**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure abuse screening, training, and background checks were conducted for 2 of 5 sitters (Sitter #1 and #2) which placed Resident #51 at risk for potential abuse. The facility's failure to perform screening, training, abuse registry checks, and background checks placed Resident #51 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The Regional Administrator and the Regional Liaison was informed of the Immediate Jeopardy for F-600 on 1/21/2020 at 1:19 PM, in the Conference Room. The facility was cited F-600 at a scope and severity of J which is Substandard Quality of Care. An extended survey was conducted on 1/16/2020. The Immediate Jeopardy was removed onsite and was effective from 11/30/19 through 1/21/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received 1/21/2020 at 6:05 PM. The corrective actions were validated onsite by the survey team on 1/21/2020 and 1/22/2020 through review of completed screening and background checks of the current sitters, review of in-service training records, review of sign in sheets, review of monitoring procedures for future sitters, resident interviews, and staff interviews. The findings include: Review of the facility's policy titled, Abuse Prevention Program, dated 12/2016, showed .Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Conduct employee background checks .Require training/orientation programs . Review of the facility's policy titled, Private Duty Sitters dated 5/2017, showed .The use of private duty sitters will be permitted when approved by the resident's Attending Physician and the facility's Director of Nursing Services .May not administer direct care to the resident unless authorized in writing by the Attending Physician . The facility was unable to provide documentation of abuse screening, background checks, training, or written authorization by the attending physician for Sitter #1 and Sitter #2. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses Dementia, Bipolar Disorder, Psychosis, and Atherosclerosis. Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #51 had severely impaired cognitive skills for daily decision making, required supervision of one person with transfers and walking in the room, required limited assistance of one person to walk in corridor, dressing, eating, toilet use, and personal hygiene. Review of the Care Plan revised 1/5/2020, showed, .The resident has an ADL [Activities of Daily Living] self-care performance deficit .The resident requires (extensive assistance) by (1) staff to dress .The resident requires (limited assistance) by (1) staff to eat . Observation in the resident's room on 1/12/2020 at 9:38 AM, showed Sitter #2 assisting Resident #51 to the bathroom. During an interview conducted on 1/12/2020 at 9:45 AM, Sitter #2 was asked if she was a family friend or a Certified Nursing Assistant (CNA). Sitter #1 stated that she was a sitter. Observation in the Dining Room on 1/13/2020 at 5:59 PM, showed Sitter #1 assisting Resident #51 with her evening meal. During an interview conducted on 1/13/2020 at 6:34 PM, with Sitter #1, who was sitting with Resident #51, Sitter #1 was asked if she was a family friend or a Certified Nursing Assistant (CNA). Sitter #1 stated, .I'm not a CNA, but I have 30 years experience .I have been here a year on Thanksgiving [14 months] .At the other facility I was sitting, I had to give blood to make sure I don't have a disease, a background check .No, nothing here . During an interview conducted on 1/13/2020 at 7:05 PM, the Business Office Manager Assistant was asked for the personnel files (that should contain abuse screenings, training, and background checks) for Resident #51's sitters. She denied knowing [Named Sitter #1 and Sitter #2] . Observation in the Dining Room on 1/14/2020 at 12:32 PM, showed Sitter #1 assisting Resident #51 with her midday meal. During an interview conducted on 1/16/2020 at 2:28 PM, the Administrator was asked what steps were taken to screen private duty sitters for a history of abuse. The Administrator stated, We check the abuse registry and background checks . The facility failed to continue implementation of the plan of correction after the complaint survey on 7/22/2019 where Abuse was cited at the IJ level. The facility was unable to provide documentation the abuse screening or background checks had been performed on the sitters, which placed Resident #51 in Immediate Jeopardy. The survey team verified the Removal Plan by: 1. On 1/21/2020, the Private duty sitters background, sex offender, and Tuberculin (TB) screenings were completed. Abuse training started immediately on 1/21/2020 with sitters in house. Communication with resident families in question was completed to ensure that all sitters before employment need to meet with administration before being invited to the facility to ensure applicable screenings and trainings are completed. The survey team reviewed the resident assessments, resident interview statements, and staff interview statements, and interviewed residents and staff regarding the education provided by the facility. 