed there was no documentation related to a verbal and physical altercation with R67.2. Review of the EMR for R67 revealed he was admitted to the facility on [DATE] with a diagnosis of, but not limited to, depression unspecified, anxiety disorder unspecified, and insomnia unspecified.Review of the care plan for R67 documented R67 has a psychosocial well-being problem related to mood disturbance as evidenced by a (Patient Health Questionnaire-9) PHQ-9 score of 13 with interventions to monitor for changes in mood, withdrawal, hopelessness, or worsening depressive symptoms and report concerns to the interdisciplinary (IDT) team.Review of the care plan for R67 documented R67 has intervention to monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes.Review of the Progress Notes in the EMR for R67 revealed there was no documentation related to a verbal and physical altercation with R74. During an interview on 08/12/2026 at 9:31 AM, Receptionist AA stated she witnessed a verbal altercation between R74 and R67 in their bedroom doorway. She confirmed R67 was yelling and cursing at R74, and she went to the room to de escalate the situation. She stated she proceeded to inform the Director of Nursing (DON) of the situation between R74 and R67 and requested her assistance. Further, Receptionist AA stated that after the Director of Nursing(DON) addressed the situation between R74 and R67, the DON did not ask her to write a statement or document about what took place. She stated the DON only verbally asked her what happened.During an interview on 08/12/2026 at 1:07 PM, the DON stated R74 and R67 never had an altercation. However, the DON confirmed that when she went to address the concern between R74 and R67, she witnessed R74 using the reacher device to hit R67 with the door. She stated she was unsure how many times R74 hit R67 with the door prior to her arrival.During an interview on 08/12/2026 at 4:41 PM, the Administrator revealed he was not aware of the suspected verbal and physical abuse between R74 and R67 that took place on 08/06/2026.

Based on observations, resident and staff interviews, record review of the Safety Data Sheet, and review of the facility policies titled, Accident and Incident Prevention, Reporting and Response and Storage of Equipment, Chemicals, and Supplies, the facility failed to ensure that one of three sampled residents (R22) did not have unsecured chemicals in the resident's Memory Unit room. This failure could have allowed other residents in the Memory Unit to access the chemicals without authorization.Findings include:Review of the Safety Data Sheet Ammoniated Ready To Use Glass Cleaner documented the following Handling and Storage instructions: Avoid contact with eyes. Keep containers tightly closed in a dry, cool, and well ventilated place. Keep out of the reach of children.A review of the policy titled, Accidents and Incident Prevention, Reporting and Response, dated May 2026 documented Policy Statement -The facility is committed to maintaining a resident environment that is as free as possible from accident hazards while meeting individual needs.A review of the policy titled, Storage of Equipment, Chemicals and Supplies, dated July 2026 documented the following statement under Procedure .Chemicals should be in a locked area when not in use and not in resident care areas without direct supervision.Review of a list of residents who wandered in the unit documented that six residents were identified as going in and out of other residents' rooms.An observation on 08/11/2026 at 10:30 AM revealed a bottle of ammonia cleaner sitting on the floor under the sink area in R22's room.An interview on 08/11/2026 at 10:40 AM with the Registered Nurse (EE) confirmed that the bottle of ammonia found on the floor in R22's room should not have been left in the resident's room.An interview on 08/11/2026 at 10:50 AM with R22 revealed that she asked housekeeping to leave the cleaner where she could use it in the bathroom.An interview on 08/12/2026 at 11:00 AM with the Housekeeping Director revealed that the facility had a policy for chemicals, and no chemicals or sprays were to be left in resident rooms. She stated that if chemicals were found, it should be removed quickly.An interview on 08/13/2026 with the Infection Preventionist (IP) revealed that she had educated housekeeping staff along with the rest of the facility staff. She stated that the general concept of cleaning was that chemicals remained in their containers and residents were not supposed to have cleaning items left in their rooms. She stated that housekeeping staff was instructed to keep chemicals locked in their carts. She further stated that, as part of infection control measures, she checked chemicals to ensure they were locked in the cart.An interview on 08/13/2026 at 10:05 AM with Housekeeper DD revealed that chemicals were required to remain locked up.An interview on 08/13/2026 at 10:25 AM with the Administrator revealed that his expectation for housekeeping was that all cleaning products should be locked in the housekeeper's carts. He stated that no cleaning supply should ever be left in a resident's room. He stated that the housekeeping supervisor was responsible for ensuring this did not occur. He said he expected the housekeeping supervisor to report any issues to him.

Based on observation, record review, facility policy review, and resident, resident family, and staff interviews, the facility failed to ensure four of eight residents (Residents (R) 17, 43, 136, and 188) reviewed for abuse out of 46 sampled residents were free from abuse. This had the potential and/or physical harm to the residents. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 indicated, Residents have the right to be free from abuse, neglect . Protect residents from abuse, neglect .by anyone including but not necessarily limited to: a. facility staff; b. other residents .Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; neglect of residents .identify and investigate all possible incidents of abuse, neglect .protect residents from any further harm during investigations. Review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property dated 08/22/22 indicated, It is the policy of this center that each resident has the right to be free from mistreatment of any kind .Each resident will be treated with respect and dignity at all times. The center will foster an environment that recognizes the worth and uniqueness of all individuals with regards to person-centered care and to promote respect . Definitions .Neglect means the failure of the center .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . 1.Review of a Facility Incident Report dated 03/06/25 indicated Type of Incident-Neglect. Details of Incident- [name of R136] is alleging that Certified Nursing Assistant (CNA) [48] neglected him by not turning him timely. Review of the Facility Follow Up Investigation dated 03/13/25 indicated, [name of R136] alleged that [name of CNA 48] neglected him by not turning him timely. The investigation indicated [name of R136] said he called and requested assistance at 2:03 AM on March 6, 2025. He said the CNA did not come to his room until 6:30 AM. When [name of CNA 48] was interviewed, she said she did not go in until 6:30 AM as she felt the resident was rude. The facility concluded, It was determined that the accusation of neglect was Substantiated. Review of R136's undated Admission Record located in the Electronic Medical Record (EMR) under the Profile tab, revealed R136 was admitted to the facility on [DATE]. Review of R136's Care Plan, dated 11/01/24 and located under the Care Plan tab of the EMR, indicated [name of R136] is (high) risk for falls r/t [related to] Paralysis, bilateral [affecting both sides] lower/upper extremity contractures. Interventions indicated, The resident needs prompt response to all requests for assistance. Review of R136's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/24 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also indicated R136 had impairments on both sides of the upper and lower extremities, and the resident was completely dependent on staff for Activities of Daily Living (ADLs). Review of R136's quarterly MDS with an ARD date of 05/02/25 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The MDS further indicated that R136 had impairments on both sides of the upper and lower extremities and was completely dependent on staff for ADLs. During an observation and interview on 05/19/25 at 10:30 AM, R136 was lying in bed. R136 was observed to have a red stylus pen in his mouth and only able to use his stylus pen to touch his cell phone which was mounted to the mobility bar. He was also observed to only be able to move his head up and down. During an interview, R136 stated, From what I remember this was on a Wednesday .I called the nurse who told me someone was coming. I called around 2:00 AM or so. The CNA [identified as CNA48] came into my room. I asked her who my aide was. She said she was. I told her nobody came into my room to turn me. She [referring to CNA48] told me that I would have to wait until the next shift. She told me she was busy and would not be able to help me. Then around 6:00 AM or 6:30 AM, or so she came to change my roommate then told me I can do you, but this will be the first and last time I do this. R136 stated, The nurse [identified as Registered Nurse (RN) 2] came in and told me, 'I asked [name of CNA48] to come in and turn you.' The resident stated that he was eventually turned, but it was around 6 or 6:30 AM. When this incident occurred, R136 stated This was unacceptable, and I felt like it was neglect. Review of a written statement from RN2 dated 03/10/25 and provided by the facility indicated, I had asked the CNA [referring to CNA48] who was the assigned CNA to be working with [name of R136] to go and turn him at 2:00 AM. She refused. I let the CNA know that refusing to do a patient that is assigned to you on a shift is a problem. She agreed with me but still refused. I told her I was going to report her to the DON [Director of Nursing], and she said, 'you can go right ahead.' .The CNA [referring to CNA 48] went into [name of R136] room around 5:00 AM or so to turn him. He was very upset about the whole situation. Review of a phone interview that was conducted with CNA48 on 03/03/25 revealed, [name of CNA48] stated that everything started on Monday March 3, 2025. [name of CNA48] said R136 wanted her to get him ready at 3am for a 7am Dr. appointment. She [CNA 48] told him that it was too early, and she would get him ready at 6:00 AM. He refused and she told him that the CNA coming in for the next shift would get him ready. He [R136] got upset. When asked about the incident that occurred Wednesday night [referring to March 6, 2025], she [CNA48] admitted that she did not go into [name of R136's] room to provide care for him until 6:30 AM. During an interview on 05/20/25 at 11:11 AM, regarding the incident that occurred on 03/06/25 involving R136, the Administrator stated, I was contacted by the Social Worker on March 6, 2025, that he [referring to R136] had concerns and since he used the word 'neglect' we reported it as an allegation of neglect. He then stated, The girl [referring to CNA48] confessed that she didn't go back into his room until 6:30 AM, so we substantiated it for neglect. During an interview on 05/21/25 at 7:13 AM, regarding the incident that occurred with R136 and CNA48 on 03/06/25, RN2 stated that she was the nurse working the night of March 6, 2025. RN2 stated, He [referring to R136] called and said that he needed to be turned around 2:00 AM or 2:30 AM. I told him I would send someone in his room. I told [name of CNA48] since you have him on your assignments, and since you are his assigned CNA, you need to go and turn him. She [referring to CNA48] started arguing that nobody told her she had him. She refused to go into his room and was saying she wasn't assigned to him. I told her since she was on the clock and was assigned to him that she needed to go into his room and turn him. She again said that she was not going to. I told her I was going to let the Director of Nursing know that you are refusing to turn him. RN2 stated Towards the end of the morning around 5:00 AM or 5:30 AM or so I went in the room with [name of CNA48] and apologized to him about the confusion as to who was assigned to him. He was very upset. At that time, we ended up turning him. He was not wet. He just needed to be turned. RN2 stated that she waited until morning until the DON came into work to report the incident. During a second interview on 05/21/25 at 2:53 PM regarding the incident that occurred with R136 and CNA48 on 03/06/25, when RN2 was asked why she did not assist R136 when he was requesting to be turned around 2:00 AM or 2:30 AM, RN2 stated, I was busy with my work. I asked [name of CNA48] and she told me she wasn't going to do it. I had my own work to do. I want to say we went into his room around 5:00 AM or 5:30 AM or so to turn him. An unsuccessful attempt to contact CNA48 via phone was made on 05/21/25 at 9:30 AM. During an interview on 05/21/25 at 12:30 PM, regarding the incident that occurred on 03/06/25, the DON stated she was not notified during the night by any staff which included RN2 about any incident regarding R136 until she came into work around 7:30 AM the next morning. The DON stated, I agree it would be neglect on part of the nurse and the CNA. She [regarding RN2] should have called me or the Administrator immediately. We did not focus on why the nurse did not go into the room to turn him. We were more focused on why the CNA didn't go in. She [referring to RN2] as the nurse could have gone in his room to turn him. During an interview on 05/21/25 at 1:00 PM, the Administrator stated he was not notified by RN2 or CNA48 of this incident anytime during the night. He stated, Nobody called me. The Administrator stated, I see where it was neglect on part of the nurse as well when this happened. She should have called me, and she also could have gone into his [referring to R136] room and turned him. 2. Review of R189's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE]. The resident discharged on [DATE]. Review of R189's discharge Minimum Data Set (MDS) assessment located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 10/13/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. R189 had no delirium, no mood, and no behaviors. Review of R188's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE]. Review of R188's quarterly MDS located in the MDS tab in the EMR, with an ARD of 10/12/24, revealed a BIMS score of eight out of 15, which indicated moderate cognitive impairment. Review of R188's discharge MDS assessment located in the MDS tab in the EMR, with an ARD of 12/06/24, documented the resident had verbal behavioral symptoms directed toward others for one to three days during the assessment period. Review of R188's Care Plan, initiated 02/19/24, documented the resident displayed verbally/physically abusive behaviors and racial comments such as hitting and spitting at staff. Interventions included analyzing key times, places, circumstances, triggers, and what de-escalates behavior and document, and to assess the resident's understanding of the situation. The care plan was last revised on 08/21/24, prior to the 10/03/24 incident. Review of R188's Care Plan, located in the EMR under the Care Plan tab and initiated 04/18/24, revealed R188 was verbally abusive. Interventions included to provide one-to-one supervision as needed. Review of the Facility Incident Report form, dated 10/03/24, provided by the facility revealed that on 10/03/24 at approximately 10:32 AM, R188 was documented to have thrown a full bottle of Gatorade at R189 and call her names. The bottle did not make contact with R188.a skin assessment was conducted .no areas of redness or bruising were present .(R188) was immediately removed, and her room was changed .The police, physician, responsible, and Ombudsman were notified. Witness statement from R189, dated 10/03/24, stated, .(R188) was yelling and calling me out .throw (sic) a full drink at me and it hit the floor. Review of R188's Progress Note, located under the Progress Note tab in the EMR and dated 10/03/24 at 10:32 AM, indicated that .was made aware by the Activity Coordinator that the resident threw her unopened Gatorade bottle at her roommate (R189) .The resident was cursing at the roommate and told her to Get out .Went into the room along with the Director of Nursing (DON) and spoke with the resident .Made her aware that she cannot throw items at her roommate, other residents or staff. Review of the Facility Incident Report investigation revealed that staff members interviewed all stated that they heard (R188) call (R189) a Black B---- and then they heard the sound of the bottle hitting the floor .When the officer arrived at the facility, the officer interviewed both residents .The officer issued a citation to (R188) for disorderly conduct. During an interview on 05/22/25 at 6:58 AM, the Administrator stated that during his investigation of the 10/03/24 resident to-resident abuse between R188 and R189 he learned that R188 had thrown a bottle of Gatorade at R189, but it did not hit her. He stated that he moved R188 to a different room. The Administrator stated that this was why the police officer came back to the facility and issued R188 a citation for a warrant. 3. Review of R17's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] and readmitted on [DATE]. Review of R17's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/25/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) was not assessed and the staff documented R17 as having severely impaired cognition. Review of R17's Progress Note dated 03/25/25 and located under the Progress Notes tab of the EMR revealed Resident was observed in female room with hands in her diaper. Resident was removed from the room immediately and put one on one monitoring, female resident was assessed and unharmed at this time, resident's family notified of incident, DON [Director of Nursing] and administrator notified at this time. Resident was transferred to [name] hospital for a psych [psychiatric] evaluation. 3. Review of R43's Admission Record located under the Profile tab of the EMR revealed the resident was admitted on [DATE]. Review of R43's quarterly MDS with an ARD of 03/28/25 and located under the MDS tab of the EMR revealed a BIMS score was not assessed and the staff documented R43 as having severely impaired cognition. Review of R43's Progress Note dated 03/25/25 and located under the Progress Notes tab of the EMR revealed Resident was assessed and remains unharmed, no bruising or redness noted to vaginal area, no injuries noted. Resident's family notified of incident. During an interview on 05/19/25 at 12:59 PM, Family Member (FM) 1 stated there was an incident that he was aware of with R43 and another resident. He stated she was fine, and nothing happened and that they (the staff) had stopped it before anything occurred. Review of the facility's investigation, pr ovided by the facility and dated 03/31/25, revealed The nurse on duty stated that the last time she saw [R17] was between 12:00 AM and 1:00 AM. She said he was lying in his bed .it was determined after a thorough investigation that it was substantiated .We will implement the following measures: 1. Staff education on identifying and reporting changes in behavior. 2. Staff education on handling changing residents. 3. Both residents received a trauma assessment. 4. Both residents' care plans were updated. 5. Resident will both be seen by psych services. 6. Medical Director/ NP [Nurse Practitioner] is reviewing and modifying [R17's] medication. Review of the police report provided by the facility, dated as first reported 03/25/25, revealed Once on the scene, I spoke to the call [Certified Nursing Assistant (CNA) 16] who explained that while she was working at the nursing home .she walked into the room of [R43]. When she walked into the room, she saw another patient in [R43's] room, sitting on her bed. [CNA16] said the male patient; [R17] had his hand in [R43's] underwear .I was told that [R43] is alert but cannot talk or move that much. As for [R17], he is on multiple psych medications .one on one with [R17] until was transported. During an interview on 05/20/25 at 10:40 AM, Registered Nurse (RN) 1 stated before the incident R17 had been staring at women, appeared drooling, and then he would start to laugh. She stated he was very aggressive before he was sent out for two weeks. She stated he was very calm now. She stated they had two CNAs on the floor since the incident and a lot of in-services. During an interview on 05/20/25 at 12:59 PM, the DON stated R17 had behaviors which was why he was in the memory care unit. She stated she was not aware of any sexual behaviors before the incident. During an interview on 05/21/25 at 10:29 AM, the Administrator stated R17 was fine before the incident, and he was not aware of any behavior prior to. He stated he got a call from a nurse, and he drove to the facility. He stated the police were already at the facility and that R17 was in the common area. He stated R17 left the facility using 1013 transport (legal document used to authorize the involuntary transportation and evaluation of an individual experiencing severe mental health crisis). He stated no other facility was willing to take him. He stated he was told [R17] tried to put his hand inside. He stated he had to complete his report before he received the police report. He stated to his understanding R17 touched R43's naval area and not inside her brief. He stated for safety; they increased staffing in the memory care unit. During an interview on 05/21/25 at 12:17 PM, CNA16 stated at around 3:00 AM, she had gone upstairs to the supply closet. She stated when she came back down, she passed R43's room and saw R17 sitting on her bed. She stated she asked him what he was doing, and he told her he was visiting a friend. She stated R17 had his hand physically down her brief. She stated she felt like he had just done that, and it had not been long. She stated as soon as R17 saw her, he withdrew his hand. She stated she had never seen that behavior from him. She stated he was sent out by 7:00 AM.

