**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family and staff interviews, and policy review, the facility failed to provide appropriate pain management for 1 out of 5 residents reviewed (Resident #6). Clinical record review revealed on 9/26/23 at 4:00 p.m., Resident #6 fell and sustained a hematoma to her head. The facility staff failed to conduct a dementia pain assessment for 16 hours, or treat the resident's pain. The facility sent the resident to the emergency room (ER) where the resident was assessed to have a subdural hematoma (brain bleed), fracture of the right clavicle, and a urinary tract infection. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of September 26, 2023 on December 19, 2023 at 12:15 p.m. The facility staff removed the Immediate Jeopardy on December 19, 2023 by implementing the following actions: 1) DON/Designee completed Inservice with licensed staff 12/19/2023 on A) Change in Condition B) Pain Management C) Interventions for Pain Management and Pain Relief. D) Physician notification of new pain 2) DON and or designee completed 100% audit on residents with any symptoms of pain A) Completed Pain interview B) Interventions were administered C) Dr/NP were notified as needed 3) DON/Designee will educate new hires on: A) Change in Condition B) Pain Management C) Interventions for Pain Management D) Physician Notification of new pain. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 50 residents. Findings Include: The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed the diagnosis Diabetes Mellitus, hypertension, renal insufficiency, aphasia (loss of ability to understand or express speech), altered mental status. Resident #6 required limited assistance for bed mobility, transfers, toileting, and for personal care. Resident #6 used a wheeled walker to ambulate and was frequently incontinent of urine. Resident #6 had a Brief Interview for Mental Status (BIMS) score of 1 which suggested a severe cognitive impairment. The Care Plan dated 9/15/23, instructed the staff to ambulate Resident #6 with a wheeled walker, provide assistance with transfer, toileting, personal hygiene and dressing with the assistance of 1 staff member. Resident #6 was identified as a fall risk and staff was directed to check frequently and assist as needed. Progress notes 9/26/23 at 4 p.m. for Resident #6 revealed: a. Staff I, Licensed Practical Nurse (LPN) notified that Resident #6 fell. b. Assessment complete and Neuro checks were initiated. c. A 4 cm x 5 cm bruise and swelling noted to the right side of forehead. d. Resident #6 was confused at the time and Urinary tract infection (UTI) was suspected. e. Three staff assisted the resident in a wheelchair, to the nurse's station for 1 on 1 supervision. f. Family was notified. g. Staff J, Advance Registered Nurse Practitioner (ARNP) was notified. h. A new order for one time dose of 12.5 mg Hydralazine due to blood pressure (BP) of 165/101 and obtain a urine sample. The Medication Administration Record (MAR) for Resident #6 dated September 2023 revealed: a. Tylenol 650 mg administered on 9/26/23 at 5 p.m. lacked documentation of pain assessment. b. Tylenol 650 mg, to be given 2 times a day, lacked documentation on dates 9/1, 19, 20, 12, 22 26, 27 at 8 a.m. and 9/3/23 at 5 p.m. c. Acetaminophen 650 mg every 4 hours as needed for mild pain not administered in September. d. Pain level assessment lacked documentation on 9/1, 2, 3, 19, 20, 21, 22, 26, and 9/27/23. The Neurological Evaluation for Resident #6 documented: a. Neurological assessments were initiated on 9/26/23 at 4 p.m. b. At 4:00 p.m. blood pressure (BP) 165/101, pulse (P) 92, Respiration (R) 18 (temperature was not assessed), LOC (level of Consciousness) 4+ (Lethargic, sleepy or drowsy), Pupils 4 and reactive to light (+), Hand grips refused, Lacked pain assessment. c. At 5:15 p.m. BP 129/95, P 98, R 18, LOC 4+ Lethargic, pupils 4+ Hand grasps AB (absent) d. Lack of documentation for the following assessment date and time: 1. On 9/26/23 at 5:45, 6:45, 7:45, 9:45, and 11:45 p.m. 2. On 9/27/23 at 1:45, 3:45, and 7:45 a.m. e. 9/27/23 at 11:15 a.m. revealed: BP 154/48, P 116, R 16, LOC 3+ stuporous (not awake), lacked assessment of pupil size, responsiveness, hand grips and pain assessment. Progress note dated 9/27/23 at 11:10 a.m. for Resident #6 revealed: a. Staff M, RN asked by staff to assess Resident #6. b. Resident eyes closed, did not respond to name or touch. c. Vital Signs: temperature (T) 100.4, P 114, R 16, BP 158/48. d. Unable to arouse the resident. Progress note dated 9/27/23 at 11:25 a.m. for Resident #6 revealed that Staff M, RN notified the family who requested transport to the Emergency department for evaluation and the ambulance was notified. The Situation, Background, Assessment, and Recommendation (SBAR) dated 9/27/23 at 11:25 a.m., completed by Staff M, RN, the findings included: a. Unresponsiveness b. Condition, symptom, sign had not occurred before c. Pain: does the resident have pain? yes, non-verbal, occasional moan or groan, facial grimacing d. testing none e. Interventions none f. Family was notified on 9/27/23 at 11:25 a.m. g. On 9/27/23 at 11:38 a.m. Staff J, ARNP notified. Progress note dated 9/27/23 at 11:55 a.m. revealed that Resident #6 was transported to the local hospital. During an interview on 12/18/23 at 3:29 p.m. Staff P, CNA stated Resident #6 was pleasantly confused on 9/26/23, which was her normal. Staff P stated she was in the hall when she heard a loud thunk and started searching rooms. Staff P stated she found Resident #6 face down in her room with a big goose egg on her forehead. Staff P stated she stayed with the resident while Staff O, CNA went to get Staff I, LPN. Staff P stated Resident #6's face was grimaced, she acted confused, moving to try to sit up and dazed, eyes not tracking and not responsive to her name. Staff P stated Staff O returned with Staff I who took vital signs then instructed the CNA's to get her up to the recliner. Staff P stated Resident #6 was not acting like herself, and the CNA's checked on her every 15 minutes, then Staff I instructed CNA's to place her in a wheelchair and take her to the nurse's station. Staff P stated they were instructed to take Resident #6 to bed about 7 p.m. and she was normally a 1 person assist but at that time was a 2 person assist with a gait belt. During an interview on 12/18/23 at 3:47 p.m. Staff O, CNA stated on 9/26/23 about 4 p.m. she was caring for a resident and heard a loud thump. Staff O stated, I knew it was a body hitting the floor. Staff O stated she assisted Staff P, CNA and found Resident #6 on the floor, on her right side, 4-5 steps from her recliner with the walker at her feet. Staff O stated Resident #6 rolled over and had a bruise to her head and did not recognize her name. Staff O stated she went after Staff I, LPN who took Resident #6 vitals but she did not have a flashlight to assess neuro's, did not assess the resident's arms or legs, and gave direction to Staff O and Staff P to get the resident up to the recliner. Staff O stated she assisted Staff P to clean Resident #6 as she was incontinent, then placed her in a wheelchair to assist her to the nurse's station. Staff O stated Resident #6 did not eat supper and was directed to put Resident #6 to bed at 7 p.m. by Staff K, RN who stated it was ok to put her to bed. Staff O stated she had been a CNA for 9 years and Resident #6 was not ok and she asked Staff I and Staff K if they were going to send her to the hospital. Staff O stated she and Staff P checked on her often to be sure she was still breathing due to Resident #6 did not arouse again after being put to bed. Staff O stated Staff K did not go into Resident #6's room to assess her. During an interview on 12/18/23 at 1:09 p.m. Staff I, LPN stated she worked on 9/26/23, 6 a.m. to 6 p.m. and was notified by staff CNA's that Resident #6 had an unwitnessed fall in her room about 4 p.m. Staff I stated, She had a goose egg on her forehead. Staff I stated it took 3 staff to get Resident #6 off the floor. Staff I stated she had notified Staff J, ARNP and was told to monitor the resident. Staff I stated she initiated a neurological sheet with the date and times neuro checks were to be completed and it was given to the 6 p.m. to 6 a.m. staff nurse in report, Staff K, RN. Staff I stated Resident #6 was restless, could not sit still, and cried. During an interview on 2/18/23 at 2:59 p.m., Staff D, CNA stated she worked the evening shift on 9/26/23. Staff D stated Resident #6 was in a wheelchair at the nurse's station with a nasty bruise on her forehead and Resident #6 said it hurt when touched. During an interview on 12/19/23 at 3:47 p.m. Staff A, CNA stated she worked on 6/27/23 at 6 a.m., rounded with the night shift CNA's who reported that they did not hear Resident #6 get up to the bathroom during the night so they did not go in. Staff A stated Resident #6 looked like she was in discomfort and asked Staff K, RN what happened to her, and was told by Staff K that he had given Resident #6 pain medication. Staff A stated she proceeded to give Resident #6 a bed bath. Staff A stated Resident #6 moaned when turned. Staff A stated Resident #6 did not eat so she left her in bed, changed her once and then went to get Staff M, RN around 11 a.m. to make an assessment due to Resident #6 looked rough. During an interview on 12/18/23 at 3:01 p.m. Staff M, RN stated she had worked as the previous