2. The Interim Administrator, the Interim Director of Nursing, the Admissions Nurse Liaison, the Admissions Coordinator, and the Human Resources Department had in-service education on the requirements of the resident families to have the sitters come in to have their abuse training/screenings, and their background checks completed. The survey team interviewed staff regarding the education provided by the facility. 3. The DON or her designee will check in with resident responsible parties and sitters daily to ensure that the sitter has a facility file before sitting with the resident on each shift and a running list will be kept on all sitters as they come into the facility with Human Resources (HR). The survey team reviewed personnel files and interviewed staff. Noncompliance of F-600 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to identify, thoroughly investigate, and protect vulnerable residents from further abuse for injuries of unknown source that could be indicative of abuse for 2 of 3 sampled residents (Resident #12 and #64) reviewed for abuse. The facility's failure to identify and thoroughly investigate bruising to Resident #12's left upper arm and posterior forearm and Resident #64's dark purple colored marks around the resident's neck, placed Resident #12 and #64 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy (IJ) for F-610 on 1/17/2020 at 8:15 PM, in the Conference Room. The facility was cited at F-610 at a scope and severity of J, which is Substandard Quality of Care. An extended survey was conducted on 1/16/2020. The IJ was effective from 11/30/2019 through 1/21/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received 1/21/2020 at 6:05 PM and the Removal Plan was validated onsite by the survey team on 1/21/2020 and 1/22/2020 through review of in-service training records and staff interviews. The findings include: Review of the facility's policy titled, Abuse Investigation and Reporting, revised 7/2017, showed, .All reports of resident abuse, neglect .injuries of unknown source .shall be .thoroughly investigated by facility management .Role of the Administrator .If an incident or suspected incident of resident abuse .or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual .The Administrator will ensure that any further potential abuse .is prevented .The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety .of the resident .Role of the Investigator .The individual conducting the investigation will, as a minimum .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate, family members, and visitors .Interview other residents to whom the accused employee provides care or services .Review all events leading up to the alleged incident .The investigator will consult daily with the Administrator concerning the progress/findings of the investigation . Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised 3/2018, showed, .Assessment and Recognition .Assessment data will include .Injury assessment .bruising .swelling .Pain assessment .Current behavior .The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear Cause Identification .The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes . Review of the facility's policy titled, Unexplained Injuries, revised 12/20/2019, showed, .All unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated .if the injury is of unknown source .investigation procedures shall be implemented in accordance with the facility's abuse policies and procedures .An injury should be classified as an 'injury of unknown source' when both of the following conditions are met .a .The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and .b .The injury is suspicious because of .The extent of the injury or .The location of the injury .the injury is located in an area not generally vulnerable to trauma .An injury of unknown source shall be investigated even if the resident is discharged .or an injury of unknown source is identified after discharge . Review of the facility's policy titled, Skin Assessment, revised 12/20/2019, showed, .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter .The assessment may also be performed after a change of condition .Documentation of skin assessment .Include date and time of the assessment, your name, and position title .Document observations .skin conditions . 