Based on resident and staff interviews and record review, the facility failed to ensure residents received proper treatment and services to maintain vision and hearing abilities for one of two residents reviewed for communication (Resident (R) 22) out of 46 sampled residents. The failure to ensure communication deficits were properly assessed and managed placed the facility residents at risk of social isolation. Findings include: Review of R22's Admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was originally admitted on [DATE], with diagnoses including non-Hodgkin lymphoma, hypertension, and diabetes mellitus. Review of R22's quarterly Minimum Data Set (MDS) located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 03/01/25 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. The MDS also revealed R22 was documented to have minimal difficulty in hearing, which indicated some hearing difficulty in some environments. Review of R22's Care Plan, located in the EMR under the Care Plan tab, with an initiated date of 12/12/21, revealed a care plan for a communication problem related to hearing deficit. Approaches included .to ensure availability and functioning of adaptive communication equipment: message board .hearing aids .refer to Audiology for hearing consult as ordered . Review of R22's Audiology Assessment, dated 09/30/24 and located in the resident's EMR under the Misc tab documented, The patient was referred by the facility for decreased hearing. The patient complains of hearing loss .She had a hearing aide [sic] for the right ear .but reports it stopped working/helping .A pocket talker is going to be requested for this patient at this time. During an interview on 05/19/25 at 10:49 AM, R22 stated that she could not hear well. She stated that she used to have hearing aids, but they were lost a long time ago. R22 said that if she could hear better, it would be easier to understand what people say. She said that someone said they would look into it for her, but they never got back to her. During an interview on 05/21/25 at 7:35 AM, Certified Nursing Assistant (CNA) 9 stated she had not seen R22 use a hearing device and confirmed the resident was hard of hearing. Upon entrance to R22's room, CNA9 spoke loudly into R22's ear to ask if she had a hearing device. R22 asked CNA9 to look in her purse, where a single hearing aid was found. R22 said it did not work. CNA9 said she had not seen R22 use any hearing devices. During an interview on 05/21/25 at 7:38 AM, Licensed Practical Nurse (LPN) 3 stated that she had not seen R22 use any form of hearing device. During an interview on 05/21/25 at 7:44 AM, the Social Service Director (SSD) stated that ancillary service providers come to the facility approximately every quarter and see about 20 residents at a time since they could not see them all at once. The SSD also stated she kept a list but was not familiar with R22 having any hearing issues. Upon review of her list, she stated that R22 had not been seen the last time audiology had come to the facility. After reviewing the 09/30/24 audiology report for R22, the SSD stated she had not been familiar with the recommendation for a pocket talker and would look into it. During an interview on 05/21/25 at 11:00 AM, the Director of Nursing (DON) stated that the last SSD had left the facility in January 2025, before the current one had started. She confirmed that the last SSD had not always followed up on things, and that she would expect there to be better communication with ancillary services. During an interview on 05/21/25 at 12:55 PM, the SSD stated she had discovered that R22's invoice for the pocket talker had not been paid, and that it was why it had not been provided to the resident. During an interview on 05/21/25 at 1:47 PM, the DON stated that the facility did not have a policy regarding ancillary services.

Based on observation, record review, staff interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for two of 46 sampled residents (Resident (R) 9 and R18). Failure to code the MDS correctly regarding R18's feeding tube, and R9 for hospice care, could lead to inaccurate assessment and care planning of the resident. Findings include: Review of the RAI Manual, dated 10/01/19 indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment . 1. Review of R9's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] and a readmitted [DATE], with medical diagnoses that included adult failure to thrive and unspecified dementia. Review of R9's Physician order, dated 12/04/24 and located under the Orders tab in the EMR revealed a hospice wound order Review of R9's annual MDS with an Assessment Reference Date (ARD) of 03/14/25 and located in the resident's EMR under the MDS tab revealed the facility failed to document R9 was receiving hospice services. 2. Review of R18's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE] with medical diagnoses including encounter for attention to gastrostomy (G-Tube) and dysphasia following cerebral infarction. Review of R18's Physician order, dated 04/16/25 revealed orders for enteral feeding through G-Tube and medications were to be administered through the G-Tube. Review of R18's admission MDS with an ARD of 04/30/25 and located in the resident's EMR under the MDS tab revealed during the assessment, the facility failed to document R18 had a G-Tube and was receiving nutrition and medication through the G-Tube. During an interview on 05/20/25 at 2:01 PM, the MDS Coordinator (MDSC) reviewed R9's and R18's MDS and confirmed the MDS did not indicate R9 was receiving hospice services; and that R18's MDS was not accurate as it did indicate the resident had a G-Tube. During an interview on 05/22/25 at 5:04 PM, the Regional Director of Clinical Operations (RDCO) confirmed the facility using the RAI manual for accuracy of MDS assessments.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure care plans were comprehensively developed for two of 46 sampled residents (Resident (R) 18 and R52) reviewed for care plans. This deficient practice placed the residents at risk for unmet care needs. Findings include: Review of the facility policy titled Care Plan-Comprehensive, dated 01/23, revealed A Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. An Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a Comprehensive Care Plan for each resident. The Comprehensive Care Plan has been designed to: . identify the professional services that are responsible for each element of care; . Incorporate risk factors associated with identified problems. 1. Review of R18's Admission Record located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnoses including encounter for attention to gastrostomy (G-Tube) and dysphasia following cerebral infarction. Review of R18's admission Minimum Data Set (MDS) with an ARD of 04/30/25 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R18 was cognitively intact. During an observation on 05/20/25 at 4:38 PM, R18 was lying in bed. Licensed Practical Nurse (LPN) 9 was in the resident's room administering medication via the resident's G-tube. During an interview on 05/21/25 at 7:45AM, R18 expressed a preference to have medications administered through the G-Tube and not by mouth because the medications tasted bitter. Review of R18's Care Plan under the Care Plan tab initiated 04/17/25 in the EMR lacked documentation of a focus for G-tube care. During an interview on 05/20/25 at 2:01 PM, the MDS Coordinator (MDSC) stated that there should have been a care plan developed related to R18's G-tube care, administration of medications, and nutrition. During an interview on 05/21/25 at 10:41 PM, the Director of Nursing (DON) confirmed residents with a g-tube should have a care plan for resident's plan of care. 2. Review of R52's Admission Record located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnoses including unspecified dementia with psychotic disturbance, and delusional disorders. Review of R52's Physician Orders located in the resident's EMR under the Orders tab revealed physician orders dated 01/22/25 for Seroquel [an antipsychotic] Oral Tablet 25 MG (quetiapine fumarate) Give 1 tablet by mouth two times a day for Psychotic disorder due to known physiological condition and sertraline [an antidepressant] HCl Oral Tablet 50 MG (sertraline HCl) Give 1 tablet by mouth one time a day related to unspecified dementia with psychotic disturbance and delusional disorders. Review of R52's Care Plan under the Care Plan tab in the EMR lacked documentation of a plan of care for the resident's psychotropic medications to include antipsychotic and antidepressant medications. During an interview on 05/22/25 at 12:41 PM, the MDSC confirmed R52 did not have a care plan related to psychotropic medication and antipsychotic medications, including monitoring of behaviors and care needed. During an interview on 05/22/25 at 12:44 PM, the Director of Nursing (DON) confirmed residents on psychotropic medications should have a care plan focus when on the medications.