Director of Nursing (DON) in the facility and worked on 9/27/23 as the day nurse, 6 a.m. to 6 p.m. Staff M stated she had received report at 6 a.m. from Staff K, RN that Resident #6 had a fall but Staff K did not share the extent of the fall. Staff M stated she was caring for a very sick resident down a different hall all morning until Staff A, CNA came to find her around 11 a.m. and stated Resident #6 was not waking up. Staff M stated she found Resident #6 unresponsive and notified Staff J, ARNP and the resident's family then transferred the resident to the hospital. Staff M stated she found the neuro sheet under a stack of papers at the nurse's station. Staff M stated she interviewed Staff K over the phone who stated he had not assessed Resident #6 during the night as she was asleep. Staff M stated it was normal practice for staff to call and notify the DON if there was a fall and there was no notification given to her. During an interview on 12/19/23 at 8:52 a.m., Resident #6's son stated his mother was quarantined in her room behind a closed door due to COVID and had two falls, a week apart. The son stated the family was notified of both falls but felt this last fall on 9/26/23 was down played. The son stated he received a call on 9/27/23 asking if the family would want her evaluated at the local hospital due to a possible UTI. The son stated he went to the hospital, I could not believe it, I could not recognize her ''. The son stated he spoke with his brother since this was more than a UTI and felt it was more than the local hospital could handle, therefore had Resident #6 transferred to the tertiary hospital for higher level of care. The son stated he was not going to send his mother back to this facility, requested the hospital Hospice to assist with the location of a facility, then transferred mother to a different facility until she passed from her injuries 2 weeks later on 10/28/23. Tertiary Hospital Record Review for Resident #6 dated 9/27/23 revealed: a. Subdural Hematoma (blood between the brain and its outermost covering). b. Bruises to right head and right shoulder c. Acute Encephalopathy (brain disease that alters brain function causes infection, tumor, and stroke) d. Fracture of the right clavicle e. UTI (urinary tract infection) f. Unresponsive to sternal rub g. Tachycardia (fast heart rate) h. Febrile (high body temperature) i. Vital Signs Blood pressure 138/79, Pulse 113, Respirations 20, Temperature 100.6 j. admitted to the tertiary hospital During an interview on 12/19/23 at 8:59 AM Staff N, Medical Examiner Investigator stated the cause death for Resident #6 was a result of complications from blunt force trauma injuries to head and clavicle, date of death [DATE]. During an interview on 12/18/23 at 1:20 p.m., Staff J, ARNP, stated she had received a call on 9/26/23, informed that Resident #6 fell, hit her head and the neurological test was normal. Staff J stated an order was given to monitor the resident and expected a call if there were changes or an inability to awaken the resident. Staff J stated she did not receive a follow up call, no one identified that Resident #6 was crying, restlessness that would suggest pain or confusion. Staff J stated, I would have sent her out if I felt she had further injuries or if in pain. Policy titled Pain Management dated 11/15/22 revealed: a. Recognize when Resident is experiencing pain and identify circumstances when pain can be anticipated. b. Observe for nonverbal indicators, change in gait, increased pulse or blood pressure, decline in activity of daily living (ADL), increased restlessness, facial expressions (grimacing), behavioral changes, difficulty eating, and negative vocalizations (groaning or crying). c. Verbal descriptors d. Nursing will complete a Pain Evaluation Tool, appropriate for the resident's cognitive status. e. Nursing will reassess resident's pain management for effectiveness. f. Nursing will notify the practitioner if the resident's pain is not controlled by the current treatment regimen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family and staff interviews, observations, and policy review, the facility failed to maintain a safe environment free from resident abuse for 8 of 9 residents reviewed for abuse (Resident #2, #3, #4, #5, #6, #8, #11, #15). Clinical record review revealed on 9/26/23 at 4:00 p.m., Resident #6 fell and sustained a hematoma to her head. After the initial hour of assessments, the facility staff neglected to conduct follow up assessments and neurological assessments (as per ordered by the provider) throughout the evening, night and next morning. On 9/27/23 the day shift Certified Nurses Aide (CNA) requested for a nurse to assess Resident #6 who was unconscious, (16 hours after last assessment).The facility sent the resident to the emergency room where the resident was assessed to have a Subdural Hematoma (brain bleed), fracture of right clavicle, urinary tract infection (UTI), Tachycardia (fast heart rate) and Fever. Resident #2 was physically aggressive with Resident #8, kicked Resident #5, and struck Residents #4, #11, and #15, and kicked and punched Resident #3. Resident #5 struck Resident #2. Staff X was physically rough with Resident #3 when removing him from the medication cart area. The above incidents spanned over a time frame from at least June of 2023 until October 2023. Staff reported that residents were scared of Resident #2 when he would arrive in a common area. The facility reported a census of 50 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of September 26, 2023 on December 19, 2023 at 12:15 p.m. The facility staff removed the Immediate Jeopardy on December 19, 2023 by implementing the following actions: 1) The Director of Nursing (DON)/Designee educated staff 12/19/23 on A) Abuse Prevention B) Neurological evaluations with un-witnessed falls, head injuries. C) Change in Condition notifications with physician and responsible parties. D) follow up evaluations with falls/changes in conditions 2) DON/Designee audited falls/changes in condition for proper follow up evaluations and neurological evaluations 3) DON/Designee will be notified with falls for proper follow up. A) Will review for proper evaluations and notifications as well as appropriate interventions. The scope lowered from J to E at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed the diagnosis Diabetes Mellitus, hypertension, renal insufficiency, aphasia (loss of ability to understand or express speech), altered mental status. Resident #6 required limited assistance for bed mobility, transfers, toileting, and for personal care. Resident #6 used a wheeled walker to ambulate and was frequently incontinent of urine. Resident #6 had a Brief Interview for Mental Status (BIMS) score of 1 which suggested a severe cognitive impairment. The Care Plan dated 9/15/23, instructed the staff to ambulate Resident #6 with a wheeled walker, provide assistance with transfer, toileting, personal hygiene and dressing with the assistance of 1 staff member. Resident #6 was identified as a fall risk and staff was directed to check frequently and assist as needed. Progress notes 9/26/23 at 4 p.m. for Resident #6 revealed: a. Staff I, Licensed Practical Nurse (LPN) notified that Resident #6 fell. b. Assessment complete and Neuro checks were initiated. c. A 4 cm x 5 cm bruise and swelling noted to the right side of forehead. d. Resident #6 was confused at the time and Urinary tract infection (UTI) was suspected. e. Three staff assisted the resident in a wheelchair, to the nurses station for 1 on 1 supervision. f. Family was notified. g. Staff J, Advance Registered Nurse Practitioner (ARNP) was notified. h. A new order for one time dose of 12.5 mg Hydralazine due to blood pressure (BP) of 165/101 and obtain a urine sample. Neurological Evaluation form directed staff to complete post fall if resident hit head or unwitnessed fall: every 15 minutes for 1 hour every 30 minutes for hour every hour for 2 hours every 2 hours for 8 hours every 4 hours for 12 hours every shift for 72 hours. The Neurological Evaluation for Resident #6 revealed with start date of 9/26/23 documented as follows: a. Neurological assessments were initiated on 9/26/23 at 4 p.m. b. At 4:00 p.m. blood pressure (BP) 165/101,pulse (P) 92, Respiration (R) 18 (temperature was not assessed), LOC (level of Consciousness) 4+ (Lethargic, sleepy or drowsy), Pupils 4 and reactive to light (+), Hand grips refused, Lacked pain assessment. c. At 5:15 p.m. BP 129/95, P 98, R 18, LOC 4+ Lethargic, pupils 4+ Hand grasps AB (absent) d. Lack of documentation for the following assessment date and time: 1. On 9/26/23 at 5:45, 6:45, 7:45, 9:45, and 11:45 p.m. 2. On 9/27/23 at 1:45, 3:45, and 7:45 a.m. e. 9/27/23 at 11:15 a.m. revealed: BP 154/48, P 116, R 16, LOC 3+ stuporous (not awake), lacked assessment of pupil size, responsiveness, hand grips and pain assessment. f. The Neurological assessment initiated on 9/26/23 at 4 p.m. lacked documentation of last every four hour assessment, and lacked documentation of the required assessments for the every 72 hour evaluations. Progress note dated 9/27/23 at 11:10 a.m. for Resident #6 revealed: a. Staff M, RN asked by staff to assess Resident #6. b. Resident eyes closed, did not respond to name or touch. c. Vital Signs: temperature (T) 100.4, P 114, R 16, BP 158/48. d. Unable to arouse the resident. Progress note dated 9/27/23 at 11:25 a.m. for