1. Review of the medical record, showed Resident #12 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Osteoarthritis, Osteoporosis, Aphasia, Anxiety, Dementia, Depression, and a Pathological Hip Fracture. Review of the Care Plan dated 7/3/2019, showed that Resident #12 had impaired decision making skills, short and long term memory problems, was totally dependent on (1) staff for eating, personal hygiene and oral care, dressing, and toilet use, and was totally dependent on (2) staff for transfers with a mechanical lift. Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #12 had severe cognitive impairment, no behaviors, walking did not occur, and was totally dependent on staff for all activities of daily living (ADLs). Review of the 24 Hour Report/Change of Condition Report dated 11/30/2019, showed, .Bruising, pain, swelling to (L) [left] Arm. Incident report done .stat [immediately] x-ray ordered . Review of the Radiology Results Report dated 11/30/2019, showed, .Reason for Study .PAIN IN LEFT SHOULDER .PAIN IN LEFT ARM .PAIN IN LEFT ELBOW .PAIN IN LEFT WRIST .Conclusion .Modest degenerative joint disease of the left shoulder .no fracture or dislocation seen .Grossly intact left humerus .Grossly intact left elbow .Grossly intact osseous appearance of the left forearm .Mild to modest degenerative joint disease of the left wrist .no fracture seen .mild soft tissue swelling . Review of the Incident Report, showed, .11/30/2019 .Incident Location: Unknown .Nursing Description .called to residents [resident's] room by [Named Certified Nursing Assistant (CNA) #5], upon entering I observed resident lying supine with bruising, redness, inflammation and pain to upper left arm .Resident Description: Resident Unable to give Description .Immediate Action Taken .Tylenol 500mg [milligrams] given crushed PO [by mouth] without difficulty, [Named physician] notified and xray [x-ray] ordered stat [immediately] .upon moving ULE [upper left extremity] resident shows favor with grimace to face and stiffening of BUE [bilateral upper extremities] .Other info [information] .incident of unknown origin .No witnesses found . There was 1 staff statement signed by CNA #5 and dated 11/30/2019 attached to the incident report which showed, .When provide care for [Named Resident #12] She clings her arms to Body and It make [makes] it hard to put on her cloth [clothes] . There were no additional staff statements or interviews, no resident statements or interviews, and no resident assessments included with the incident report. Review of the Weekly Skin Check dated 12/5/2019, showed Resident #12 had .bruising to left upper arm . The facility was unable to provide additional documentation for monitoring of the bruising for Resident #12. During an interview conducted on 1/16/2020 at 10:06 AM, the Administrator was asked if she was aware of the shoulder and arm bruising and swelling. The Administrator stated, No ma'am. The Administrator was asked if she should have been notified. The Administrator stated, Yes, ma'am. The Administrator was asked if she reviewed all the incident reports. The Administrator stated, .I don't review every single incident report. Observation in the resident's room on 1/17/2020 at 7:44 PM, revealed Resident #12 lying in bed with her bilateral arms contracted, her right hand fingers in her mouth, with a large greenish-colored bruise to her left upper arm and another greenish bruise to her left posterior forearm. During an interview conducted on 1/16/2020 at 11:16 AM, Licensed Practical Nurse (LPN) #5 was asked if she was aware of the bruising and swelling of Resident #12's arm that was documented on 11/30/2019. LPN #5 stated, It was shown to me and reported to the administration. LPN #5 was asked who showed it to her. LPN #5 stated, My aide that day .I don't know what caused the actual bruising. It was just shown to me and I reported it to the Administrator and called the doctor. LPN #5 was asked if Resident #12 moves around a lot. LPN #5 stated, No. She holds her arms up .to keep her hands in her mouth . LPN #5 was asked to describe what her arm and shoulder bruising and redness looked like when she saw it on 11/30/2019. LPN #5 stated, It was on her upper arm and here [pointed to forearm area]. LPN #5 was asked if it was swollen. LPN #5 stated, Yes, and we x-rayed it. During an interview conducted on 1/17/2020 at 1:05 PM, the Director of Nursing (DON) was asked if she was aware of the incident that was documented as redness, bruising, and swelling to Resident #12's left arm on 11/30/2019. The DON stated, They came and got me on that one .I talked to staff. I got statements from the staff that takes care of her. The DON was asked if she only interviewed 1 staff member. The DON stated, She was the one that found it, and stated she does clench up when she does her changing of her clothes . The DON was asked if she informed the Administrator. The DON stated, We discuss them, but it wasn't an abuse situation. The DON was asked how she knew it was not abuse. The DON stated, .We investigated it and determined the cause of when it occurred from clenching her arms . Review of the facility's incident report, showed there was only 1 staff statement, but there was no investigation for Resident #12's injury of unknown origin. 