Based on record review, resident and staff interviews, and facility policy review, the facility failed to ensure timely medication administration for one of seven residents (Resident (R) 286) reviewed for medication administration of 46 sample residents. The facility further failed to ensure physician orders were followed for the administration of medications using the gastrostomy (G-Tube) for one of six residents (Resident (R) 18). This had the potential for creating anxiety to the resident and possible medication administration errors or choking. Findings include: Review of the facility's policy titled, Administering Medications, dated 04/19, revealed Medications are administered within one (1) hour of their prescribed time, unless otherwise specified. 1.Review of R286's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] and had a discharge date of [DATE] with diagnoses which included chronic obstructive pulmonary disease, asthma, hemiplegia (one sided paralysis) and hemiparesis (one-sided muscle weakness), and unspecified combined systolic (congestive) and diastolic (congestive) heart failure. Review of R286's five-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/25, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R286 was cognitively intact. Review of the Medication Admin Audit Report, provided by the facility and dated 01/01/25- 01/18/25, revealed the following: -01/08/25 for methocarbamol oral tablet 500 MG [milligram]: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/08/25 at 17:00 (5:00 PM) with the Administration Time: 01/08/25 at 19:58 (7:58 PM). -01/10/25 for Spiriva HandiHaler Inhalation Capsule 18 MCG [microgram]: 1-capsule inhale orally one time a day related to other asthma. Schedule date: 01/10/25 at 7:00 (7:00 AM) with the Administration Time: 01/10/25 at 10:38 AM. -01/11/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/11/25 at 9:00 AM with the Administration Time: 01/11/25 at 11:03 AM. -01/12/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/12/25 at 9:00 AM with the Administration Time: 01/12/25 at 13:09 (1:09 PM). -01/14/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/14/25 at 17:00 (5:00 PM) with the Administration Time: 01/14/25 at 19:04 (7:04 PM). -01/16/25 for ipratropium-albuterol inhalation solution 0.5-2.5 MG/3ML [milligram/milliliter]: 1-vial inhale orally every 6-hours related to chronic obstructive pulmonary disease with (acute) exacerbation. Schedule date: 01/16/25 at 00:00 with the Administration Time: 01/16/25 at 5:54 AM. -01/17/25 for ipratropium-albuterol inhalation solution 0.5-2.5 MG/3ML: 1-vial inhale orally every 6-hours related to chronic obstructive pulmonary disease with (acute) exacerbation. Schedule date: 01/17/25 at 00:00 with the Administration Time: 01/17/25 at 4:56 AM. -01/17/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/17/25 at 9:00 AM with the Administration Time: 01/17/25 at 13:32 (1:32 PM). -01/17/25 for aspirin EC low strength oral tablet delayed release 81 MG: Give 1-tablet by mouth one time a day related to cerebral infarction. Schedule date: 01/17/25 at 9:00 AM with the Administration Time: 01/17/25 at 13:26 (1:26 PM). -01/17/25 for hydrochlorothiazide oral tablet 15 MG: give 1-tablet by mouth one time a day related to unspecified combined systolic congestive and diastolic (congestive) heart failure. Schedule date: 01/17/25 at 9:00 AM with the Administration Time: 01/17/25 at 13:26 (1:26 PM). -01/17/25 for atorvastatin calcium oral tablet 40 MG: Give 1-tablet by mouth one time a day for hemiplegia and hemiparesis. Schedule date: 01/17/25 at 9:00 AM with the Administration Time: 01/17/25 at 13:27 (1:27 PM). -01/18/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/18/25 at 17:00 (5:00 PM) with the Administration Time: 01/18/25 at 19:56 (7:56 PM). Review of the performance improvement plan worksheet (PIP) provided by the facility and dated 03/18/25, revealed medications not being administered on time by nurses/ CMAs [Certified Medication Aide Tech]. Identify root causes: 1. Lack of education .Design and implement changes.1. Inservice all nurses and CMA's regarding proper time management. Reviews of the Education In-service Attendance Record, provided by the facility and dated 03/18/25, revealed three out of the five staff (Activity Director/ Medication Aide Tech), Licensed Practical Nurse (LPN) 5, and LPN8, identified as administering medications late were not on the list as educated. During an interview on 05/21/25 at 1:47 PM, the Director of Nursing (DON) stated the medication administration should be one-hour before to one-hour after the time displayed. She confirmed the late medications were out of policy and unacceptable. 2. Review of R18's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] with medical diagnosis including encounter for attention to gastrostomy (G-Tube). Review of R18's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 04/05/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R18 was cognitively intact. Review of R18's physician Orders dated 04/16/25 located in the EMR under the Orders tab revealed medications were to be crushed and administered through the G-Tube. Review of the Medication Administration Record (MAR) located in the EMR for May 2025 documented medications were administered on 15-day shifts by Certified Medication Aide Tech (CMAT) 1. During an interview on 05/21/25 at 9:19 AM, CMAT confirmed the role of the CMAT was to administer oral medications and not to administer by G-Tube. The CMAT confirmed all the medications she had administered to R18 were by mouth and was not according to physician's orders. During an interview on 05/21/25 at 9:09 AM, the Licensed Practical Nurse (LPN)2/Charge Nurse confirmed the role of the CMAT was for oral medications only and not to administer by G-Tube. LPN2 confirmed CMAT1 had not requested LPN2 to administer medications for R18 by G-Tube as CMAT1 was administering the medications by mouth for R18. LPN2 confirmed the physician's order for medication administration for R18 was by G-Tube and not by mouth and CMAT1 was not following the physician's orders. During an interview on 05/21/25 at 7:45 AM, R18 expressed the desire to have all the medications delivered by the G-Tube and not by mouth due to the medication taste. During an interview on 05/22/25 at 4:50 PM, the Director of Nursing (DON) confirmed the physician's orders were to be followed, including medication orders, for the residents. Review of the facility policy titled Administering Medications, revised 04/19, revealed Medications were administered in accordance with prescriber orders .Medication administration times are determined by resident need and benefit, not staff convenience. Factors that were considered include: . honoring resident choices and preferences, consistent with his or her care plan.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents were treated with respect and dignity for four of 10 residents (Resident (R) 59, R287, R10, and R86) and failed to ensure a resident (R36) needing assistance with meals was assisted by staff sitting down, and failed to ensure a resident (R18) had their choice honored to receive medications by gastrostomy tube (G-Tube) out of 32 residents reviewed in the sample. As a result of this deficient practice the residents may negatively respond emotionally or may be triggered by past experiences to staff yelling/swearing. Residents may not feel respected or honored by staff hovering over residents while assisting with eating and not feeling valued when medication administration choices were not honored. Findings include: Review of the facility policy titled Administering Medications, revised 04/18, revealed Medication administration times are determined by resident need and benefit, not staff convenience. Factors that were considered include: . honoring resident choices and preferences, consistent with his or her care plan. Review of the facility policy titled Resident Rights, revised 02/01, revealed the Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include resident's right to: a dignified existence; be treated with respect, kindness, and dignity; be free from [verbal] abuse and neglect . 1. Review of R86's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/21/25 located in the EMR under the MDS tab revealed a brief interview for mental status (BIMS) score of 13 out of 15, indicating R56 was cognitively intact. 2. Review of R10's quarterly MDS with an ARD of 01/17/25 located in the EMR under the MDS tab revealed no BIMS score due to the resident being rarely/never understood or severely cognitively impaired. During a phone interview on 05/20/25 at 9:50 AM, Registered Nurse (RN) 4 explained Licensed Practical Nurse (LPN) 1 had entered an isolation room for COVID with a treatment cart on 03/18/25. RN4 told LPN1 that it was a break in protocol to take the cart into a resident room and LPN1 began yelling and swearing at RN4 being belligerent in front of two residents, R86 and R10. During an interview on 05/20/25 at 11:01 AM, LPN 1 confirmed the argument on 03/18/25 with RN4 in front of R10 and R86 explaining there was an issue between LPN1and RN4 that included being disrespectful to each other. LPN1 admitted her behavior was unacceptable and was regretful. LPN1 allowed RN4 to push her buttons resulting in a screaming match and LPN1 admitted was unprofessional and disrespectful to the residents in the room. During an interview on 05/21/25 at 5:33 PM, the Director of Nursing (DON) verbalized the expectation for any type of care, not to take the treatment cart into any room, and proper customer service, was being respectful to staff and residents. The DON revealed counseling sessions with the staff about the incident and RN4 no longer works at the facility. 3. Review of R287's admission MDS located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/21/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R287 was cognitively intact. 4. Review of R59's quarterly MDS with an ARD of 02/17/25 revealed a BIMS score of 15/15 indicating R59 was cognitively intact. During an interview on 05/21/25 at 8:26 AM, R59 reported about two months ago there was an argument in the hallway in the middle of the day between two staff members. They were yelling and swearing at each other and R59 was upset because R59 does not like hearing swearing in R59's presence and since this was R59's home, swearing was unacceptable and disrespectful. The resident said once in the middle of the night while sleeping and a loud argument woke R59 up with swearing, screaming about knowing how to do my job. R59 was very concerned if the staff were fighting. They got very loud and R59 did not like it at all and for the next several nights, had difficulty falling asleep. During an interview on 05/21/25 at 7:30 AM, RN2 recounted an encounter on 11/11/24 with LPN6 at change of shift at 11:30 PM when there was a disagreement between RN2 and LPN6. RN2 was feeling threatened by LPN6 when LPN6 moved in very close to RN2, violating RN2's personal space, pointing fingers in RN2's face, yelling and being very rude. Feeling threatened RN2 with raised voice, called for support from the CNA staff on the floor, the argument went on for several minutes and then LPN6 backed down and left the unit. During an interview on 05/21/25 at 10:26 AM the Director of Nursing (DON) was aware of the explosive incident on 11/11/24 between RN2 and LPN6 and both nurses were suspended during the investigation of the incident. Written warnings were issued and LPN6 no longer worked at the facility. The DON confirmed the behaviors of both nurses was unacceptable and the expectation was the staff acted respectfully towards each other, especially on the nursing unit. The DON confirmed because of the incident, the investigation showed the residents were affected by the explosive incident between the staff and as a result the residents were not respected or treated with the dignity they deserve from the staff. 5. Review of R36's annual MDS with and ARD of 04/11/25 revealed R36 had a BIMS score of five out of 15 indicating severe cognitive impairment and needs substantial maximal assistance with eating, helper does more than half the effort. Review of R36's Care Plan under the Care Plan tab in the EMR revealed a focus for activities of daily living (ADL) with intervention set up assist with eating. monitor for adequate intake, assist as needed Date Initiated: 05/25/21. During an observation on 05/19/25 at 12:30 PM, during the lunch meal R36 was in a wheelchair at table with lunch set up in front them. R36 was attempting to feed himself. At 12:31 PM, Certified Medication Aide Tech (CMAT)1 stopped by the table, while standing, placed a bite of food into R36's mouth and walked away. At 12:37 PM, CMAT1 stopped by and placed a bite in R36's mouth while standing and walked away. This same action of walking by R36 and placing a bite of food in the resident's mouth and walking away occurred a total of seven times. During an interview on 05/19/25 at 12:52 PM, LPN2/Charge Nurse observed CMAT1 walking by and feeding R36 from a standing position and confirmed the staff were not to stand to assist residents when feeding, the staff were to sit at the same level as the resident, to respectfully assist in feeding. During an interview on 05/21/25 at 10:44 AM, the DON confirmed when residents were assisted with eating their meals, support staff who were feeding residents were to sit at the same level as the residents. 6. Review of R18's Admission Record located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnosis including encounter for attention to gastrostomy (G-Tube). Review of R18's admission MDS with an ARD of 04/30/25 revealed a BIMS score of 13 out of 15, indicating R18 was cognitively intact. Review of R18's physician Orders dated 04/16/25 located in the EMR under the Orders tab revealed orders for enteral feeding through G-Tube and medications were to be administered through the G-Tube. During an interview on 05/21/25 at 9:19 AM, CMAT1 confirmed the role of the CMAT was to administer oral medications and not to administer by G-Tube. CMAT1 confirmed all the medications they administered to R18 were crushed and placed in pudding or applesauce and administered by mouth. The CMAT confirmed the resident had an order for the medications to be administered via the G-tube. During an interview on 05/21/25 at 7:45AM, R18 expressed a preference to have medications administered through the G-Tube and not by mouth, the medications tasted bitter.

Based on record review and staff interviews, the facility failed to ensure risk versus benefits were provided to the resident and/or the resident representative for one of six residents (Resident (R) 336) reviewed for unnecessary medications of 32 sample residents. This failure had the potential to affect the residents and/or representative medication knowledge. Findings include: Review of R336's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] and readmitted on [DATE]. R336 had diagnoses which included dementia. The resident was documented as passing away 01/18/25. Review of R336's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/24 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) was not assessed and the resident was documented as having severely impaired cognition. Review of R336's Order Summary Report located under the Orders tab of the EMR revealed an order dated 01/31/23 of Trazodone [an antidepressant with an off label use for insomnia] HCL [hydrochloride] oral tablet 50 MG (milligrams). Give one tablet by mouth at bedtime for insomnia. The Trazodone was discontinued on 10/20/24. Review of R336's EMR revealed there was no documented evidence the risks and benefits were completed for the Trazodone medication ordered by the resident's physician. During an interview on 05/21/25 at 8:21 AM, the Director of Nursing (DON) and the Regional Director of Clinical Operations (RDCO) both confirmed they did not have documented evidence that the risks and benefits were explained to R136 and/or the resident's representative prior to the use of Trazadone. During an interview on 05/21/25 at 3:57 PM, the DON stated the facility did not have a policy related to risk versus benefit for medications. Cross Reference F605