Resident #6 revealed that Staff M, RN notified the family who requested transport to the Emergency department for evaluation and the ambulance was notified. The Situation, Background, Assessment, and Recommendation (SBAR) dated 9/27/23 at 11:25 a.m., completed by Staff M, RN, the findings included: a. Unresponsiveness b. The condition, symptom, sign had not occurred before c. Pain: does the resident have pain? yes non-verbal occasional moan or groan, facial grimacing d. testing none e. Interventions none f. Family was notified on 9/27/23 at 11:25 a.m. g. On 9/27/23 at 11:38 a.m. Staff J, ARNP notified. Progress note dated 9/27/23 at 11:55 a.m. revealed that Resident #6 was transported to the local hospital. During an interview on 12/18/23 at 3:29 p.m. Staff P, CNA stated Resident #6 was pleasantly confused on 9/26/23, which was her normal. Staff P stated she was in the hall when she heard a loud thunk and started searching rooms. Staff P stated she found Resident #6 face down in her room with a big goose egg on her forehead. Staff P stated she stayed with the resident while Staff O, CNA went to get Staff I, Licensed Practical Nurse (LPN). Staff P stated Resident #6's face was grimaced, she acted confused, moving to try to sit up and dazed, eyes not tracking and not responsive to her name. Staff P stated Staff O returned with Staff I who took vital signs then instructed the CNA's to get her up to the recliner. Staff P stated Resident #6 was not acting like herself, and the CNA's checked on her every 15 minutes, then Staff I instructed CNA's to place her in a wheelchair and take her to the nurses station. Staff P stated they were instructed by Staff K, RN to take Resident #6 to bed about 7 p.m. and she was normally a 1 person assist but at that time was a 2 person assist with a gait belt. During an interview on 12/18/23 at 3:47 p.m. Staff O, CNA stated on 9/26/23 about 4 p.m. she was caring for a resident and heard a loud thump. Staff O stated, I knew it was a body hitting the floor. Staff O stated she assisted Staff P, CNA and found Resident #6 on the floor, on her right side, 4-5 steps from her recliner with the walker at her feet. Staff O stated Resident #6 rolled over and had a bruise to her head and did not recognize her name. Staff O stated she went after Staff I, LPN who took Resident #6 vitals but she did not have a flashlight to assess neuro ' s, did not assess the residents arms or legs, and gave direction to Staff O and Staff P to get the resident up to the recliner. Staff O stated Resident #6 did not eat supper and was directed to put Resident #6 to bed at 7 p.m. by Staff K, RN who stated it was ok to put her to bed. Staff O stated she had been a CNA for 9 years and Resident #6 was not ok and she asked Staff I and Staff K if they were going to send her to the hospital. Staff O stated she and Staff P checked on her often to be sure she was still breathing due to Resident #6 did not arouse again after being put to bed. Staff O stated Staff K did not go into Resident #6's room to assess her. During an interview on 12/18/23 at 1:09 p.m. Staff I, LPN stated she worked on 9/26/23, 6 a.m. to 6 p.m. and was notified by staff CNA's that Resident #6 had an unwitnessed fall in her room about 4 p.m. Staff I stated, She had a goose egg on her forehead. Staff I stated it took 3 staff to get Resident #6 off the floor. Staff I stated she had notified Staff J, Advanced Registered Nurse Practitioner (ARNP) and was told to monitor the resident. Staff I stated she initiated a neurological sheet with the date and times neuro checks were to be completed and it was given to the 6 p.m. to 6 a.m. staff nurse in report, Staff K, Registered Nurse (RN). Staff I stated Resident #6 was restless, could not sit still, and cried. During an interview on 12/18/23 at 1:20 p.m., Staff J, ARNP, stated she had received a call on 9/26/23, informed that Resident #6 fell, hit her head and the neurological test was normal. Staff J stated an order was given to monitor the resident and expected a call if there were changes or an inability to awaken the resident. Staff J stated she did not receive a follow up call, no one identified that Resident #6 was crying, restlessness that would suggest pain or confusion. Staff J stated, I would have sent her out if I felt she had further injuries or if in pain. Staff J stated she had provided training to nursing staff in the past to include tube feeding, neuro and dementia pain assessments. Staff J stated, There is a big gap in the knowledge of the nurses here. During an interview on 12/19/23 at 3:47 p.m. Staff A, CNA stated she worked on 6/27/23 at 6 a.m., rounded with the the night shift CNA's who reported that they did not hear Resident #6 get up to the bathroom during the night so they did not go in. Staff A stated Resident #6 looked like she was in discomfort and asked Staff K, RN what happened to her, and was told by Staff K that he had given Resident #6 pain medication. Staff A stated she proceeded to give Resident #6 a bed bath. Staff A stated Resident #6 moaned when turned. Staff A stated Resident #6 did not eat so she left her in bed, changed her once and then went to get Staff M, RN around 11 a.m. to make an assessment due to Resident #6 looked rough. During an interview on 12/18/23 at 3:01 p.m. Staff M, RN stated she had worked as the previous Director of Nursing (DON) in the facility and worked on 9/27/23 as the day nurse, 6 a.m. to 6 p.m. Staff M stated she had received report at 6 a.m. from Staff K, RN that Resident #6 had a fall but Staff K did not share the extent of the fall. Staff M stated she was caring for a very sick resident down a different hall all morning until Staff A, CNA came to find her around 11 a.m. and stated Resident #6 was not waking up. Staff M stated she found Resident #6 unresponsive and notified Staff J, ARNP and the resident's family then transferred the resident to the hospital. Staff M stated she found the neuro sheet under a stack of papers at the nurses station. Staff M stated she interviewed Staff K over the phone who stated he had not assessed Resident #6 as she was asleep. Staff M stated it was normal practice for staff to call and notify the DON if there was a fall and there was no notification given to her. During an interview on 12/19/23 at 8:52 a.m., Resident #6's son stated his mother was quarantined in her room behind a closed door due to COVID and had two falls, a week apart. The son stated the family was notified of both falls but felt this last fall on 9/26/23 was down played. The son stated he received a call on 9/27/23 asking if the family would want her evaluated at the local hospital due to a possible UTI. The son stated he went to the hospital, I could not believe it, I could not recognize her ''. The son stated he spoke with his brother since this was more than a UTI and felt it was more than the local hospital could handle, therefore had Resident #6 transferred to the tertiary hospital for higher level of care. The son stated he was not going to send his mother back to this facility, requested the hospital Hospice to assist with the location of a facility, then transferred mother to a different facility until she passed from her injuries 2 weeks later on 10/28/23. Tertiary Hospital Record Review for Resident #6 dated 9/27/23 revealed: a. Subdural Hematoma (blood between the brain and its outermost covering). b. Bruises to right head and right shoulder c. Acute Encephalopathy (brain disease that alters brain function causes infection, tumor, and stroke) d. Fracture of the right clavicle e. UTI (urinary tract infection) f. Unresponsive to sternal rub (chest bone) g. Tachycardia (fast heart rate) h. Febrile (high body temperature) i. Vital Signs Blood pressure 138/79, Pulse 113, Respirations 20, Temperature 100.6 j. admitted to the tertiary hospital During an interview on 12/19/23 at 8:59 AM Staff N, Medical Examiner Investigator stated the cause death for Resident #6 was a result of complications from blunt force trauma injuries to head and clavicle, date of death [DATE]. The policy titled Neurological Evaluation dated 3/28/23 revealed: a. A neurological evaluation will be performed by a licensed nurse when a resident's status warrants suspected head injury, CVA (stroke) and/or unwitnessed fall to identify a change of condition related to a possible head injury. b. Concern over change in mental status c. A change in level of consciousness d. Inspect pupil reaction with flashlight, e. Observe if resident moves all extremities f. Observe if the resident obeys commands & pain g. Notify physician for pupil reaction changes, decrease level of consciousness, changes in vital signs and or change of condition 2. The Quarterly Minimum Data Set(MDS) assessment tool, dated 6/8/23, listed diagnoses for Resident #2 which included non-Alzheimer's dementia, traumatic brain injury, and communication deficit. The MDS stated the resident had physical behavioral symptoms directed towards others(e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) for 1-3 days in the 7 day review period and listed the resident's Brief Interview for Mental Status(BIMS) score as 4 out of 15, indicating severely impaired cognition. The facility policy Abuse Prevention, revised 10/21/22, define abuse as willful infliction of injury resulting in physical harm, pain, mental anguish or emotional distress and stated abuse included resident-to-resident and staff-to-resident interactions. The policy defined neglect as the failure of an employee to provide reasonable or necessary services to maintain the physical and mental health of any consumer when that failure presented either imminent danger to the health, safety, or welfare of a consumer or a substantial probability that death or serious physical injury would result. The policy stated the facility was committed to protecting the resident from abuse. The Significant Change in Status MDS assessment tool, dated 3/31/23, listed diagnoses for Resident #8 which included non-Alzheimer's dementia, repeated falls, and adult failure to thrive. The MDS listed the resident's BIMS score as 2 out of 15, indicating severely impaired cognition. The admission MDS assessment tool, dated 6/7/23, listed diagnoses for Resident #5 which included diabetes, anxiety disorder, and insomnia. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The admission MDS assessment tool, dated 6/30/23, listed diagnoses for Resident #3 which included non-Alzheimer's dementia, encephalopathy(disease of the brain), and constipation. The MDS listed the resident's cognition as severely impaired. The Quarterly MDS assessment tool, dated 5/25/23, listed diagnoses for Resident #11 which included non-Alzheimer's dementia, anxiety disorder, and depression. The MDS listed the resident's BIMS score as 12 out of 15, indicating moderately impaired cognition. The Quarterly MDS assessment tool, dated 5/10/23, listed diagnoses for Resident #15 which included diabetes, anxiety, and depression. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The Annual MDS assessment tool, dated 5/22/23, listed diagnoses for Resident #4 which included seizure disorder, anxiety disorder, and weakness. The MDS listed the resident's BIMS score as 0 out of 15, indicating severely impaired cognition. A 12/14/22 12:47 p.m. Nurses Note stated Resident #2 had increased behaviors and went into another resident's room and yelled at them, raised his fist at them, and defecated(had a bowel movement) in the hall. A 5/1/23 10:23 p.m. Nurses Note stated there were female residents who were afraid of Resident#2 and male residents who did not know what to do when he approached. A 5/26/23 3:48 p.m. Nurses Note stated Resident #2 attempted to hit a resident with his wheelchair. The other resident was scared and was consoled by staff. A 6/7/23 5:21 a.m. Progress Note for Resident #2 stated the resident had Resident #8 cornered in his room and was physically abusive towards him. The note stated Resident #8 reported that Resident #2 kicked him in the legs and the resident's legs were a little red but unsure if it was related to the incident. A untitled, undated facility document stated on 7/3/23 Resident #2 kicked Resident #5 and hit his finger. A 7/5/23 10:41 p.m. Nurses Note for Resident #2 stated Resident #2 was found in his room on the floor along with Resident #3. It appeared that a physical altercation between the 2 was what led to both men being on the floor. An Entity Self-Report stated Resident #2 and Resident #3 ended up on the floor during a physical altercation and Resident #2 struck Resident #3 with a closed fist. A 7/9/23 12:50 p.m. Behavior Note stated the Resident #2 was observed attempting to trip another resident. A 7/14/23 3:40 p.m. Nurses Note stated another resident reported Resident #2 kicked another resident (Resident#5) in the side of the right knee while he was walking past so the other resident slapped Resident #2 in the face. A 7/19/23 10:51 a.m. Behavior Note stated Resident #2 started hitting Resident #11 and then she hit him back with a newspaper. A 8/5/23 Incident Report stated Resident #2 hit another resident(Resident #15) on the hand after the other resident bumped his wheelchair when going around him. A 8/7/23 6:45 a.m. Incident Note stated Resident #2 kicked another resident(Resident #3) who just happened to be standing there and it was unprovoked. An 8/8/23 10: 25 a.m. Behavior Note stated a staff member intervened as the resident was going to hit another resident sitting at the table. An 8/8/23 1:12 p.m. Behavior Note stated the resident transferred to the ER due to behaviors. An 8/9/23 7:15 a.m. Nurses Note stated the resident returned from the ER and had an order to increase Trazadone(a sedative). An 8/10/23 1:45 p.m. Incident Note stated the resident kicked Resident #4. An 8/11/23 untitled document, written by Staff CC Certified Medication Assistant(CMA) stated on 8/10/23, Resident #2 aggressively swung his foot and kicked Resident #4 on her foot and Resident #4 screamed out in pain. An 8/13/23 Incident Report stated Resident #2 punched Resident #3 on the left side of his face. A 9/5/23 Witness Statement, written by Staff O Certified Nursing Assistant(CNA), stated Resident #2 kicked Resident #3 in the left leg around the shin and knee area. A 10/2/23 Incident Note stated Resident #2 was a victim of physical aggression. He sat in the common area with blood running down his face and stated he thought he was punched. A 10/2/23 Activities Note for Resident #5 stated Resident #5 was the aggressor in the above incident with Resident #2. Resident #5 stated that he and Resident #2 were arguing about a seat and that he hit Resident #2 at least twice with an open hand. A 10/8/23 6:30 p.m. Nurses Note stated Resident #2 approached another resident and slammed his hand down on the table beside her and told her to be quiet and shut up you idiot. A 10/14/23 11:49 a.m. Nurses Note stated another resident was making loud noises and Resident #2 went over and smacked her. A 10/14/23 Incident Report stated staff observed Resident #2 slap Resident #4's arm. A 10/17/23 Social Services note stated the resident would transfer to another facility. Care Plan entries for Resident#2 directed staff with the following interventions: 3/7/23 Zoloft(an antidepressant) 50 milligrams initiated and 15 minute checks and redirection as needed. 4/13/23 Analyze key times, places, circumstances, triggers and deescalate the behavior and document. Juice, snacks and complements have been successful. 5/1/23 Assess for the cause of the situation. 5/25/23 Assess for pain and verbal and non-verbal indications. 6/1/23 and 7/5/23 Medication adjustments made. 6/15/22 The resident has hit staff and other residents and the facility attempted to relocate. 7/15/23 Looking for other placement for the resident. 7/19/23 Facility finding additional resources for the resident to deal with his aggression. 8/5/23 Daughter requested evaluation for infection. 8/7/23 and 8/8/23 Sent out to the hospital for evaluation. 8/9/23 15 minute checks to continue until other placement found for the resident. 8/10/23 The facility would contact the Medical Director for insight to assist with keeping the resident and others safe. 8/10/23 One time dose of lorazepam (an anti-anxiety medication) and quieter eating environment. 10/30/23 Adjustments to pain medication and antidepressants to address issues that may cause behaviors. 10/30/23 Reach out to [name redacted, assisting agency] for assistance. 10/30/23 Observe interaction with other residents and keep other residents safe and remove them from the situation. 10/30/23 TV in room to entertain. 10/30/23 When noting onset of agitation, intervene before agitation escalates. On 12/7/23 at 10:58 a.m. via phone Staff O Certified Nursing Assistant (CNA) stated Resident #2 was aggressive and unpredictable. She stated there were multiple times when he harmed other residents. They tried to implement 15 minute checks but he would still do this (harm other residents). She stated there were some residents who were fearful because of him. On 12/7/23 at 1:25 p.m., Staff J Advanced Registered Nurse Practitioner(ARNP) stated Resident #2 was aggressive and could be the sweetest and nicest or rough, angry, and downright mean. He would try to stick his foot out at others and had multiple behavioral issues which could have ended up with him getting hurt. She stated she wrote a discharge order for him to go to another facility for memory care. On 12/7/23 at 2:15 p.m., Staff H Registered Nurse (RN), Minimum Data Set(MDS) Coordinator stated Resident #2 was either pleasant or agitated and it didn't take very much for him to become agitated. She stated she knew of several people that he hit or kicked. She stated she did not know of any interventions which were effective and they tried managing his pain and therapy. They were unable to distract him and he did not interact well in activities. On 12/11/23 at 9:51 a.m., the Social Services Supervisor stated Resident #2 had a lot of behaviors and the residents were really scared of him. She stated there were not a lot of warning signs when he would get aggressive and stated at first he became aggressive with the more mobile people who could talk back. Towards the end of his stay though, he started to seek out residents who were more vulnerable She stated his behaviors lasted over a period of months and would go up and down. There were times when it got really bad and then got better. She stated there were a lot of aggressive behaviors which would endanger residents and staff. She stated they implemented 15 minute checks but it did not prevent him from hurting other residents. She stated she would be in her office and came out right away(if she heard something going on) but she could not stop him towards the end. On 12/11/23 at 10:09 a.m. via phone, Staff U former Administrator stated Resident #2 had a traumatic brain injury and they care planned many interventions to decrease his behaviors. She stated things would go well for a while and then he would strike out or hit another resident who was more verbal. She stated at the end of his stay he would target residents who could not protect themselves and stated it was a period of months that he was physically aggressive towards other residents. She stated it increased in June and July(2023) and he would strike someone so quickly they did not have the opportunity to stop him. She stated they discharged him to keep the other resident's safe and she was fearful he would hurt someone. On 12/12/23 at 9:57 a.m., Staff M former Director of Nursing(DON) stated Resident #2's behavior started to change and he would act out unprovoked and if another residents rolled by, he would strike out. He was difficult to redirect and aggressive with staff, which lasted up until the time of discharge. She stated they would try(an intervention) and it was at first successful but then stopped working. She felt there was a risk to other residents. On 12/21/23 at 2:54 p.m. the Assistant Director of Nursing(ADON) stated she remembered hearing about Resident #2 hurting other residents and none of the facility's interventions worked in preventing it from happening again. 