2. Review of the medical record, showed Resident #64 was admitted to the facility on [DATE] with diagnoses of Dementia, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Transient Cerebral Ischemic Attack. Review of the quarterly MDS dated [DATE], showed Resident #64 had severe cognitive impairment per the staff assessment, no behaviors, required limited staff assistance for eating, required extensive staff assistance for bed mobility and dressing, was totally dependent on staff for toilet use, personal hygiene and bathing, walking and locomotion off the unit did not occur, transfers and locomotion on the unit only occurred once or twice with 1-person staff assistance. Review of the Care Plan revised 12/8/2019, showed that Resident #64 was totally dependent on (1) staff to provide bathing, required extensive assistance by (1) staff to turn and reposition in bed, was totally dependent on (1) staff for dressing, required extensive assistance by (1) staff to eat, was totally dependent on (1) staff for personal hygiene and oral care, was totally dependent on (1) staff for toilet use, was totally dependent on (1) staff for transferring, had potential/actual impairment to skin integrity due to fragile skin such as skin tears and bruising and interventions to follow facility protocols for treatment of injury. Review of the 24 Hour Report/Change of Condition Report for the North hall dated 12/18/2019, showed, .[Named Resident # 64] .Incident .Bruising on neck . Review of the Incident Report dated 12/18/2019, showed, .Location .Resident's Room .Nursing Description .Resident was lying in bed .resident had hand lying on his neck, when resident moved his hand this nurse observed purple colored marks where resident's hand was resting, when asked CNA she states that resident has had that area around his neck for a long time, after assessing area the resident was observed with his hand resting back around his neck in the discolored area .Resident Description .Resident Unable to give Description .Mobility .Bedridden .purple bruising noted around the front of resident's neck .Resident keeps hand resting on resident's neck .No Witnesses found . There was 1 staff statement signed by CNA #3 and dated 12/19/2019 attached to the incident report, which showed, .I have seen the discoloration around [named Resident #64] neck for several weeks never thought anything about it except when I clean him I always have to remove his hand from around his neck . During a telephone interview with CNA #3 on 1/19/2020 at 9:51 AM, CNA #3 agreed with her statement and stated that she reported the bruise to Resident #64's nurse, and the nurse said it was because Resident #64 always kept his hand around his neck. There were no additional staff statements or interviews, no resident statements or interviews, and no resident assessments included. Review of the Nurse's Note dated 1/10/2020 at 11:23 AM, showed, .Dark purple bruising noted below neckline, upper portion of chest. Aide stated bruising has been noted before . Review of the Wound Measuring Guide dated 1/17/2020, showed the bruise to Resident #64's neck/chest area was 7.5 x 15 centimeters. Observation in the resident's room on 1/12/2020 at 8:49 PM, 1/13/2020 at 8:02 AM and 5:45 PM, 1/14/2020 at 7:59 AM, 8:59 AM, 9:48 AM, 12:58 PM, 3:52 PM, and 4:59 PM, 1/15/2020 at 4:53 PM, 1/16/2020 at 7:56 AM and 2:51 PM, 1/17/2020 at 3:07 PM, 1/18/2020 at 2:07 PM, 1/19/2020 at 10:56 AM, 1/20/2020 at 5:16 PM, and 1/21/2020 at 8:42 AM, showed Resident #62 did not have his hand resting around his throat or neck area during any of these observations. Observation in the resident's room on 1/13/2020 at 5:45 PM, showed Resident #64 with a large dark purple discolored area around the base of his neck and the collar bones, and narrow tubular shaped dark purple discolored areas extended around both sides of the neck. During an interview conducted on 1/14/2020 at 10:49 AM, LPN #3 was asked if he was aware of the bruising to Resident #64's neck and chest area. LPN #3 confirmed he was aware of the bruising but was not aware of how the bruise occurred. LPN #3 was asked who reported the bruise. LPN #3 stated, I'm not sure. During an interview conducted