Based on observations, record review, facility policy review, and resident and staff interviews, the facility failed to ensure residents' call light was within reach for one of one resident (Resident (R)136) reviewed for accommodation of needs. This failure placed the resident at risk of functionality not being maintained due to severe physical limitations, dignity, and well-being in accordance with his own needs and preferences, the resident could potentially not be able to call for assistance when needed. Findings include: Review of the facility's policy titled, Accommodation of Needs, revised March 2021, indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The policy further indicated, The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. Review of the facility's policy titled, Call Light, Answering, dated April 2022 indicated, The purpose of this procedure is to respond to the resident's requests and needs. Key Procedural Points .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Review of R136's undated Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed R136 was admitted to the facility on [DATE] with diagnoses that included functional quadriplegia, displaced spiral fracture of shaft of humerus, right arm, posterior subluxation [incomplete or partial dislocation of a joint or organ] of right hip, contracture of muscle unspecified upper arm, contracture of muscle left upper arm, contracture of muscle right lower leg, contracture of muscle left lower leg, and complete lesion at C5 [cervical spinal vertebrae] level of cervical spinal cord. Review of R136's Nursing Initial 48-hour Care Plan, dated 10/31/24 and located under the Assessment tab of the EMR, indicated, Specialty Interventions Related to Resident's Health Condition. Intervention: Resident call light and bedside table on dominant side. Review of R136's Care Plan, dated 11/01/24 and located under the Care Plan tab of the EMR, indicated [name of R136] is (high) risk for falls r/t [related to] Paralysis, bilateral [affecting both sides] lower/upper extremity contractures. Interventions were Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of the R136's Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/07/24 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also indicated R136 had impairments on both sides of the upper and lower extremities, and the resident was completely dependent on staff for Activities of Daily Living (ADLs). Review of R136's quarterly MDS with an ARD date of 05/02/25 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have BIMS score of 15 out of 15 which indicated the resident was cognitively intact. The MDS further indicated that R136 had impairments on both sides of the upper and lower extremities and was completely dependent on staff for ADLs. During an observation and interview on 05/19/25 at 10:30 AM, R136 was observed lying in bed on his right side. At this time, the flat round touch pad call light and cord was observed to be hanging over the mobility bar located behind the resident on the left side of the head of the bed and almost touching the floor. R136's call light touch pad device was completely behind R136 where he could not reach it. R136 was observed to have a red stylus pen in his mouth and only able to use his stylus to touch his cell phone and move his head up and down. R136 stated, I need help with everything. I cannot move my body. My legs and hands are contracted. I can only move my head a little. R136 then stated, When I need help, I have to get on my phone and call the nurses station by dialing the number with my pen that I hold in my mouth. When R136 was asked if he could use his touch pad call light to call for assistance, he stated, Yes, but only if they put the call light close to me where I can hit it with my chin. Yes, I would be able to use it, but half the time it's out of my reach. During an observation on 05/19/25 at 12:30 PM, R136 was lying in bed on his right side. The flat round touch pad call light and cord was again to be observed to be hanging over the mobility bar located behind the resident on the left side of the head of the bed and out of reach. During an observation on 05/19/25 at 3:00 PM, R136 was lying in bed on his left side. The flat round touch pad call light and cord was still observed to be located hanging over the mobility bar located on the left side of the head of the bed and almost touching the floor. At this time, it was not positioned where the resident could use it. During an observation on 05/20/25 at 12:11 PM, R136 was lying in bed on the right side. At this time, he was talking on the cell phone that was observed to be mounted to the mobility bar on the right side of the head of the bed. At this time, the flat round touch pad call light and cord were observed to not be within reach and hanging over the mobility bar located behind the resident on the left side of the bed and almost touching the floor. During an observation on 05/20/25 at 1:41 PM, R136 was lying in bed on the right side with his eyes closed. At this time, the flat round touch pad call light and cord were observed to not be within reach and hanging over the mobility bar and almost touching the floor as was before. During an interview on 05/20/25 at 1:45 PM, Licensed Practical Nurse (LPN) 4 was asked if R136 would be able to use the touch pad call light to call for assistance. LPN4 stated, Yes, he would be able to use it. He can move his head and chin to push it if he needed to. He is alert and oriented x4. During an interview on 05/20/25 at 1:47 PM, Registered Nurse (RN) 3 was asked if R136 would be able to use the touch pad call light to call for assistance. RN3 stated, Yes, he has a 'Pancake' touch pad 'that's what we call it,' that he can use. He can also use his stylus and push the call light. Yes, he can definitely use it. During an interview on 05/20/25 at 1:50 PM, LPN1 was asked if R136 would be able to use the touch pad call light to call for assistance. LPN1 stated, Yes, he is total care [completely dependent on staff]. He must have everything done for him. He can use the touch pad call light if it is close to him. He is able to move his head to touch it. During an observation on 05/20/25 at 2:55 PM, R136 was lying in bed on his back. At this time, the flat touch pad call light and cord was observed to not be within reach of the resident and was observed to be hanging over the mobility bar on the left side and almost touching the floor. During an observation on 05/20/25 at 3:05 PM, R136 was observed lying in bed on his back. At this time, the flat touch pad call light was now observed to be next to the resident's chin to where he could push it if needed. During an interview and observation on 05/21/25 at 10:12 AM, Certified Medication Aide Tech (CMAT) 2 was asked if R136 could use the flat touch pad call light to call for assistance if needed. CMAT2 stated, Yes [name of R136] can use his call light but only if you put it by his head or shoulder and position it to where he can use it. He can use his head to push it, but it needs to be positioned close by. At this time during an observation with CMAT2, R136 was lying on the left side of the bed. The call light was observed to be hanging over the mobility bar behind the resident and almost touching the floor. It was observed to be out of reach. At this time, CMAT2 stated, It shouldn't be like this and confirmed it was not within reach of R136. CMAT2 proceeded to pick it up from the mobility bar and place it near the resident's head to where he could reach it. During an observation and interview on 05/22/25 at 5:30 AM with LPN7, R136 was lying on his back in bed with his eyes closed. The flat touch pad call light was observed to be located near R136's chin to where he could tap it if needed. LPN7 was asked if R136 could use the flat touch pad call light to call for assistance, the LPN stated, Yes, he can use it. There have been times when I've come in and the call light is on the floor. He can also use his stylus to use his cell phone to call us if he needs anything. As his nurse, I would expect the call light [to] be within his reach. During an interview on 05/22/25 at 10:30 AM, regarding the use of call light being accessible for R136, and what the expectation would be, the Director of Nursing (DON) stated, The call light should be within reach at all times.

Based on record review, staff interviews, and review of the facility's policy, the facility failed to ensure their primary system for identifying a resident's code status accurately reflected the resident's end of life wishes for two of 46 sampled residents (Resident (R) 9 and R43) reviewed for code status. This failure placed the residents at risk for their wishes not to be honored, risk of there being a delay in treatment, and death. Findings include: 1. Review of R9's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] and a readmitted [DATE]. Review of R9's EMR header information revealed the resident's code status was identified as Full Code and Do Not Resuscitate (DNR). Review of R9's Physician's Orders for Life Sustaining Treatment (POLST) form dated [DATE] and located in the resident's EMR under the Misc tab revealed Do Not Resuscitate [DNR] was selected. The POLST form was signed by the resident's representative and the resident's physician. Review of R9's Progress Note, dated [DATE] and located in the resident's EMR under the Progress Notes tab revealed the Social Services Director (SSD) documented, A care plan meeting was held with the resident and his daughter today. Resident/family desire a full code status and wishes will be honored at this time. The resident will remain in this facility for LTC [long term care]. No questions or concerns. Review of R9's POLST form dated [DATE] and located in the resident's EMR under the Misc tab revealed Attempt Resuscitation (CPR [Cardiopulmonary Resuscitation]) was selected which indicated the resident's code status was Full Code. The POLST form was signed by the resident's representative and the resident's physician. Review of R9's Physician Order located in the resident's EMR under the Orders tab revealed an order dated [DATE] of Code Status: Do Not Resuscitate and an order dated [DATE] of Code Status: Full Code. During a record review and interview on [DATE] at 11:33 AM, Licensed Practical Nurse (LPN) 2 reviewed the header in R9's EMR for code status. LPN2 stated she was confused by the code status information that was displayed as the EMR header indicated the resident was both a Full Code and a DNR and it was not clear what action to take. During an interview on [DATE] at 3:51 PM, the SSD stated the process for when a resident and/or representative requested a code status change, an updated POLST form was completed (signed by resident/representative and a physician), then uploaded to the resident's EMR under the Misc tab, and then an email was sent to nursing to update the resident's physician's order and the resident's care plan in the EMR. The SSD also stated the change in code status was also communicated in the daily morning meeting for the facility staff. During an interview on [DATE] at 9:21 AM, the LPN3 confirmed the process for updating a resident's code status was once the SSD informed nursing of the need to update the code status in the EMR, an order would be added to the physician's orders, and if there was a previous order, that order would be discontinued. LPN3 also stated during the process of updating the code status for R9, she was interrupted and failed to delete the old code status order resulting in the resident's EMR indicating two different code status options. LPN3 further stated this was where the nurses referred to when they needed to know what a resident's code status was. LPN3 stated R9's EMR which reflected two different code statuses and two different physician orders would create confusion about what to do for the code status of R9. During an interview on [DATE] at 12:46 PM, the Director of Nursing (DON) confirmed there was usually an audit done for orders updated in the daily morning meeting to ensure two people were reviewing the orders. This was not done for R9 when the new POLST order was updated, and it should have been confirmed by a second nurse. 2. 2. Review of R43's Admission Record located under the Profile tab of the EMR revealed the resident was admitted on [DATE]. Review of R43's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score was not assessed and the staff documented R43 as having severely impaired cognition. Review ofR43's Care Plan, located under the Care Plan tab of the EMR and initiated on [DATE], revealed the Resident/ family desires a DNR [Do Not Resuscitate] status. Review of R43's physician Order Summary Report located under the Orders tab of the EMR revealed an active order for code status: Full Code, order date [DATE]. Review of R43's Physician Orders for Life-Sustaining Treatment (POLST) located under the Misc tab of the EMR, dated [DATE] and signed by the physician on [DATE], revealed Allow Natural Death (AND)- Do Not Attempt Resuscitation. During an interview on [DATE] at 7:43 AM, the Licensed Practical Nurse (LPN) 1 stated they would look in the EMR for the correct code status. She stated it would have been a discrepancy in the medical record as described above, and the EMR physician order would trump it. During an interview on [DATE] at 8:04 AM, the Social Services Director (SSD) stated when a resident was admitted , she gave them the POLST to sign and asked if they had a Power of Attornaey (POA). She stated that the form then got sent to the business office and uploaded. She stated she audited for changes and would send an email to the Unit Manager and Director of Nursing (DON); along with mentioning it in the morning clinical meeting. The SSD confirmed R43's code status was a DNR after looking at the EMR. She verified the orders had not been changed to reflect it. She stated it should have been changed in the system on [DATE]. She stated she had sent an email on [DATE] to the Unit Manager and the DON, along with talking about it in the morning meeting. During an interview on [DATE] at 11:30 AM, the DON stated there was a miscommunication with the SSD and it should have been changed immediately. During an interview on [DATE] at 12:15 PM, the DON stated she had a lot going on that day and missed it. Review of the facility's policy titled Advanced Directives, revised ,d+[DATE], revealed Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff.a