3. The admission MDS assessment tool, dated 6/30/23, listed diagnoses for Resident #3 which included non-Alzheimer's dementia, encephalopathy(disease of the brain), and constipation. The MDS listed the resident's cognition as severely impaired. A 9/2/23 written statement by Staff W Certified Nursing Assistant(CNA) stated Staff X Certified Medication Aide(CMA) was verbally and physically aggressive with a resident and stated don't touch me I know where your hands have been while shoving the resident's hands and body away from him. Staff X then grabbed the resident's arm and forcefully redirected him. A 9/2/23 written statement by Staff DD Registered Nurse(RN) stated on 9/2/23 at approximately 6:30 a.m., Resident #3 began talking to Staff X and reached out to touch his arm. Staff X then grabbed the resident around the left biceps and placed his closed fist on the resident's back and physically moved him away from his medication cart. The resident had slight redness and a possible bruise beginning on his left upper arm. On 12/19/23 at 1:06 p.m., via phone, Staff W stated Staff X tried to pass medication and Resident #3 was being Resident #3. She stated Staff X turned Resident #3 hard enough that he had a bruise on his arm. Staff W stated Staff X was hateful and told the residents they stunk. On 12/19/23 at 2:06 p.m., via phone, Staff Y Scheduler stated on the day of the alleged incident with Resident #3, Staff X was getting ready to start the medication pass and Resident #3 walked over to Staff X's medication cart but before the resident touched anything Staff X told the resident to get the f---(expletive) away from his cart. Staff X then grabbed Resident #3's arm and jerked him away from the medication cart and put his fist in his back to push him away. She stated the resident was in shock and got defensive. She stated they removed the resident from the area and she notified the Administrator and Staff X left the facility immediately. On 12/21/23 at 8:52 a.m. via phone, Staff DD, RN stated Staff X prepared some medications and Resident #3 liked to be up in your face. Staff X was irritated and grabbed the resident's arm to lead him away. Staff DD stated there was some redness on his arm but no bruising. On 12/21/23 at 2:54 p.m. Staff V Assistant Director of Nursing (ADON) stated staff should not grab residents by the arm in a rough manner. On 1/3/23 at 11:46 a.m., Staff V stated residents should be safe from other residents and staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy review, the facility failed to conduct assessments and provide timely interventions for 6 out of 6 residents with a change of condition (Resident #13, #6, #1, #14, #8 & #10). The facility failed to assess Resident #13 after the Speech Therapist conducted a swallowing evaluation that revealed moderately severe dysphagia, and clinical signs of aspiration during the study on 10/11/23, and subsequently the resident was hospitalized [DATE] with Hypoxia (lack of oxygen), fever, acute aspiration pneumonia, Rhinovirus (common cold), Methicillan-resistant Staphylococcus Aureus (MRSA, a contagious antibiotic-resistant staph infection) positive in both nares, acute kidney injury and a leaking PEG feeding tube that required replacement. Clinical record review revealed on 9/26/23 at 4:00 p.m., Resident #6 fell and sustained a hematoma to her head. The facility staff initiated neurological assessments but failed to conduct follow-up neurological assessments and report changes to the provider for 16 hours. The facility then sent the resident to the ER where the resident was assessed to have a subdural hematoma (brain bleed), fracture of the right clavicle and urinary tract infection. The facility failed to provide an assessment for Resident #1 and #14 after a change of condition which required hospitalization and failed to provide an assessment and intervention for Resident #8 & #10 after identification of no bowel movements. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 11, 2023 on December 7, 2023 at 12:25 p.m. The facility staff removed the Immediate Jeopardy on December 11, 2023 by implementing the following actions: 1. DON Completed In-Service w/Licensed Staff on 12/7/23: a. Recognizing & Reporting Change in Condition. i. Completed eLearning Healthcare Academy Course on Recognizing/Reporting Resident Changes in Condition. b. Change of Condition Evaluation. c. Implementation of Interventions w/Change in Condition. d. Notification of Change in Condition Policy. e. admission readmission Orders Policy. 2. DON/Designee Completed 100% Audit on Residents on 12/7/23: a. Completed Change of Condition Evaluation. b. Implemented Interventions w/Change in Condition. c. Physician/NP/RR Notifications were Completed. d. Staff educated on Admission/Readmit orders e. Verify Admits/readmission Medication Orders with Physician/NP. 3. DON/Designee will Orientate New Hires/Agency Employees on 12/7/23: a. Complete eLearning Course; Recognizing/Reporting Resident Changes in Condition. b. Change in Condition Evaluation. c. Implementation of Interventions w/Change in Condition. d. Following Notification Change in Condition Policy. e. admission readmission Orders Policy. The scope lowered from K to E at the time of the survey after ensuring the facility implemented educaiton and their policy and procedures. The facility reported a census of 50 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #13 revealed a diagnosis of chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease (GERD), complete loss of teeth due to periodontal disease and tracheostomy with dependence on supplemental oxygen. Resident #13 had a Brief Interview for Mental Status (BIMS) of 15 suggesting an intact cognition. Care Plan dated 5/2/23 directed staff to observe, document and report any difficulty breathing, acute signs of respiratory insufficiency, respiratory infection and difficulty swallowing. Document titled Therapy and Nursing Communication (Speech Therapy Evaluation and Plan of Treatment) dated 10/11/23 for Resident #13. Staff EE, Speech Therapist (ST) evaluation and treat for correct diet revealed: a. Clinical impressions: Resident #13 demonstrated moderately severe oral pharyngeal dysphagia (difficulty swallowing) characterized by clinical signs of aspiration (robust and repeated coughing) for thin liquids and mechanical soft solids. b. Recommendation to continue puree diet with nectar thickened liquids (NTL), one bite at a time, sit upright after oral intake for 30 minutes. c. Strongly recommend to have Modified Barium Swallow (MBS) to rule out aspiration, determine most appropriate diet and therapeutic exercises for rehabilitation. Progress note dated 10/18/23 at 9:51 p.m. documentation by Staff J, Advanced Registered Nurse Practioner (ARNP) revealed Resident #13 had diminished lung sounds in bases of lungs and recommended for staff to continue to monitor for changes. Progress notes dated 11/6/23 at 8:30 p.m., documentation by Staff J, ARNP, revealed Resident #13 had: a. A history of swallowing difficulties that included aspiration pneumonia. b. Diminished lung sounds in the bases of both lungs. c. Teeth removed and had yet to be fitted for dentures. d. A plan for a swallow study ordered. e. Tube feedings as needed for nutrition. f. A recommendation for staff to continue to monitor for changes in condition. Nurses progress notes reviewed for Resident #13 dated 10/10/23 through 11/12/23 which lacked assessments by nursing staff, and the barium swallow evaluation appointment to rule out aspiration was not followed through. Progress note dated 11/12/23 at 1:54 p.m. for Resident #13 stated the nurse was notified in report that Resident #13 was sent out due to respiratory distress and oxygen sat in the 70's (oxygen saturation in the blood normal 95-100%). During an interview on 12/6/23 at 3:39 p.m. Staff EE, Speech Therapist (ST) stated that on 10/11/23 she informed the Staff FF, Therapy Director that Resident #13 had aspirated during the swallowing evaluation, she would notify the staff nurse who would notify the physician. During an interview on 12/7/23 at 9:52 a.m. Staff FF, Therapy