on 1/14/2020 at 10:53 AM, CNA #2 was asked if she was aware of the bruise to Resident #64's neck and chest area. CNA #2 stated, It started small. We didn't know what it was. It started as a small spot [pointed between collar bones on her own body]. I went in there the other day and then it had spread all the way down. CNA #2 was asked when it started as a small spot. CNA #2 stated, It was probably about 5 weeks ago .I ended up letting [Named LPN #3] know about it . CNA #2 was asked when she notified the nurse. CNA #2 stated, I think it was last week. During an interview conducted on 1/14/2020 at 11:05 AM, CNA#1 confirmed she was aware of the bruise to Resident #64's neck and chest area. CNA #1 was asked if she knew who found it. CNA #1 stated, Probably me and [Named CNA #2]. CNA #1 was asked what she did when she found it. CNA #1 stated, I'm not sure .I did tell [Named LPN #1]. I do know that. CNA #1 was asked if she documented the bruise or that she had notified the nurse. CNA #1 stated, No. During an interview conducted on 1/15/2020 at 3:26 PM, LPN #1 stated she was not aware of the bruise to Resident #64's neck and chest area. LPN #1 confirmed CNA #1 had not reported it to her. During an interview conducted on 1/17/2020 at 9:15 AM, the Administrator was asked what was the procedure for injuries of unknown origins. The Administrator stated, We immediately start an investigation. The Administrator was asked what should be included in the investigation. The Administrator stated, We look at the documentation and talk to staff who have cared for the resident to figure out where or when it could have occurred. The Administrator was asked if they take staff statements. The Administrator stated, Yes. The Administrator was asked if other residents were interviewed. The Administrator stated, Yes. The Administrator was asked if the resident and other residents were assessed for injury. The Administrator stated, Yes. We normally do a full facility audit. The Administrator was asked if an investigation was done for the incident documented for Resident #64 on 12/18/2019. The Administrator did not answer. The Administrator was asked if she was aware of the bruising. The Administrator stated, No. The Administrator was asked if the incident should have been investigated. The Administrator stated, Yes. The Administrator was asked if an incident note and 1 staff statement was a thorough investigation. The Administrator stated, There should be more statements, more resident interviews and assessments. During an interview conducted on 1/17/2020 at 1:04 PM, the DON was asked if she was aware of the incident that was documented for Resident #64 on 12/18/2019. The DON stated, Yes. They [staff] came to me the day they did the incident report .said it looks like where he lays his hand on the chest .the aide said he does lay that hand on his chest constantly. The DON was asked if an investigation was done for the injury of unknown origin. The DON stated, No ma'am .It's an injury of unknown origin if you can't determine where something came from. The DON was asked how she knew what caused the bruising, and if he had always been placing his hands on his neck and chest since he had been admitted to the facility. The DON stated, I don't know how long he has been here. The DON was asked if this was a habit he had always had, then would the sudden large bruising be a red flag. The DON stated, I don't know . During a telephone interview conducted on 1/17/2020 at 1:22 PM, LPN #2 confirmed she had written the incident report for the bruising on 12/18/2019. LPN #2 was asked what she does when she finds something like that bruise. LPN #2 stated, Report it .I thought administrative staff always follow up on stuff like that. They have to sign off on our incidents. LPN #2 was asked if anyone ever came and interviewed her about the incident. LPN #2 stated, No. LPN #2 was asked if she had been asked to write a statement. LPN #2 stated, I did the incident report, but as far as a statement, no. During an interview conducted on 1/17/2020 at 8:47 PM, LPN #6 was asked what happened concerning the bruise on Resident #64's neck. LPN #6 stated, .I don't know what the deal is with that .I just saw it the other night. LPN #6 was asked if she reported it when she saw it. LPN #6 stated, I didn't report it . During an interview conducted on 1/17/2020 at 9:49 PM, the Regional Administrator was asked if an injury of unknown origin investigation should consist of only 1 interview. The Regional Administrator stated, No. You ask every person that worked in that time frame. Then you look at every resident on that hallway. See if it was the same staff that cared for them . During an interview conducted on 1/18/2020 