Based on record review, staff interviews, and facility policy review, the facility failed to ensure monitoring of psychotropic medication side effects was conducted for one of six residents (Resident (R) 336) reviewed for unnecessary medications of 46 sample residents. This failure had the potential to result in an excess of medication provided to the residents resulting in oversedation. Findings include: Review of the facility's undated policy titled, Alternatives to Antipsychotics for Mood Disorders and Behaviors in LTC [Long Term Care], revealed Trazodone was indicated for depression. Trazodone has been used in mood disorders associated with poor/diminished sleep .Monitor for efficacy .Monitor for increased falls risk and cumulative anticholinergic side effects. Review of R336's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] and readmitted on [DATE]. R336 had diagnoses which included dementia. The resident expired on [DATE]. Review of R336's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) was not assessed and the resident was documented as having severely impaired cognition. Review of R336's Care Plan located under the Care Plan tab of the EMR revealed the resident used antidepressant medication, resolved [DATE]. Interventions included reporting to nurses, signs and symptoms which included fatigue, change in normal behavior, and insomnia. Review of R336's Care Plan, located under the Care Plan tab of the EMR revealed the resident used psychotropic medications, resolved [DATE]. Interventions included monitoring, recording, and report to MD [Medical Doctor] prn [as needed] side effects and adverse reactions which included fatigue and insomnia. Review of R336's physician Order Summary Report located under the Orders tab of the EMR revealed an order, dated [DATE], of Trazodone HCL [hydrochloride] oral tablet 50 MG (milligrams). Give one tablet by mouth at bedtime for insomnia. The Trazodone was discontinued on [DATE]. There were no orders related to the monitoring of side effects for Trazodone use. Review of the facility's investigation dated [DATE]and provided by the facility revealed the resident was observed drowsy at the dining table. Head dropped to the plate. Staff quickly raised R336's head from the plate. Review of R336's Progress Note dated [DATE] and located under the Progress Notes tab of the EMR revealed Observed drowsy but able to awaken without difficulty. NP [Nurse Practitioner] made aware with orders for UA C&S [urinary analysis culture and sensitivity] and CMP [comprehensive metabolic panel] on Monday. Daughter made aware but preferred for resident to be sent to the emergency room for evaluation. During an interview on [DATE] at 8:21 AM, the Director of Nursing (DON) and the Regional Director of Clinical Operations (RDCO) both confirmed there should have been monitoring for the Trazodone. The DON stated R336 had been more drowsy than normal. She also stated he had been drowsy on and off. They stated this medication should have been monitored for side effects.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure all allegations of abuse and neglect were reported immediately but not later than two hours after the allegation for two of eight residents reviewed for abuse and/or neglect (Resident (R) 136 and R188) out of 46 sampled residents. This failure placed all residents of the facility at risk for further abuse and/or neglect. Findings include: Review of the facility's policy titled, Abuse Prevention Policy, last revised 03/01/18, revealed The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion .The resident has the right to be free from mistreatment, neglect .Reports of allegations or suspected abuse, neglect or exploitation .will be reported immediately .When abuse, neglect or exploitation is suspected the Licensed Nurse should: .Notify the Director of Nursing and Administrator .When suspicion or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted .Ensure that all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made . 1.Review of a Facility Incident Report, dated 03/06/25 revealed Type of Incident-Neglect .Details of Incident- [name of R136] is alleging that Certified Nursing Assistant (CNA) 48 neglected him by not turning him timely. Review of R136's undated Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab revealed R136 was admitted to the facility on [DATE]. Review of the R136's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/07/24 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R136's quarterly MDS with an ARD date of 05/02/25 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have BIMS score of 15 out of 15, which indicated the resident was cognitively intact. During an observation and interview on 05/19/25 at 10:30 AM, R136 lying in bed. When R136 was asked about the incident regarding CNA48. he stated, This was unacceptable, and I felt like it was neglect. Review of a written statement from RN2 dated 03/10/25 and provided by the facility revealed I had asked the CNA [referring to CNA 48] who was the assigned CNA to be working with [name of R136] to go and turn him at 2:00 AM. She refused. I let the CNA know that refusing to do a patient that is assigned to you on a shift is a problem. She agreed with me but still refused. I told her I was going to report her to the DON [Director of Nursing] . During an interview on 05/21/25 at 7:13 AM, regarding the incident that occurred with R136 and CNA 48 on 03/06/25, RN2 stated that she was the nurse working that nightRN2 stated, He [referring to R136] called and said that he needed to be turned around 2:00 AM or 2:30 AM. I told him I would send someone to his room. I told [name of CNA48] since you have him on your assignments, and since you are his assigned CNA, you need to go and turn him. CNA48 refused to go into R136's room. I told her I was going to let the Director of Nursing [DON] know that you are refusing to turn him. RN2 stated that she waited until morning until the DON came into work to report the incident. During an interview on 05/21/25 at 12:30 PM, regarding the incident that occurred on 03/06/25, the DON stated that she was not notified during the night by any staff which included RN2 about any incident regarding R136. The DON also stated when she came into work around 7:30 AM (over five hours later from when R136 requested assistance) that morning, RN2 reported the incident to her. he DON further stated, . [RN2] should have called me or the Administrator immediately but that didn't happen. The DON then stated, I agree it was also a delay in reporting to me or the Administrator. The nurse [referring to RN2] waited many hours to report the CNA [referring to CNA48] not wanting to turn a resident. She waited to report anything until I came in to work at 7:30 AM. During an interview on 05/21/25 at 1:00 PM, the Administrator stated that he was not immediately notified by RN2 or CNA48 of the neglect incident during night shift. The Administrator also stated, Nobody called me. The Administrator stated, I was notified by the Social Worker that following morning that [name of R136] had a complaint about not being turned the previous night. The Administrator stated it was his expectation he would have been immediately notified of the neglect. 2. Review of R188's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE]. The resident was discharged on [DATE]. Review of the Facility Incident Report form, dated 10/03/24, revealed that the resident representative for R188 reported to the police that Certified Nursing Assistant (CNA)50 allegedly slapped R188 twice to the right side of her face. The CNA was suspended pending the outcome of the allegation. Review of the Police Incident Report revealed that on 10/03/24 at approximately 1:52 AM, there was a reported allegation of staff-to-resident abuse between R188 and CNA50. The family member of R188 (FM) 2 was also documented in the facility at this time. Review of the Administrator email to the State agency revealed the incident was State reported as an allegation of potential abuse on 10/03/24 at 10:40 AM, about 8 hours later, which was a delay in reporting. 3. Review of R189's Admission Record located in the EMR under the Profile tab revealed an admitted [DATE]. The resident discharged on [DATE]. Review of R189's discharge MDS located in the MDS tab in the EMR, with an ARD of 10/13/24, revealed a BIMS assessment with a recorded score of 15 out of 15 which indicated no cognitive impairment. R189 had no delirium, no mood, and no behaviors. On 10/03/24 at approximately 1:52 AM, there was a reported allegation of staff-to-resident abuse between R188 and CNA50. The family member of R188 (FM) 2 was also documented in the facility at this time. Record review revealed a Progress Note in the Progress Note tab for R188, dated 10/03/24 at 7:52 AM, revealed, .(FM2) verbally abused resident roommate (R189), stated angry black woman .used profanity towards resident roommate (R189). Review of the Facility Incident Report form, dated 10/03/24, revealed that on 10/03/24 at approximately 10:32 AM, R188 was documented to have thrown a full bottle of Gatorade at R189 and call her names. The police, physician, responsible, and Ombudsman were notified. Review of the Administrator email to the State agency revealed the incident was State reported as an allegation of potential abuse on 10/03/24 at 8:34 PM, about 10 hours after the facility became aware of the incident. During an interview on 05/22/25 at 6:58 AM, the Administrator stated that he did not have documentation that the incident of potential verbal abuse between R188's family member and R189 had been reported. He confirmed that if FM2 had come in and was verbally abusive to R189 there should have been a reportable incident to the State agency for that, which there was not. He said he did not know why he was not informed of the potential allegation of staff-to-resident abuse between R188 and CNA50 by the staff at the time of the incident which was 1:52 AM. He confirmed he should have been informed timely. The Administrator stated that the nurse on duty also did not inform him timely and was also no longer working at the facility. During an interview on 05/22/25 at 7:10 AM, the Regional Director of Clinical Operations stated that if a police officer came to the facility, even after regular hours, the Administrator should be alerted and notified timely. Upon reviewing the witness statements from the incident between R189 and the resident representative of R188, she confirmed that the potential verbal abuse by FM2 against R189 should have been reported and investigated. During an additional interview on 05/22/25 at 3:14 PM, the Regional Director of Clinical Operations confirmed that the potential allegation of visitor-to-resident verbal abuse between R189 and FM2 was not reported. During an interview on 05/22/25 at 3:22 PM, the Director of Nursing (DON) stated that she wanted to see any allegations of abuse reported right away, any physical abuse, financial exploitation, misappropriation of funds, any abuse, as soon as possible. She confirmed it should be reported within a two-hour window. She stated she would have wanted to see the incident between the family member of R188 verbally yelling at R189 be reported to the State agency for investigation.

Based on staff interviews, record review, and facility policy review, the facility failed to conduct a thorough investigation for incidents of potential abuse for three of nine residents (Resident (R) 136, R188, and R189) reviewed out of 28 sampled residents, for potential staff-to-resident abuse for R136 and R188, and visitor-to-resident abuse for R189. The failure to investigate potential allegations of abuse for facility residents placed all residents at risk of abuse. Findings include: Review of the facility's policy titled, Abuse Prevention Policy, last revised 03/01/18, revealed The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion .When abuse, neglect or exploitation is suspected the Licensed Nurse should: .Notify the Director of Nursing and Administrator .Complete an incident report and initiate an immediate investigation to prevent further potential abuse .Once the resident is cared for and the initial reporting has occurred, an investigation should be conducted. Components of an investigation may include interview with the involved resident, if possible, and document all responses .Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. Obtain witness statements, according to policy. All statements should be signed and dated by the person making the statement. Document the entire investigation chronologically. Ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made . 1. Review of the Facility Incident Report form, dated 10/03/24, revealed that the resident representative for R188 reported to the police that Certified Nursing Assistant (CNA)50 allegedly slapped R188 twice to the right side of her face. Police were present at the facility, the responsible party, and Ombudsman were notified of the allegation. The CNA was suspended pending the outcome of the allegation. Continued review of the investigation revealed a witness statement from the 10/03/24 incident with CNA50, dated 10/02/24 (sic), stated, R188 was receiving care and started to have behaviors in the middle of changing her .She started spitting, hitting, and screaming and disturbing her roommates. There was no evidence that a complete investigation was completed of the incident between R188 and CNA50. Witness statements were completed only for the roommates of R188, and two CNAs at the facility. No additional staff members were interviewed for the investigation to determine if there were any other potential staff-to-resident abuse situations from CNA50. Additional residents from the facility were not interviewed to determine if they felt safe residing on the same unit with R188, or if they had experienced any staff-to-resident abuse from CNA50. The failure to do a complete and thorough investigation of the 10/03/24 staff-to-resident abuse allegation between R188 and CNA50 additionally led to the failure to do a thorough investigation of the visitor-to-resident verbal abuse between R189 and Family Member (FM)2. This was documented in the resident record for R188 as verbal abuse of R189 but was not reported nor investigated. During an interview on 05/22/25 at 6:58 AM, the Administrator stated that he did not have documentation that the incident of potential verbal abuse between FM2 and R189 had been reported. He confirmed that if FM2 had come in and was verbally abusive to R189 there should have been a reportable incident to the State agency for that, which there was not. He stated that he had not been made aware that resident witness statements from R189 and R62 had stated that FM2 had been in the resident room and had been verbally abusive with R189. The Administrator said that he had interviewed other residents after the staff-to-resident abuse allegation between R188 and CNA50 but had not documented any of those additional interviews. He confirmed he was not aware if he should have documented more interviews during the alleged incident of abuse. During an interview on 05/22/25 at 7:10 AM, the Regional Director of Clinical Operations upon reviewing the witness statements from the incident between R189 and FM2, she confirmed that the potential verbal abuse by FM2 against R189 should have been reported and investigated. During an additional interview on 05/22/25 at 3:14 PM, the Regional Director of Clinical Operations confirmed the potential allegation of visitor-to-resident verbal abuse between R189 and FM2 was not thoroughly investigated. She stated that a complete abuse investigation should include speaking with all assigned staff at the time of the incident, and to get written statements. She said even if staff were not working on the same floor, the staff could still be interviewed to see what they were aware of. She said she expected residents to be interviewed from the same room, and in the area to see if they heard anything or saw anything. The Regional Director of Clinical Operations said that she would want all the information she could get from residents and staff. During an interview on 05/22/25 at 3:22 PM, the Director of Nursing (DON) stated that for a thorough abuse investigation it would definitely include to first ensure the patient was safe. She said the person suspected of possible abuse would be off work. She confirmed that the investigation would then be to get statements, follow-ups, and check equipment. She stated that they would do patient interviews, and see what the outcomes were, and to see if any other residents or staff were involved. The DON said she would want to make sure they had not left anything out. She stated she would have wanted to see the incident between FM2 verbally yelling at R189 be reported to the State agency for investigation. 2.Review of a Facility Incident Report, dated 03/06/25 revealed Type of Incident-Neglect .Details of Incident . [name of R136] is alleging that Certified Nursing Assistant (CNA) 48 neglected him by not turning him timely. Review of the facility's Facility Follow Up Investigation, dated 03/13/2025 revealed . [name of R136] alleged that [name of CNA48] neglected him by not turning him timely . [name of R136] said he called and requested assistance at 2:03 AM on March 6, 2025. He said the CNA did not come to his room until 6:30 AM. When [name of CNA 48] was interviewed, she said she did not go in until 6:30 AM as she felt the resident was rude . The facility conclusion revealed It was determined that the accusation of neglect was Substantiated . Further review of the facility's investigation revealed written statements were obtained from Registered Nurse (RN) 2, a phone interview with CNA48, and 11 additional resident interviews were conducted; however, there was no investigation conducted as to why RN2 did not assist R136 with turning at 2:00 AM, or anytime during the night. Review of R136's undated Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab revealed R136 was admitted to the facility on [DATE]. Review of the R136's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/07/24 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R136's quarterly MDS with an ARD date of 05/02/25 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have BIMS score of 15 out of 15 which indicated the resident was cognitively intact. During an interview on 05/21/25 at 12:30 PM, regarding the incident that occurred on 03/06/25, when asked why the facility did not consider neglect on part of RN2 or consider this as part of the facility investigation, the DON stated, I agree it would be neglect on part of the nurse [RN2] too. We did not focus on why the nurse did not go into the resident's room to turn him. We were more focused on why the CNA didn't go in. She as the nurse could have gone in his room to turn him. During an interview on 05/21/25 at 1:00 PM the Administrator stated I see where it was neglect on part of the nurse as well when this happened. She could have gone into his [referring to R136] room and turned him. When the Administrator was asked why the facility did not conduct a thorough investigation and investigate why RN2 did not go in R136's room to turn him during the night, he stated, We did not look into why the nurse did not go in and turn him. That was not part of our investigation. It should have been investigated, and it was not.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure a complete discharge summary was provided to the resident and/ or resident representative (RP) for one of three residents (Resident (R) 338) reviewed for discharges of 46 sample residents. This failure had the potential to affect the residents and/or representatives' knowledge of the residents' discharge plan. Findings include: Review of the facility's policy titled, Transfer or Discharge, Facility-Initiated, dated 10/2022, revealed Orientation for Transfer or Discharge (Planned) 1. A post-discharge plan is developed for each resident prior to his or her discharge. This plan will be reviewed with the resident, and/or his or her family, at least 24 (24) hours before the resident's discharge or transfer from the facility. Review of R338's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted [DATE] and the date of discharge was 12/19/24. Review of R338's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/24 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R338 was cognitively intact. Review of R338's Discharge Summary and Instructions located under the Assessment tab of the EMR, dated 12/19/24, revealed the following missing components: -2A. Psychosocial Status of the Resident (Social Services) - Blank and unsigned. -2B. Preparation for Discharge and Post Discharge Care (Social Services) - Blank and unsigned. During an interview on 05/20/25 at 1:17 PM, Licensed Practical Nurse (LPN) 3 stated she did not know the resident, but she filled out her section of the discharge summary. LPN3 also stated the Social Service Director's (SSD) portion of the discharge summary was not completed. She stated she faxed it to the resident's daughter. She confirmed the summary was not complete. During an interview on 05/20/25 at 1:39 PM, the Social Services Director (SSD) stated the discharge summary needed to be completed and then provided to the resident and family. She stated she did not see that the resident received any home health services and did not see where a discharge date was picked. She stated she started in this position in early January 2025 and was not here during this time. She confirmed the discharge summary was not fully complete and she stated she was not able to find the recapitulation summary of the resident's stay.

Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure residents with a urinary catheter bag were properly positioned in a manner to prevent potential urinary tract infections due to contamination for one of three residents (Resident (R)10) reviewed for urinary catheters out of a total sample of 46 residents. The failure to ensure catheter bags were properly positioned placed the resident at risk of infection. Findings include: Review of the facility's undated policy titled, Indwelling Urinary Catheter Use, revealed It is the policy of the facility to ensure the appropriate use of indwelling urinary catheters in accordance with State and Federal Regulations, and national guidelines .Indwelling urinary catheters and drainage bags should not be changed at routine or fixed intervals. Indwelling urinary catheters and drainage bags are changed when there is indication of infection, obstruction, or as clinically indicated. Review of R10's Admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was originally admitted on [DATE] with diagnoses including multiple sclerosis, other sequelae of cerebral infarction, and pressure ulcer of sacral region. Review of R10's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/25and located in the MDS tab in the EMR revealed a Brief Interview for Mental Status (BIMS) assessment with no recorded score out of 15, which indicated severe cognitive impairment. R10 was documented to require a catheter. Review of R10's Physician Orders located in the EMR under the Orders tab revealed a order dated 04/16/25 for Change indwelling Foley Cath [Catheter] 16 F [French]/10 ml [milliliters] every month and PRN [as needed] every day shift every 28 day(s) . Review of R10's Care Plan, initiated 04/16/25 and located in the resident's EMR under the Care Plan tab revealed the resident had an indwelling foley catheter related to sacrum end stage skin failure. Interventions dated 04/16/25 revealed .position catheter bag and tubing below the level of the bladder and away from the entrance room door, and to monitor and document the intake and output as per facility policy. During an observation on 05/19/25 at 10:25 AM, R10 was lying in bed with her eyes closed. R10's uncovered indwelling catheter collection bag was hanging from the right side of the resident's bed, resting on the floor. During an observation on 05/19/25 at 12:12 PM, R10 was lying in bed with her eyes closed. The catheter bag was still in the same position, resting uncovered on the floor. During an observation on 05/20/25 at 8:12 AM, R10 was observed resting in bed. The catheter bag was again observed uncovered and resting on the floor. During an observation on 05/20/25 at 9:50 AM, R10 was lying in her bed resting. The catheter bag was observed uncovered and resting on the floor. During an observation and interview on 05/20/25 at 9:51 AM, Licensed Practical Nurse (LPN) 2 and LPN3 stated that catheter bags should be kept off the floor. LPN2 observed R10 in bed, and confirmed the catheter bag was resting on the floor. LPN3 stated that a staff member must have lowered the resident's bed and proceeded to raise the resident's bed. The urinary catheter tubing stretched, but the catheter bag did not rise off the floor because the bag was not hooked to the bed. During an interview on 05/20/25 at 10:18 AM, the Regional Director of Clinical Operations (RDCO) stated that she expected urinary catheter bags to be hung off the floor.

Based on interviews and record review, the facility failed to verify the Advance Directive and initiated Cardiopulmonary Resuscitation (CPR) for one resident (R) (R#77) who was a Do Not Resuscitate (DNR). The census on [DATE] was 78 residents, of which 8 residents were identified as DNR. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 7:50 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. At the time of exit on [DATE] an acceptable Allegation of Compliance (A[NAME]) had not been received, therefore the IJ remains ongoing. The Immediate Jeopardy is outline as follows: An Advance Directive order was signed by R#77's daughter on [DATE] and signed by 2 Physicians, the primary Physician and the concurring Physician, on [DATE]. R#77 experienced a change in condition on [DATE] when the Certified Nursing Assistant (CNA), who was responsible for getting R#77 up and ready for the day, found her in bed, around 4:30 a.m., sweaty and not speaking. The CNA took R#77 to the bathroom, then returned her to her room. Around 5:00 a.m., R#77 became unresponsive and members of the licensed staff-initiated CPR while one staff member went to the nurses' station to verify R#77's code status in the clinical records. When that staff member returned to R#77's room with the information that R#77 was a DNR, CPR was terminated. R#77 expired in the facility. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of; 42 CFR 483.10(g)(14)(i)-(iv) Notify of Changes Injury/Decline/Room, etc. Residents Rights: F580-S/S: J 42CFR 483.21(b)(1) Comprehensive Resident Centered Care Plans: F656-S/S: J 42CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards: F658-S/S: J 42CFR 483.24(a)(3) Cardio-Pulmonary Resuscitation (CPR):F678-S/S: J 42 CFR 483.70 Administration: F835-S/S: J 42 CFR 483.75(g)(1)(i)-(iv)(2)(i) QAA Committee: F868-S/S: J Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. Findings Include: The facility had a CPR, Self-Determination, And No Cardiopulmonary Resuscitation (CPR) Request policy. The Policy Statement read: To comply with the resident's desires for self-determination. Policy Standard of Practice include: 1. CPR - The resident must be informed that he or she my initiate an advanced directive upon admission. An advanced directive may be a living will, a durable power of attorney for healthcare, or both. Some states have additional, state-specific, directives. 2. CPR will be attempted for all residents unless there is a NO DNR order written by the physician on the physician's orders [REDACTED]. 3. A NO DNR request may be reversed at any time when the request is given in writing by the resident, family, or responsible party. 4. If CPR is initiated, 911 will be dialed to summon emergency medical aid. Personnel will continue CPR until care is transferred to ambulance personnel. 5. Once CPR is initiated, it will not be stopped unless a physician presents orders for it to be stopped. R#77 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of R#77's care plan revealed on [DATE] in the event of a [MEDICAL CONDITION] no CPR will be initiated, with an outcome of DNR order signed [DATE], and with interventions that include, honor resident's request for no CPR. Review of nurse notes on [DATE] at 8:55 a.m. reads: At 4:30 a.m. CNA making rounds and noticed resident vomiting and wheezing. Writer did assessment. Resident had thick, mucous around mouth and was clammy. CNA assist resident to restroom and dressed resident and laid her down to bed. Resident made shallow breaths and became unresponsive. No vitals at 5:00 a.m. Nurse note on [DATE] at 9:16 a.m. reads: At 4:30 a.m. vital signs: BP=,[DATE], R=26, P=54, T=97.2. Nurse note on [DATE] at 9:21 a.m. reads: 911 placed and EMS came, and resident expired. Responsible Party (RP) notified, and MD notified. An interview was conducted with Licensed Practical Nurse (LPN) GG on [DATE] at 2:41 p.m. regarding how they know what a resident's code status is. She stated, it is in the electronic record and can be assessed by going into the resident's profile. She further stated, if you click on the Dash tab it includes quick information about the resident such as code status, latest vitals and allergies [REDACTED]. The nurse assigned to the resident puts the code status in based on the orders that are received from the Medical Doctor (MD). If the resident's status changes from a full code to a DNR then the nurse per the MD's order would go in and change it . She stated if a resident was found unresponsive based on what is in the clinical record she would initiate CPR and continue until the EMTs arrived. (sic) During an interview on [DATE] at 2:41 p.m. with LPN HH regarding how she would know what a resident's code status is, she stated, from the orders. It is in the electronic record under the resident's orders and the Medication Administration Record [REDACTED]. The code status comes over from the orders that are sent from the hospital and the nurse who receives the resident puts the orders in will also enter the code status.(sic) During an interview on [DATE] at 6:01 p.m. with the Administrator she stated if a resident is found unresponsive, a code is called. She stated that residents are not physically flagged as a DNR so one staff member will go check the electronic medical record for advance directive status while the other will start CPR. Continued interview revealed that once it is verified the resident is a DNR, resuscitation efforts are stopped. When the Administrator was asked about documentation of a DNR status she stated that the information was to be documented, and can be found, on the resident's face sheet. The Administrator then stated that, when a resident expires in the facility, the nurse is required to document what happened in the resident's chart under the progress note, call 911, the coroner, police, DON, Physician, and the family. She stated that the DON reviews the documentation and if there are questions regarding the death the DON will discuss her concerns with the nurse and other staff who were present and, if any corrections were needed, she would document her review findings in the medical record. During an interview with the DON on [DATE] at 6:33 p.m. she stated she did not complete a review of the circumstances surrounding R#77's death. During an interview on [DATE] at 9:18 a.m. with the Administrator revealed she has a vague recollection as to what occurred on [DATE] when R#77 expired. She stated she was the senior management contacted by the nurse at the time of the incident and had talked the nurse through the process. The Administrator stated that she knows the nurse remained in the facility until late in the morning to complete paperwork and this was why she did not review the documentation and was not aware that it was not completed. During a telephone interview on [DATE] at 9:25 a.m. with CNA CC she stated on [DATE] she went into R#77's room sometime after 4:00 a.m. because the resident was on her get up list. She stated R#77 was lying in bed and was pale and sweaty. She stated when she asked her if she was ok R#77 did not respond to her. CNA CC stated it was routine for her to go in, get the resident up, take her to the bathroom, and dress her. CNA CC stated that on [DATE], when the resident didn't respond to her asking if she was ok, she took her into the bathroom and assisted her onto the toilet. At that point she stated she noted that R#77 was short of breath so she got her cleaned up, after having used the bathroom, and took R#77 back to bed where she assisted her in sitting on the side of the bed. She stated she asked R#77 again if she was ok and when she did not answer she became concerned and called for LPN AA and when she arrived the nurse assessed the resident and made the statement that something was not right and went out of the room to call for the other nurse on duty. CNA CC stated when LPN AA returned with the other nurse, LPN BB, LPN AA said they had to do CPR. She stated someone brought the board into the room and one of the two nurses started CPR, but stated she wasn't sure which nurse started CPR, while the other nurse went to check R#77's code status. She stated when the nurse who was gone to check the code status for R#77 returned, the nurse said that the resident was a DNR and CPR was discontinued. During an interview on [DATE] at 2:04 p.m. with LPN BB revealed she was working on another unit the evening of [DATE] but was visiting R#77's unit when CNA CC reported that R#77 was nonresponsive, or didn't look right, and stated she couldn't remember which it was. She stated that she and LPN AA went into R#77's room and found that R#77 had no pulse, was unresponsive, and they could not get any vital signs. LPN BB stated she began chest compressions and told LPN AA to get R#77's code status and when LPN AA returned she advised her to stop CPR because R#77 was a DNR, so she stopped doing CPR at that point. LPN BB stated she does not know if 911 was called because when she stopped CPR she asked LPN AA if she could help with notifications and paperwork and LPN AA told her no and at that point she went back to her floor. During an interview on [DATE] at 3:15 p.m. with the Social Worker revealed that when a resident enters the facility with a DNR, and the DNR document is available, she uploads it into the resident's clinical record and updates the resident care plan. She stated she then sends out an email to the Interdisciplinary Team (IDT), including the nursing staff, with the resident name added to the list of existing DNR's. The Social Worker stated that if a resident decided to change from a full code to a DNR, and even with a resident who has an existing DNR, she has a meeting with the resident and their family to educate them about what a DNR is and has the family sign a new DNR form. She stated she sends the new form to the Physician for his signature and when she receives the form back she follows the same process of uploading the document into the system, updating the care plan, and sending out an email to the IDT, including nursing staff, with an updated list of Resident's who are a DNR. During a telephone interview on [DATE] at 3:40 p.m. with LPN AA revealed on the morning of [DATE] she was at the nurses' station when CNA CC said to come look at R#77 because she had a change in skin color. LPN AA stated when she went into R#77's room she observed her to be sitting on the side of the bed. She stated she assessed R#77 and took vitals, heard audible wheezing, observed R#77 to be sweating, checked her blood sugar, noted the resident had no temperature, and that her vital signs were stable. LPN AA stated she could not remember the numbers of the vital signs but said she recorded them in R#77's electronic medical record. LPN AA stated that CNA CC asked her if she wanted her to get the resident up and she advised CNA CC to put R#77 back to bed and she was going to go call the Medical Doctor (MD). LPN AA stated when CNA CC laid R#77 down on the bed she noted R#77 turning pale in color and was breathless. She stated that LPN BB was already in the room at this time so she ran out to get the crash cart and when she returned with the crash cart both she and LPN BB began to do CPR on R#77. She stated that LPN BB was doing chest compressions and she was operating the bag and LPN BB asked her to go and check the resident's code status. LPN AA stated she went to the nurses' station and first called 911 and then checked the code status on the electronic medical records under R#77's profile on her admission record and found that R#77 was a DNR. She stated after obtaining the resident's code status, while on her way back to R#77's room, she saw the Emergency Medical Technicians (EMT) were at the front door and someone let them in. LPN AA stated that the EMT's asked her if R#77 was a DNR and when she told them yes she stated they told her to stop CPR. She stated that CPR was stopped and the EMT called the time of death and asked her for relevant paperwork such as R#77's face sheet. LPN AA stated the time was around 5:00 a.m., but stated she wasn't sure. She stated she then notified the family, then the MD, and lastly the coroner. LPN AA stated she did make some notes but she wasn't sure what happened to them. When asked how she is made aware that a resident is a DNR she stated that if there is a change in DNR status, or a new resident is admitted with a DNR, this is put on the 24-hour report and if a resident expires the nurse on duty calls the DON or Administrator for advice on the death. She stated there is also a book on the process but in this case, with R#77, she called the DON and the DON reminded her to call the Coroner because the body was still in the facility. LPN AA stated that, the weekend supervisor came in and assisted her in the process. She stated she remembered completing the paperwork and is not sure why it is not in the records.