Director, stated she was notified by Staff EE that Resident #13 had aspirated during the swallow study and the recommendations to continue the thickened liquids, puree diet and he needed a swallow study done. Staff FF stated she relayed this information to the nurse in charge and notified the dietary staff of the diet recommendations. Staff FF stated she also provided the information to the Utilization Review meeting staff and Staff M, former Director of Nursing (DON) was present. During an interview on 12/6/23 at 9:04 a.m. Staff H, MDS Coordinator stated she had notified the provider the day after Resident #13 transferred to the hospital and documented it due to not being documented in pointclickcare progress notes by the agency staff nurse who transferred Resident #13. Staff H stated she was surprised that Resident #13 was transferred as she was unaware of his issues. Staff H stated if a resident was having issues, they are to be placed on the Hot Chart sheet and the nurses are to assess the resident and document in the nurses notes. Staff H stated, Nobody consistently puts notes on the Hot Chart sheet. During an interview on 12/6/23 at 12:00 p.m. Staff M, Former DON, stated Resident #13 was evaluated by speech therapy and Staff FF Therapy Director informs nursing so it can be put in the book at the nursing station, updated on the medication orders and care plan by the MDS coordinator. Staff M stated she was not aware Resident #13 had aspirated and was not informed that he was transferred to the hospital and did not recall if the provider was notified. During an interview on 12/7/23 at 1:33 p.m., Staff J, Advanced Registered Nurse Practioner (ARNP), stated she had seen the speech therapy evaluation and was aware Resident #13 had aspirated during the evaluation. Staff J stated she would expect the nurses to assess Resident #13 after that evaluation, At least his heart and lungs. Staff J stated she did not receive a call with an update for Resident #1's condition and did not receive a call that he was transferred. Staff J stated, I would expect the nurse to call me, I did not know and feel terrible. Tertiary Hospital Record Review for Resident #13 dated 11/14/23 revealed: a. Treated in the emergency room on [DATE] with a high probability of imminent life deterioration due to acute respiratory failure. b. admitted to the Medical Intensive Care Unit (MICU). c. Hypoxia (lack of oxygen) d. Fever e. Acute aspiration pneumonia f. Rhinovirus with MRSA positive in both nares g. Acute kidney injury h. Leaking PEG feeding tube that required replacement. 2. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed the diagnosis Diabetes Mellitus, hypertension, renal insufficiency, aphasia (loss of ability to understand or express speech), altered mental status. Resident #6 required limited assistance for bed mobility, transfers, toileting, and for personal care. Resident #6 used a wheeled walker to ambulate and was frequently incontinent of urine. Resident #6 had a Brief Interview for Mental Status (BIMS) score of 1 which suggested a severe cognitive impairment. The Care Plan dated 9/15/23, instructed the staff to ambulate Resident #6 with a wheeled walker, provide assistance with transfer, toileting, personal hygiene and dressing with the assistance of 1 staff member. Resident #6 was identified as a fall risk and staff was directed to check frequently and assist as needed. Progress notes 9/26/23 at 4 p.m. for Resident #6 revealed: a. Staff I, Licensed Practical Nurse (LPN) notified that Resident #6 fell. b. Assessment complete and Neuro checks were initiated. c. A 4 cm x 5 cm bruise and swelling noted to the right side of forehead. d. Resident #6 was confused at the time and Urinary tract infection (UTI) was suspected. e. Three staff assisted the resident in a wheelchair, to the nurses station for 1 on 1 supervision. f. Family was notified. g. Staff J, Advance Registered Nurse Practitioner (ARNP) was notified. h. A new order for one time dose of 12.5 mg Hydralazine due to blood pressure (BP) of 165/101 and obtain a urine sample. Neurological Evaluation form directed staff to complete post fall if resident hit head or unwitnessed fall: a. every 15 minutes for 1 hour b. every 30 minutes for hour c. every hour for 2 hours d. every 2 hours for 8 hours e. every 4 hours for 12 hours f. every shift for 72 hours. The Neurological Evaluation for Resident #6 revealed: a. Neurological assessments were initiated on 9/26/23 at 4 p.m. b. At 4:00 p.m. blood pressure (BP) 165/101,pulse (P) 92, Respiration (R) 18 (temperature was not assessed), LOC (level of Consciousness) 4+ (Lethargic, sleepy or drowsy), Pupils 4 and reactive to light (+), Hand grips refused, Lacked pain assessment. c. At 5:15 p.m. BP 129/95, P 98, R 18, LOC 4+ Lethargic, pupils 4+ Hand grasps AB (absent) d. Lack of documentation for the following assessment date and time: e. On 9/26/23 at 5:45, 6:45, 7:45, 9:45, and 11:45 p.m. f. On 9/27/23 at 1:45, 3:45, and 7:45 a.m. g. On 9/27/23 at 11:15 a.m. revealed: BP 154/48, P 116, R 16, LOC 3+ stuporous (not awake), lacked assessment of pupil size, responsiveness, hand grips and pain assessment. Progress note dated 9/27/23 at 11:10 a.m. for Resident #6 revealed: a. Staff M, RN asked by staff to assess Resident #6. b. Resident eyes closed, did not respond to name or touch. c. Vital Signs: temperature (T) 100.4, P 114, R 16, BP 158/48. d. Unable to arouse the resident. Progress note dated 9/27/23 at 11:25 a.m. for Resident #6 revealed that Staff M, RN notified the family who requested transport to the Emergency department for evaluation. The ambulance was notified. The Situation, Background, Assessment, and Recommendation (SBAR) dated 9/27/23 at 11:25 a.m., completed by Staff M, RN, the findings included: a. Unresponsiveness b. Condition, symptom, sign had not occurred before c. Pain: does the resident have pain? yes non-verbal occasional moan or groan, facial grimacing d. Testing none e. Interventions none f. Family was notified on 9/27/23 at 11:25 a.m. g. On 9/27/23 at 11:38 a.m. Staff J, ARNP notified. Progress note dated 9/27/23 at 11:55 a.m. revealed that Resident #6 was transported to the local hospital. During an interview on 12/18/23 at 3:29 p.m. Staff P, CNA stated Resident #6 was pleasantly confused on 9/26/23, which was her normal. Staff P stated she was in the hall when she heard a loud thunk and started searching rooms. Staff P stated she found Resident #6 face down in her room with a big goose egg on her forehead. Staff P stated she stayed with the resident while Staff O, CNA went to get Staff I, LPN. Staff P stated Resident #6's face was grimaced, she acted confused, moving to try to sit up and dazed, eyes not tracking and not responsive to her name. Staff P stated Staff O returned with Staff I who took vital signs then instructed the CNA's to get her up to the recliner. Staff P stated Resident #6 was not acting like herself, and the CNA's checked on her every 15 minutes, then Staff I instructed CNA's to place her in a wheelchair and take her to the nurses station. Staff P stated they were instructed to take Resident #6 to bed about 7 p.m. and she was normally a 1 person assist but at that time was a 2 person assist with a gait belt. During an interview on 12/18/23 at 3:47 p.m. Staff O, CNA stated on 9/26/23 about 4 p.m. she was caring for a resident and heard a loud thump. Staff O stated, I knew it was a body hitting the floor. Staff O stated she assisted Staff P, CNA and found Resident #6 on the floor, on her right side, 4-5 steps from her recliner with the walker at her feet. Staff O stated Resident #6 rolled over and had a bruise to her head and did not recognize her name. Staff O stated she went after Staff I, LPN who took Resident #6 vitals but she did not have a flashlight to assess neuro's, did not assess the residents arms or legs, and gave direction to Staff O and Staff P to get the resident up to the recliner. Staff O stated Resident #6 did not eat supper and was directed to put Resident #6 to bed at 7 p.m. by Staff K, RN who stated it was ok to put her to bed. Staff O stated she had been a CNA for 9 years and Resident #6 was not ok and she asked Staff I and Staff K if they were going to send her to the hospital. Staff O stated she and Staff P checked on her often to be sure she was still breathing due to Resident #6 did not arouse again after being put to bed. Staff O stated Staff K did not go into Resident #6 ' s room to assess her. During an interview on 12/18/23 at 1:09 p.m. Staff I, LPN stated she worked on 9/26/23, 6 a.m. to 6 p.m. and was notified by staff CNA ' s that Resident #6 had an unwitnessed fall in her room about 4 p.m. Staff I stated, She had a goose egg on her forehead. Staff I stated it took 3 staff to get Resident #6 off the floor. Staff I stated she had notified Staff J, ARNP and was told to monitor the resident. Staff I stated she initiated a neurological sheet with the date and times neuro checks were to be completed and it was given to the 6 p.m. to 6 a.m. staff nurse in report, Staff K, RN. Staff I stated Resident #6 was restless, could not sit still, and cried. During an interview on 12/18/23 at 1:20 p.m., Staff J, ARNP, stated she had received a call on 9/26/23, informed that Resident #6 fell, hit her head and the neurological test was normal. Staff J stated an order was given to monitor the resident and expected a call if there were changes or an inability to awaken the resident. Staff J stated she did not receive a follow up call, no one identified that Resident #6 was crying, restlessness that would suggest pain or confusion. Staff J stated, I would have sent her out if I felt she had further injuries or if in pain. Staff J stated she had provided training to nursing staff in the past to include tube feeding, neuro and dementia pain assessments. Staff J stated, There is a big gap in the knowledge of the nurses here. During an interview on 12/19/23 at 3:47 p.m. Staff A, CNA stated she worked on 6/27/23 at 6 a.m., rounded with the the night shift CNA's who reported that they did not hear Resident #6 get up to the bathroom during the night so they did not go in. Staff A stated Resident #6 looked like she was in discomfort and asked Staff K, RN what happened to her, and was told by Staff K that he had given Resident #6 pain medication. Staff A stated she proceeded to give Resident #6 a bed bath. Staff A stated Resident #6 moaned when turned. Staff A stated Resident #6 did not eat so she left her in bed, changed her once and then went to get Staff M, RN around 11 a.m. to make an assessment due to Resident #6 looked rough. During an interview on 12/18/23 at 3:01 p.m. Staff M, RN stated she had worked as the previous Director of Nursing (DON) in the facility and worked on 9/27/23 as the day nurse, 6 a.m. to 6 p.m. Staff M stated she had received report at 6 a.m. from Staff K, RN that Resident #6 had a fall but Staff K did not share the extent of the fall. Staff M stated she was caring for a very sick resident down a different hall all morning until Staff A, CNA came to find her around 11 a.m. and stated Resident #6 was not waking up. Staff M stated she found Resident #6 unresponsive and notified Staff J, ARNP and the resident's family then transferred the resident to the hospital. Staff M stated she found the neuro sheet under a stack of papers at the nurses station. Staff M stated she interviewed Staff K over the phone who stated he had not assessed Resident #6 as she was asleep. Staff M stated it was normal practice for staff to call and notify the DON if there was a fall and she did not receive any notification. During an interview on 12/19/23 at 8:52 a.m., Resident #6's son stated his mother was quarantined in her room behind a closed door due to COVID and had two falls, a week apart. The son stated the family was notified of both falls but felt this last fall on 9/26/23 was down played. The son stated he received a call on 9/27/23 asking if the family would want her evaluated at the local hospital due to a possible UTI. The son stated he went to the hospital, I could not believe it, I could not recognize her''. The son stated he spoke with his brother since this was more than a UTI and felt it was more than the local hospital could handle, therefore he had Resident #6 transferred to the tertiary hospital for higher level of care. The son stated he was not going to send his mother back to this facility, requested the hospital Hospice to assist with the location of a facility, then transferred mother to a different facility until she passed from her injuries 2 weeks later on 10/28/23. Tertiary Hospital Record Review for Resident #6 dated 9/27/23 revealed: a. Subdural Hematoma (blood between the brain and its outermost covering). b. Bruises to right head and right shoulder c. Acute Encephalopathy (brain disease that alters brain function causes infection, tumor, and stroke) d. Fracture of the right clavicle e. UTI (urinary tract infection) f. Unresponsive to sternal rub (chest bone) g. Tachycardic (fast heart rate) h. Febrile (high body temperature) i. Vital Signs Blood pressure 138/79, Pulse 113, Respirations 20, Temperature 100.6 j. admitted to the tertiary hospital During an interview on 12/19/23 at 8:59 AM Staff N, Medical Examiner Investigator stated the cause death for Resident #6 was a result of complications from blunt force trauma injuries to head and clavicle, date of death [DATE]. During an interview on 12/6/23 at 8:30 a.m. Staff S, DON stated her expectation of the nurse on admission was for the nurse to review the discharge orders, and after falls and change of condition, place the resident on the Hot Chart sheet and perform an assessment every shift until the DON instructs them to stop. The policy titled Neurological Evaluation dated 3/28/23 revealed: a. A neurological evaluation will be performed by a licensed nurse when a resident ' s status warrants suspected head injury, CVA (stroke) and/or unwitnessed fall to identify a change of condition related to a possible head injury. b. Concern over change in mental status c. A change in level of consciousness d. Inspect pupil reaction with flashlight, e. Observe if resident moves all extremities f. Observe if the resident obeys commands & pain g. Notify physician for pupil reaction changes, decrease level of consciousness, changes in vital signs and or change of condition 3. The MDS dated [DATE] for Resident #14 revealed a diagnosis of cerebral palsy, aphasia (inability to speak), dysphagia (difficulty swallowing), profound intellectual disabilities and a PEG tube feeding to receive nutrition and medications. The Care Plan dated 11/16/23 for Resident #14 instructed staff to observe closely for signs of pain, dehydration, no urine output, increased pulse, fever and observe and report signs of aspiration, abnormal lung sounds and abdominal distension. The care plan instructed to keep the head of the bed elevated due to the tube feeding and flush the peg tube with 200 ml (milliliters) of water every 6 hours and 30 ml of water before and after administering medications. Progress note dated 10/31/23 Resident #14's temperature (T) was 100.3 and the ARNP was aware, COVID testing was negative. Progress notes lacked nursing assessment dates 11/1/23 through 11/14/23. Progress note dated 11/14/23 at 9:40 p.m. Resident #14 was having gurgling sounds, T 99.9 heart rate 126 respirations 26 and Oxygen saturation 70%, resident was vomiting, abdomen distended. Lacked documentation of notification to ARNP and POA (power of attorney) at that time. Progress note dated 11/15/23 at 12:10 a.m. Staff J, ARNP notified of Resident #14's condition, notified POA who requested transfer to the hospital, Emergency Medical Services (EMS) notified. Tertiary Hospital Record Review for Resident #14 dated 11/15/23 revealed: a. Severe sepsis (body's extreme response to an infection) with septic shock (life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection). b. Blood pressure 69/43 c. Lab [NAME] Blood Count (WBC) 24.9 (normal 3.7-10.5) 4. The MDS dated [DATE] for Resident #10 revealed a diagnosis of Alzheimer's disease, cognitive communication deficit, dysphagia and required assistance of one person for toileting. Progress notes for Resident #10 revealed a lack of bowel assessment and intervention for November and December 2023. Physician Orders for Resident #10 revealed Milk of Magnesia Suspension give 30 cc by mouth every 24 hours As Needed (PRN) for constipation. Elimination Flow sheet December 2023 for Resident #10 revealed: a. No documentation for Bowel Movement (BM) on day shift dated 1st, 2nd, 3rd, and 4th, 2023 b. Documentation for BM evening shifts dates 1st zero, 2nd small, 3rd no documentation, 4th zero c. Documentation for BM night shift dates 1st, 3rd, and 4th no documentation. 2nd zero BM. Medication Administration Record (MAR) for Resident #10 revealed: a. December 1-4, 2023 Milk of Magnesia Suspension give 30 cc by mouth every 24 hours PRN constipation per bowel protocol was not administered. b. November 2023 Milk of Magnesia Suspension give 30 cc by mouth every 24 hours PRN constipation per bowel protocol was not administered. Document titled Nursing Hot Sheet BM's for South Hall for Resident #10 revealed: a. Date 11/14/23 last BM on 11/10/23, no PRN given and no assessment of results. b. Date 11/27/23 last BM on 11/10/23, no PRN given, no assessment of results. c. Date 12/5/23 last BM on 12/2/23, no PRN given, no assessment of results. 5. The MDS dated [DATE] for Resident #8 revealed a diagnosis of dementia, heart disease, legally blind and required the assistance of 1 for toileting. Progress notes for Resident #8 revealed a lack of bowel assessment and intervention for November and December 2023. Elimination Flow Sheet dated December 2023 for Resident #8 revealed: a. No documentation of BM's on day shift 1-4th, 2023 b. Evening shift 1st zero, 2nd small, 3rd no documentation, 4th zero BM c. Night shift no documentation on 1st, 3rd and 4th. On the 2nd zero. Document titled Nursing Hot Sheet BM's for South Hall for Resident #8 revealed: a. Date 12/4/23 last BM 12/2/23 no PRN given and no assessment completed. b. Date 11/27/23 last BM 11/22/23 no PRN given and no assessment completed. Medication Administration Record (MAR) for Resident #8 revealed: a. December 2023 Senna Plus tablet 8.6-5.0 milligram (mg), give 1 tablet by mouth one time a day for bowel management was not given on 12/2/23. b. December 2023 no order for a PRN medication to treat constipation. c. November 2023 no order for a PRN medication to treat constipation. 2. The Minimum Data Set(MDS) assessment tool, dated 10/25/23, listed diagnoses for Resident #1 which included schizophrenia, major depressive disorder, and dementia. The MDS stated the resident was dependent on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, personal hygiene, and chair to bed transfers. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 0 out of 15, indicating severely impaired cognition. A 10/31/23 Nurses Note stated the resident transferred to the hospital yesterday(10/30/23). A hospital Discharge summary, dated [DATE], stated the resident's principal diagnosis was sepsis(an infection throughout the body) due to a urinary tract infection. An 11/3/23 2:50 p.m. admission Note stated the resident arrived at the facility via ambulance. An 11/3/23 4:00 p.m. Nurses Note stated the resident had an order for doxycycline(an antibiotic) 100 milligrams(mg) due to urinary tract infection(UTI). An 11/6/23 Nurses Note, written by Staff H Advanced Registered Nurse Practitioner(ARNP) stated the resident recently returned from the hospital with a diagnosis of sepsis secondary to UTI. The Temperature Summary listed an 11/21/23 4:31 a.m. temperature of 103.6 degrees Fahrenheit. An 11/21/23 5:30 a.m. Activities Note stated the resident's daughter agreed to transfer the resident to the hospital for evaluation and treatment and the resident transferred to the ER at 5:30 a.m. The note did not include the reason for the transfer. An 11/21/23 Skilled Nursing Facility(SNF)/Nursing Facility(NF) to Hospital Transfer Form stated the resident transferred to due to a high temp of 103.6 degrees Fahrenheit. An 11/21/23 ED to Hosp-admission Note stated the resident arrived this morning due to increasing agitation and decreased alertness overnight. Staff at the facility stated she became more sleepy and had not been to meals since the evening of 11/19/23. Staff stated last night she felt warm and had a temperature of 104 degrees Fahrenheit. The facility lacked documentation of a change in condition and assessments and intervention prior to 11/21/23. The facility lacked documentation of assessments carried out from 11/19/23-11/21/23. The resident's Temperature Summary lacked a temperature from 11/15/23-11/21/23. The resident's Care Plan as of 11/21/23 did not address the resident's history of urinary tract infection or sepsis. During an interview on 1/3/23 at 9:00 a.m., the Administrator stated the facility did not have a general assessment and intervention policy. On 12/21/23 at 2:54 p.m. the Assistant Director of Nursing(ADON) was queried about her expectations if a resident did not go to meals and was lethargic. She stated she would expect staff to carry out an assessment, complete vital sights and complete a full head to toe assessment. She stated staff should notify the provider and the family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy review, the facility failed to implement their infection control policy to ensure MRSA (a contagious staph bacteria infection) was contained. Hospital record review revealed Resident #13 was hospitalized for hypoxia, aspiration pneumonia and was found to be positive for MRSA in the nares (nose). Due to the nursing staff that re-admitted Resident #13 not reviewing the hospital discharge records, lab results were not reported and the facility did not provide personal protective equipment for staff use for 10 days. The facility also failed to follow infection control practices during a meal service for Resident #19 & #20. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of November 27, 2023 on December 7, 2023 at 12:25 p.m. The facility staff removed the Immediate Jeopardy on December 7, 2023 by implementing the following actions: 1. DON Completed In-Service with (w)/Licensed Staff on Enhanced Barrier Precautions Policy on 12/7/23. 2. DON Completed In-Service w/All Staff on Enhanced Barrier Precautions Policy on 12/7/23. 3. DON Completed 100% Audit on Residents to Ensure Enhanced Barrier Policy is being followed on 12/7/23. 4. DON/Designee will Orientate New Hires/Agency Employees on Enhanced Barrier Policy on 12/7/23. The facility reported a census of 50 residents. Findings Include: 1. The MDS dated [DATE] for Resident #13 revealed a diagnosis of chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease (GERD), complete loss of teeth due to periodontal disease and tracheostomy with dependence on supplemental oxygen. Resident #13 had a BIMS of 15 which suggested an intact cognition. During an observation on 12/4/23 at 10:43 a.m. Resident #13 was in bed, in his room, unable to speak due to congestion, harsh, productive cough with thick phlegm, and had oxygen tubing that should have been in his nose, located under his chin. During an observation on 12/4/23 at 12:20 p.m. Resident #13 was in the dining room at a table with 3 lady residents, his head on the table, coughing and did not eat the food offered. During an observation on 12/4/23 at 3:15 p.m. Resident #13 was in bed. Staff T, Registered Nurse (RN) was sitting on his bed, next to Resident #13, with a torn glove on the left hand, and provided a dressing change to his neck. Document provided by the tertiary hospital consult notes dated 11/14/23 from the infectious disease practioner revealed the present illness for Resident #13 was pneumonia from pseudomonas and positive for MRSA in nares. Progress note dated 11/27/23 at 3:21 p.m. revealed Resident #13 returned from the hospital at 2 p.m. following hospitalization for pneumonia, oxygen at 3 liters, and complaints of sore throat. Progress note dated 11/28/23 at 2:31 p.m. revealed Resident #13 had been out of room for meals, poor intake, and oxygen lowered from 6 liters to 3 liters. During an interview on 12/12/23 at 1:32 PM, Staff T, Registered Nurse, (RN) stated that she didn't want to work at this facility due to lack of staffing and lack of support during admits. Staff T stated, I feel there are too many residents for one nurse and I don't want to get caught in a situation where I'll be missing information on a resident. During an interview on 12/6/23 at 8:30 a.m., Staff S, Director of Nursing (DON) stated she was unable to locate Resident #13's recent hospital and discharge documents, but the expectation of the nursing staff completing admission was to review the discharge documents, place the resident on the Hot Chart sheet and document an assessment every shift until directed to stop by the DON. Staff S, reported she had worked at this facility as an agency nurse for 5 weeks, and as director for a week. Staff S stated she was unaware that Resident #13 had MRSA. During an interview on 12/7/23 at 1:33 PM, Staff J Advanced Registered Nurse Practitioner (ARNP) stated when Resident #13 returned from the hospital on [DATE], she had asked the Director of Nursing for the discharge orders, requested to have them posted on the PointClickCare computer system for review, and it was not posted until 12/6/23. Staff J stated she was not aware of the MRSA until she was informed on 12/6/23 in the afternoon. Policy titled Surveillance for Healthcare Associated Infections dated 10/7/21 revealed the procedure was to obtain a physician's diagnosis of infection or identify conditions that meet McGreer's Criteria & Centers for Disease Control (CDC) Guidelines for surveillance in long term care settings and to review laboratory reports for cultures with pathogens. Policy titled Contact Isolation Precautions dated 10/25/22 revealed that the facility will implement contact isolation precautions on residents as appropriate to reduce risk of transmitting infectious agents such as Multi-Drug Resistant Organisms (MDRO's) to include personal protective equipment (PPE) for staff. Policy titled Enhanced Barrier Precautions dated 2/28/22 revealed that the facility may expand the use of PPE during high contact resident care activities that provide opportunities for transfer of MDRO's to hands/clothing for facility residents with wound or indwelling medical devices regardless of the MDRO colonization as well as for residents with MDRO infection/colonization. The CDC webpage https://www.cdc.gov/mrsa/healthcare//index.html published 7/31/23 contained the following information regarding MRSA in a healthcare setting: a. MRSA is usually spread by direct contact. b. The only way to know if MRSA is the cause of an infection is to perform a culture (a laboratory test) of the bacteria. c. Successful MRSA prevention requires action both at the healthcare facility level, among healthcare providers and healthcare leadership. d. Based on the current evidence, CDC continues to recommend the use of Contact Precautions for MRSA-colonized or infected patients. 2. During an observation on 12/6/23 at 9:10 a.m., Staff A Certified Nursing Assistant (CNA) ate a donut with her bare hands while she stood in front of the kitchen serving window. Without washing her hands, she picked up some clean napkins and handed them to Resident #19. Staff A then sat down next to Resident #20 and picked up one of her cups to assist her. Staff A then picked up a soiled napkin which was on the table next to another resident's empty plate and used it to wipe the table off in front of Resident #20's plate. When she did this, the soiled napkin touched Resident #20's plate. Staff A did not wash her hands during this interaction and then continued to assist Resident #20 to eat. On 12/6/23 at 3:37 p.m., Staff S Director of Nursing (DON) stated staff should not eat in the dining room and when notified of the above events related to Staff A, she stated this should not have happened and was not appropriate. On 1/3/23 at 10:55 a.m., the Administrator stated the facility did not have a policy related to infection control practices in the dining room.