Based on staff interviews and review of the records, it was determined that the facility failed to follow the plan of care related to advanced directives when they performed Cardiopulmonary Resuscitation (CPR) for one resident (R), #77 who had a current physician-order of Do Not Resuscitate (DNR) documented in the medical record. The sample size was 40. On [DATE], a determination was made that a situation existed in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. At the time of exit on [DATE], the State Survey Agency had not received an acceptable Credible Allegation of Compliance, therefore, the IJ remains ongoing. On [DATE] at 7:50 p.m., the facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy is outlined as follows: Resident (R) #77 had an advanced directive - a Do Not Resuscitate (DNR) order on record since 2011. R#77 experienced a change in condition on [DATE] when the Certified Nursing Assistant (CNA) CC, who was responsible for getting the resident up and ready for the day, found the resident in bed around 4:30 a.m., sweaty and not speaking. The CNA took the resident to the bathroom, then returned her to her room. Around 5:00 a.m., the resident became unresponsive and some members of the licensed staff initiated CPR while one staff member went to the nurses' station to verify the resident's code status in the clinical records. When that staff member returned to the resident's room with the information that the resident was a DNR, CPR on the resident was terminated. The resident expired in the facility the same day. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of; 42 CFR 483.10(g)(14)(i)-(iv) Notify of Changes Injury/Decline/Room, etc. Residents Rights: F580-S/S: J 42CFR 483.21(b)(1) Comprehensive Resident Centered Care Plans: F656-S/S: J 42CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards: F658-S/S: J 42CFR 483.24(a)(3) Cardio-Pulmonary Resuscitation (CPR): F678-S/S: J 42 CFR 483.70 Administration: F835-S/S: J 42 CFR 483.75(g)(1)(i)-(iv)(2)(i) QAA Committee: F868-S/S: J Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. Findings include: Review of the clinical records revealed Resident (R) #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical records revealed the resident expired in the facility on [DATE]. Review of the physician's orders [REDACTED]. Review of the care plan records for R#77 revealed the resident had a plan of care initiated [DATE] for no CPR to be initiated in the event the resident experienced a [MEDICAL CONDITION]. During an interview on [DATE] at 6:01 p.m. with the Administrator it was revealed when a resident is found unresponsive, a code is called and since the residents are not physically flagged as a DNR candidate (for example, with an arm band) one staff member checks the electronic records for the resident's code status, while another staff member starts CPR. If it is verified via the records that the resident is a DNR, resuscitation efforts are stopped. DNR status is to be documented in the electronic records and can be found on the resident's face sheet. During a telephone interview on [DATE] at 9:25 a.m. with CNA CC it was revealed that the CNA became concerned about the physical status of R#77 on the morning of [DATE] and called for the charge nurse, LPN AA. When LPN AA came to the resident's room, she checked the resident and said something was not right and left to call the other nurse on duty, LPN BB. When LPN AA returned with LPN BB, she said they had to do CPR. One of the two nurse (the CNA was unsure whether it was LPN AA or LPN BB) started CPR while the other nurse went to check the resident's code status. When the nurse returned to say that the resident was a DNR, the CPR was discontinued. During a telephone interview on [DATE] at 2:04 p.m. with LPN BB it was revealed she was working on another unit on the morning of [DATE], but was visiting the resident's unit when the CNA reported that R#77 was experiencing some difficulties. LPN BB went to the resident's room in the company of LPN AA. When the nurses noted that the resident had no pulse, was unresponsive, and no vitals could be obtained, LPN BB started chest compressions and asked LPN AA to get the resident's code status. Sometime later, LPN AA returned, and told LPN BB to stop CPR because resident had a DNR order. The LPN immediately ceased from performing chest compressions. Cross Refer to F678

Based on interviews, record review, and the review of the Georgia Board of Nursing Rule [DATE] Standards of Practice for Licensed Practical Nurses the facility failed to verify the Advance Directive and failed to follow their policy CPR, Self-Determination, And No Cardiopulmonary Resuscitation (CPR) Requests regarding the initiation and cessation of Cardiopulmonary Resuscitation for one resident (R), #77. The census on [DATE] was 78 residents, of which 8 residents were identified as Do Not Resuscitate (DNR). On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 7:50 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. At the time of exit on [DATE] an acceptable Allegation of Compliance (A[NAME]) had not been received, therefore the IJ remains ongoing. The Immediate Jeopardy is outline as follows: An Advance Directive order was signed by R#77's daughter on [DATE] and signed by 2 Physicians, the primary Physician and the concurring Physician, on [DATE]. R#77 experienced a change in condition on [DATE] when the Certified Nursing Assistant (CNA), who was responsible for getting R#77 up and ready for the day, found her in bed, around 4:30 a.m., sweaty and not speaking. The CNA took R#77 to the bathroom, then returned her to her room. Around 5:00 a.m., R#77 became unresponsive and members of the licensed staff-initiated CPR while one staff member went to the nurses' station to verify R#77's code status in the clinical records. When that staff member returned to R#77's room with the information that R#77 was a Do Not Resuscitate DNR, CPR was terminated. R#77 expired in the facility. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of; 42 CFR 483.10(g)(14)(i)-(iv) Notify of Changes Injury/Decline/Room, etc. Residents Rights: F580-S/S: J 42CFR 483.21(b)(1) Comprehensive Resident Centered Care Plans: F656-S/S: J 42CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards: F658-S/S: J 42CFR 483.24(a)(3) Cardio-Pulmonary Resuscitation (CPR): F678-S/S: J 42 CFR 483.70 Administration: F835-S/S: J 42 CFR 483.75(g)(1)(i)-(iv)(2)(i) QAA Committee: F868-S/S: J Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678 Findings Include: Review of the Georgia Board of Nursing [DATE]: Standards of Practice for Licensed Practical Nurses Rule ,[DATE]-.02 Standards of Practice for Licensed Practical Nurses: (1) The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice; (c) Performing comfort and safety measures; (d) Administering treatments and medications by various routes; (e) Participating in the management and supervision of unlicensed personnel in the delivery of patient care; and (f) Performing other specialized tasks as appropriately educated. The facility had a CPR, Self-Determination, And No Cardiopulmonary Resuscitation (CPR) Request policy. The Policy Statement read: To comply with the resident's desires for self-determination. Policy Standard of Practice include: 1. CPR - The resident must be informed that he or she my initiate an advanced directive upon admission. An advanced directive may be a living will, a durable power of attorney for healthcare, or both. Some states have additional, state-specific, directives. 2. CPR will be attempted for all residents unless there is a NO DNR order written by the physician on the physician's orders [REDACTED]. 3. A NO DNR request may be reversed at any time when the request is given in writing by the resident, family, or responsible party. 4. If CPR is initiated, 911 will be dialed to summon emergency medical aid. Personnel will continue CPR until care is transferred to ambulance personnel. 5. Once CPR is initiated, it will not be stopped unless a physician presents orders for it to be stopped. R#77 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].#77's care plan revealed on [DATE] in the event of a [MEDICAL CONDITION] no CPR will be initiated, with an outcome of DNR order signed [DATE], and with interventions that include, honor resident's request for no CPR. Review of nurse notes on [DATE] at 8:55 a.m. reads: At 4:30 a.m. CNA making rounds and noticed resident vomiting and wheezing. Writer did assessment. Resident had thick, mucous around mouth and was clammy. CNA assist resident to restroom and dressed resident and laid her down to bed. Resident made shallow breaths and became unresponsive. No vitals at 5:00 a.m. Nurse note on [DATE] at 9:16 a.m. reads: At 4:30 a.m. vital signs: B/P =,[DATE], R=26, P=54, T=97.2. Nurse note on [DATE] at 9:21 a.m. reads: 911 placed and EMS came, and resident expired. Responsible Party (RP) notified and MD notified. During an interview with the DON on [DATE] at 6:33 p.m. she stated she did not complete a review of the circumstances surrounding R#77's death. During an interview on [DATE] at 2:04 p.m. with LPN BB revealed she was working on another unit the evening of [DATE] but was visiting R#77's unit when CNA CC reported that R#77 was nonresponsive, or didn't look right, and stated she couldn't remember which it was. She stated that she and LPN AA went into R#77's room and found that R#77 had no pulse, was unresponsive, and they could not get any vital signs. LPN BB stated she began chest compressions and told LPN AA to get R#77's code status and when LPN AA returned she advised her to stop CPR because R#77 was a DNR, so she stopped doing CPR at that point. LPN BB stated she does not know if 911 was called because when she stopped CPR she asked LPN AA if she could help with notifications and paperwork and LPN AA told her no and at that point she went back to her floor. During a telephone interview on [DATE] at 3:40 p.m. with LPN AA revealed on the morning of [DATE] she was at the nurses' station when CNA CC said to come look at R#77 because she had a change in skin color. LPN AA stated when she went into R#77's room she observed her to be sitting on the side of the bed. She stated she assessed R#77 and took vitals, heard audible wheezing, observed R#77 to be sweating, checked her blood sugar, noted the resident had no temperature, and that her vital signs were stable. LPN AA stated she could not remember the numbers of the vital signs but said she recorded them in R#77's electronic medical record. LPN AA stated that CNA CC asked her if she wanted her to get the resident up and she advised CNA CC to put R#77 back to bed and she was going to go call the Medical Doctor (MD). LPN AA stated when CNA CC laid R#77 down on the bed she noted R#77 turning pale in color and was breathless. She stated that LPN BB was already in the room at this time so she ran out to get the crash cart and when she returned with the crash cart both she and LPN BB began to do CPR on R#77. She stated that LPN BB was doing chest compressions and she was operating the bag and LPN BB asked her to go and check the resident's code status. LPN AA stated she went to the nurses' station and first called 911 and then checked the code status on the electronic medical records under R#77's profile on her admission record and found that R#77 was a DNR. She stated after obtaining the resident's code status, while on her way back to R#77's room, she saw the Emergency Medical Technicians (EMT) were at the front door and someone let them in. LPN AA stated that the EMT's asked her if R#77 was a DNR and when she told them yes she stated they told her to stop CPR. She stated that CPR was stopped and the EMT called the time of death and asked her for relevant paperwork such as R#77's face sheet. LPN AA stated the time was around 5:00 a.m., but stated she wasn't sure. She stated she then notified the family, then the MD, and lastly the coroner. LPN AA stated she did make some notes but she wasn't sure what happened to them. When asked how she is made aware that a resident is a DNR she stated that if there is a change in DNR status, or a new resident is admitted with a DNR, this is put on the 24-hour report and if a resident expires the nurse on duty calls the DON or Administrator for advice on the death. She stated there is also a book on the process but in this case, with R#77, she called the DON and the DON reminded her to call the Coroner because the body was still in the facility. LPN AA stated that, the weekend supervisor came in and assisted her in the process. She stated she remembered completing the paperwork and is not sure why it is not in the records. Cross Refer to F678

Based on staff interviews and review of the records, the facility failed to notify the physician, in a timely manner, of the significant change in condition of one resident (R), #77 who expired in the facility. The sample size was of 40 residents. On [DATE], a determination was made that a situation existed in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. At the time of exit on [DATE], the State Survey Agency had not received an acceptable Credible Allegation of Compliance, therefore, the remains IJ was ongoing. On [DATE] at 7:50 p.m., the facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy is outlined as follows: Resident (R) #77 had an advanced directive - Do Not Resuscitate (DNR) order on record since 2011. R#77 experienced a change in condition on [DATE] when the Certified Nursing Assistant (CNA) CC, who was responsible for getting the resident up and ready for the day, found the resident in bed around 4:30 a.m., sweaty and not speaking. The CNA took the resident to the bathroom, then returned her to her room. Around 5:00 a.m., the resident became unresponsive and some members of the licensed staff initiated Cardiopulmonary Resuscitation (CPR) while one staff member went to the nurses' station to verify the resident's code status in the clinical records. When that staff member returned to the resident's room with the information that the resident was a DNR, CPR on the resident was terminated. The resident expired in the facility. Sometime later, the family was notified, then the physician was notified. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of; 42 CFR 483.10(g)(14)(i)-(iv) Notify of Changes Injury/Decline/Room, etc. Residents Rights: F580-S/S: J 42CFR 483.21(b)(1) Comprehensive Resident Centered Care Plans: F656-S/S: J 42CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards: F658-S/S: J 42CFR 483.24(a)(3) Cardio-Pulmonary Resuscitation (CPR): F678-S/S: J 42 CFR 483.70 Administration: F835-S/S: J 42 CFR 483.75(g)(1)(i)-(iv)(2)(i) QAA Committee: F868-S/S: J Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678 Findings include: Review of the policy titled Notification of Resident's Change in Condition, last revised ,[DATE] revealed the facility will promptly notify the attending physician and responsible party of a significant change in condition such as a significant change in the resident's physical, emotional, or mental status. Review of the clinical records revealed Resident (R) #77 was admitted on [DATE] the residents [DIAGNOSES REDACTED]. Review of the most recent physician's progress note dated [DATE] documented that the resident was chronically ill and in no acute distress. Review of the nurses' progress notes revealed Licensed Practical Nurse (LPN) AA documented on [DATE] at 8:55 a.m. that R#77 was noted by Certified Nursing Assistant (CNA) to be vomiting and wheezing at 4:30 a.m. that morning. The note also documented that the CNA took the resident to the bathroom, dressed her, and laid her in bed, and that at 5:00 a.m. the resident took shallow breaths and became unresponsive. Further review of the nurses' progress notes revealed that LPN AA documented on [DATE] at 9:16 a.m. that at 4:30 a.m. that day, the resident's vital signs were: BP=,[DATE]; R=26; HR=54; and T=97.2. During a telephone interview on [DATE] at 9:25 a.m. with CNA CC it was revealed that she went to the resident's room sometime after 4:00 a.m. because the resident was on her get up list. Upon entering the room, she found the resident lying in bed, sweaty and not speaking. The resident did not respond to her inquiry as to whether the resident was OK. However, the CNA's customary routine with this resident, she took the resident to the bathroom where the resident had a bowel movement. At that time, the resident seemed to be short of breath. After assisting the resident in the bathroom, the CNA took the resident back to the resident's room and sat her up on the side of the bed. When the resident still did not respond to her inquiries whether she was OK, the CNA became concerned and called for the charge nurse, LPN AA. When LPN AA came to the resident's room, she checked the resident and said something was not right, so she left to call the other nurse on duty, LPN BB. When LPN AA returned with the other nurse, she said they had to do CPR. One of the two nurse (the CNA was unsure whether it was LPN AA or LPN BB) started CPR while the other nurse went to check the resident's code status. When the nurse returned to say that the resident was a DNR, CPR was discontinued. During a telephone interview on [DATE] at 2:04 p.m. with LPN BB it was revealed she was assigned to work on another unit on the morning of [DATE], but was visiting the resident's unit when the CNA reported that R#77 was experiencing some difficulties. LPN BB went to the resident's room in the company of LPN BB. When the nurses noted that the resident had no pulse, was unresponsive, and no vitals could be obtained, LPN BB started chest compressions and asked LPN AA to get the resident's code status. Sometime later, LPN AA returned, and told LPN BB to stop CPR because resident had a DNR order. LPN BB said immediately ceased from performing chest compressions on the resident and went back to her assignment. She had no knowledge of what calls were made at that time. When she ceased from performing CPR on R#77, she asked if she could help the charge nurse, LPN BB, with notifications or paperwork and that nurse said no, so she went back to her assignment. During an interview on [DATE] at 3:40 p.m. with LPN AA it was revealed that on the morning of [DATE], she was at the nurses' station with LPN BB, when CNA CC asked her to take a look at R#77 because the resident had a change in skin color. When she went into the resident's room, she observed the resident sitting on the side of her bed. This nurse assessed the resident and discovered she was wheezing and sweating. She took the resident's vitals which she judged to be stable. The CNA asked this nurse if she wanted the CNA to continue to get the resident up and ready, but she said no, to please put the resident back to bed because she needed to call the physician. However, when the CNA laid the resident down on the bed, the nurse noted the resident was turning a pale color and was breathless. LPN BB was also in the room at that time. This nurse ran out to get the crash cart. When she returned with the crash cart, both nurses began to perform CPR on the resident. The other nurse, LPN BB, was doing chest compressions and this nurse was operating the bag. LPN BB asked this nurse to check the resident's code status and she went to the nurses' station where she first called 911 before checking the code status. She found the code status on the electronic records, under profile, and admissions. After CPR was stopped, she notified the resident's family, then the physician, then the coroner. During an interview on [DATE] at 12:51 p.m. with the Director of Nursing (DON), it was revealed that the facility has an on-call Physician that is available 24 hours a day. During the week, the Physician's Assistant or Nurse Practitioner who sees the residents on a regular basis is responsible for responding to calls relating to a resident change in condition during regular business hours which end at 5:00 p.m. After hours and on weekends, another mid-level practitioner from the same office, or another Physician who sees residents is on call. On the morning of [DATE], one of the other mid-level Physicians from the Medical Director's office was on-call. If the on-call Physician is needed because of a concern with a resident, the facility calls the relevant on-call number, chooses option 1 or 2 and the on-call Physician will call the facility back as necessary. [DATE] was a Saturday. Therefore, the staff would have called the on-call physician's line to report a change in condition for R#77. During an interview on [DATE] at 4:03 p.m. with Registered Nurse (RN) DD it was revealed the nurses have a number to reach the on-call Physician/Nurse Practitioner on the weekends. If necessary, the nurses call the number and choose option 1 or 2, as needed. Option 1 is for matters requiring immediate care or attention. For example, if a resident is ill or the staff has critical labs. Option 2 is for less urgent situations. If the nurse chooses Option 1, say for an emergency, the on-call Physician always answers immediately. She has never known the on-call Physician to not immediately answer the phone when Option 1 is chosen. Cross Refer to F678

Based on interviews and record review, the facility Administration failed to ensure effective monitoring of the Advance Directive system and failed to ensure staff were trained to respond appropriately during an emergency situation in an effort to prevent errors or delays in emergency resuscitative efforts. The facility failed to ensure procedures were in place to follow up on Advance Directive decisions. The Administrator failed to ensure the Quality Assurance Process Improvement committee was effective in identifying quality deficiencies and failed to monitor the effectiveness and implementation of plans of action. The facility had a census of 78 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 7:50 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. At the time of exit on [DATE] an acceptable Allegation of Compliance (A[NAME]) had not been received, therefore the IJ remains ongoing. The immediate jeopardy is outlined as follows: Resident (R), #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#77's care plan revealed on [DATE] in the event of a [MEDICAL CONDITION] no Cardiopulmonary Resuscitation (CPR) will be initiated, with an outcome of Do Not Resuscitate (DNR) order signed [DATE], and with interventions that include, honor resident's request for no CPR. Resident #77 experienced a change in condition on [DATE] when the Certified Nursing Assistant (CNA), who was responsible for getting R#77 up and ready for the day, found her in bed, around 4:30 a.m., sweaty and not speaking. The CNA took R#77 to the bathroom, then returned her to her room. Around 5:00 a.m., R#77 became unresponsive and members of the licensed staff-initiated CPR while one staff member went to the nurses' station to verify R#77's code status in the clinical records. When that staff member returned to R#77's room with the information that R#77 was a DNR, CPR was terminated. R#77 expired in the facility. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of; 42 CFR 483.10(g)(14)(i)-(iv) Notify of Changes Injury/Decline/Room, etc. Residents Rights: F580-S/S: J 42CFR 483.21(b)(1) Comprehensive Resident Centered Care Plans: F656-S/S: J 42CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards: F658-S/S: J 42CFR 483.24(a)(3) Cardio-Pulmonary Resuscitation (CPR): F678-S/S: J 42 CFR 483.70 Administration: F835-S/S: J 42 CFR 483.75(g)(1)(i)-(iv)(2)(i) QAA Committee: F868-S/S: J Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678 Findings include: During an interview on [DATE] at 6:01 p.m. with the Administrator she stated if a resident is found unresponsive, a code is called. She stated that residents are not physically flagged as a DNR so one staff member will go check the electronic medical record for advance directive status while the other will start CPR. Continued interview revealed that once it is verified the resident is a DNR, resuscitation efforts are stopped. During an interview with the Administrator on [DATE] at 2:00 p.m. she stated that she should have investigated R#77's unexpected death. She stated that she thought the clinical staff had completed all documentation and follow-up. When asked about in-service education regarding advance directives, the Administrator provided the surveyors with two forms titled IN-SERVICE SIGN IN SHEET. Review of the form dated [DATE] and a second form dated [DATE] noted both in-services were done by the Administrator, the topic entered was Advanced Directives, the objectives/narrative description of the presentation was blank and the signature section reflected that only two staff members were in attendance on each of the in-service forms. When asked if any additional in-services were provided the Administrator stated no not until after the surveyor brought this to our attention. The administration was unable to provide evidence that training related to Advanced Directives was presented to all clinical staff. Review of the Administrators Job Description for the job title of Administrator. The description included that the purpose of the job was to direct the day-to-day functions of the nursing center in accordance with Federal, State, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. The Job Description indicates the Supervisor is the Board of Directors. The form is signed and dated by the Administrator on [DATE], however there is no signature or date noted on the signature line for the Chairperson/Governing Board. Duties and Responsibilities include: -Plan, develop, organize, implement, evaluate and direct the facility's programs and activities in accordance with guidelines issued by the governing board. -Develop and maintain written policies and procedures and professional standards of practice that govern the operations of the facility. -Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. - Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. -Evaluate and implement recommendations from the facility's committees as necessary. Refer to F867 The administration was unable to provide evidence that Quality Assurance meeting were held at a minimum monthly in accordance to the facility written policy. Review of the facility Quality Assurance and Performance Improvement Plan (QAPI) policy dated (YEAR) revealed a QAPI committee will meet at a minimum on a monthly basis and as needed. The Administrator acknowledge that she was responsible to arrange the QAPI meeting at least monthly. Review of forms titled Advanced Directive Checklist revealed R#23 ,R #3 and R#36 signed documents regarding advanced directives. The residents comments on the tool had no corresponding follow-up by the facilty. Cross Refer to F580, F656, F658 and F678

Based on interviews, record review, and review of the Quality Assurance and Performance Improvement policy, the facility failed to utilize the Quality Assurance and Performance Improvement (QAPI) system to oversee the Advance Directive system. Resident (R), #77 had a Do Not Resuscitate (DNR) order in the clinical record on [DATE], the resident exhibited a change in condition and the facility started Cardiac [MEDICAL CONDITION] Resuscitation (CPR). Review of Advance Directive Checklist form for R#3, R#23, R#36 stated the residents has advanced directives or would like to formulate an advance directive however the facility was unable to provide evidence that the information on the form was followed up. R#29's advanced directives were incorrectly filed in the electronic record. The facility had a census of 78 residents On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on [DATE] at 7:50 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. At the time of exit on [DATE] an acceptable Allegation of Compliance (A[NAME]) had not been received, therefore the IJ remains ongoing. An Advance Directive order was signed by R#77's daughter on [DATE] and signed by 2 Physicians, the primary Physician and the concurring Physician, on [DATE]. R#77 experienced a change in condition on [DATE] when the Certified Nursing Assistant (CNA), who was responsible for getting R#77 up and ready for the day, found her in bed, around 4:30 a.m., sweaty and not speaking. The CNA took R#77 to the bathroom, then returned her to her room. Around 5:00 a.m., R#77 became unresponsive and members of the licensed staff initiated CPR while one staff member went to the nurses' station to verify R#77's code status in the clinical records. When that staff member returned to R#77's room with the information that R#77 was a DNR, CPR was terminated. R#77 expired in the facility. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of; 42 CFR 483.10(g)(14)(i)-(iv) Notify of Changes Injury/Decline/Room, etc. Residents Rights: F580-S/S: J 42CFR 483.21(b)(1) Comprehensive Resident Centered Care Plans: F656-S/S: J 42CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards: F658-S/S: J 42CFR 483.24(a)(3) Cardio-Pulmonary Resuscitation (CPR): F678-S/S: J 42 CFR 483.70 Administration: F835-S/S: J 42 CFR 483.75(g)(1)(i)-(iv)(2)(i) QAA Committee: F868-S/S: J Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. Findings Include: On [DATE] 1:00 p.m. the Administrator was interviewed regarding Quality Assurance (QA) committee meeting. The Administrator was unable to state how facility personnel provided input into the QA program to address quality deficiencies specially advanced directives. The Administrator stated that QA meetings are held monthly and during the meeting in (MONTH) (YEAR) advanced directives was identified as a concern. When asked to review the attendance sheet and the plan for advanced directives she stated the minutes were not typed yet. When asked who was responsible to follow up on the advanced directives she stated it was assigned to the Social Worker (SW) to complete audits and follow up with residents and families who requested information to formulate an advanced directive and residents who stated that they would provide a copy of their advance directive to the facility. At 4:00 p.m. the Administrator had not provided evidence of the (MONTH) (YEAR) QA attendance sheet. During an interview on [DATE] at 10:35 a.m. with the SW revealed R#29 was given information related to advanced directives and signed documentation to that effect on [DATE]. The SW stated that the documentation was incorrectly filed as an other document rather than advanced directive. On [DATE] at 2:20 p.m. during interview with the SW regarding the QA meeting in (MONTH) (YEAR) she stated that she had not attended and was not told that she had to attend a QA meeting in October. The SW said that she was not aware that advance directives was a current concern or that it was discussed in (MONTH) because she only attends QA meeting when told. When asked if she was aware that R#36 signed an Advance Directive Checklist requesting advance directive information be provided she replied no. When asked if she was aware that R#23 and R#3 indicated on their Advanced Directive Checklist tool that they have advanced directives and would provide a copy to the facility? The SW stated she is aware that some residents did not have copies of their advanced directives in their files. On [DATE] at 3:30 p.m. during a continued interview with the Administrator regarding advanced directives audits she stated It was not done and I take full responsibility for that, I should have checked with department heads and managers to make sure they were following up on all residents. When asked who followed up with residents who want to receive information on advance directives, the Administrator stated the SW was responsible for follow-up The Administrator stated that she was not aware that advance directives continued to be a concern since the last annual survey and that she trusted that her clinical staff were monitoring and auditing the clinical records. She stated, but I should have monitored myself. When ask how the QAPI committee identifies problems to be addressed the Administrator stated, the committee knows when there is a problem because they conduct random audits and when we find a problem we do a PIP (Process Improvement Plan) and I monitor the progress(sic). When ask if an unexpected death would be investigated and addressed during QA meeting she replied, yes it should have been investigated and a PIP should have been done. Review of The Quality Assurance Improvement Plan Policy dated (YEAR) the following is noted: The Quality Assurance and Performance Improvement (QAPI) committee will meet at a minimum on a monthly basis and as needed. The facility will identify areas for Quality Assurance/Performance Improvement monitoring and tools/resources to be used. This monitoring activities should focus on those processes that significantly affect resident outcomes. Their ongoing monitoring is used to establish the facility's baseline and the predictability of various outcomes. The department/committee will document finding, initiate corrective action as directed and present results to the Quality Assurance Performance Committee. The Quality Assurance Performance Improvement Committee has the responsibility for designing and implementing corrective action plans as needed to resolve identified resident aspects of care/service problem. All improvement plans will contain: a. What is to be changed? b. When and how corrective actions will be implemented? c. Who is responsible for the implementation of the corrective action? d. What time intervals is set for reassessment? to evaluate the outcome of action taken (sic) Improvement plans and effectiveness of actions will be documented in the committee minutes. Cross Refer to F678