at 2:07 PM, CNA #4 was asked when she first saw the bruise. CNA #4 stated, Tuesday [1/14/2020]. I was giving him a bath. That was the first time I noticed it .I documented it Tuesday [1/14/2020] when I saw it .The nurse had told me if I see discoloration, I don't have to document it every day. They informed me don't be doing that. Just let her know it's there once. They said because that just makes more paperwork for the nurse. I have never heard of that before .When I first saw it my thing was Oh my God somebody has choked him. But the CNA in me knows .there are a lot of different factors. There should be documentation . During a telephone interview conducted on 1/19/2020 at 9:11 AM, the Medical Director was asked if he expected the staff to follow up on incidents like injuries of unknown origin and how long were they supposed to monitor. The Medical Director stated, .Generally, if there's a suspicion, we try to identify the reasons. Then afterward, the nursing staff is supposed to make sure the safety of the patient. The Medical Director was asked if he felt the incidents should be documented and followed up. The Medical Director stated, Oh yes, definitely. The Medical Director was asked if a bruise suddenly appeared, should an investigation be done. The Medical Director stated, .If just laying his [Resident #64's] hand there is causing that dark of a bruise I'm concerned .Yeah .if there's a hand print definitely should investigate . The Medical Director was then asked about Resident #12's bruising and swelling to her left arm that was documented on 11/30/2019 and not investigated. The Medical Director stated, .I think they should have looked into that .They should have followed up and at least documented . During an interview conducted on 1/22/2020 at 11:06 AM, LPN #4 was asked what she did when she became aware of and documented the bruise to Resident #64's neck on 1/10/2020. LPN #4 stated, I told the Administrator and she said that she would take care of it. The facility was unable to provide documentation that a thorough investigation was conducted to determine the cause of the injuries of unknown source and rule out abuse for Resident #12 and #64. The facility failed to continue implementation of the plan of correction after the complaint survey on 7/22/2019 where Abuse was cited at an IJ level. The facility failed to recognize the injuries to Resident #12 and #64 as an injuries of unknown origin, failed to thoroughly investigate the injuries that could be indicative of abuse, and failed to protect the residents from further potential abuse, which placed Resident #12 and #64 in Immediate Jeopardy. The survey team verified the Removal Plan by: 1. On 1/17/2020, the DON reassessed Resident #12 and #64 to verify locations and extents of the injuries. The DON interviewed staff on shifts before and after the incidents occurred. The nursing management and nursing team completed body audits on 100% of residents on 1/17/2020 and 1/18/2020. Education was started with 100% staff on 1/17/2020 on reporting alleged abuse allegations, including injuries of unknown origin and how to conduct a thorough investigation. On 1/19/2020, interviews were conducted with residents on the 200 and 400 halls, where the incidents occurred. The survey team reviewed the resident assessments, resident interview statements, and staff interview statements, and interviewed residents and staff regarding the education provided by the facility. 2. The facility determined that all admitted residents had the potential to be affected. The DON reviewed all the resident skin audits, and any areas subject to abuse were investigated. The survey team reviewed the skin audits and documentation was available for each area identified. 3. The DON and the Administrator conducted in-service education to direct care staff which addressed circumstances that required their responsibilities related to investigations. The survey team reviewed in-service sign in sheets and interviewed staff regarding the education provided by the facility. 4. The DON or her designee will conduct random audits of 10 residents twice weekly for 4 weeks, 20 residents biweekly for 2 months, then 30 residents monthly for 2 months. The residents will be assessed and interviewed to ensure that any injuries are identified and properly investigated. The audit findings will be discussed in Resident Council and the plan of correction will be monitored during the monthly Quality Assurance meeting. The survey team reviewed the audit tools and conducted administrative staff interviews. Noncompliance of F-610 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure a Comprehensive Care Plan was developed for injuries of unknown origin and Care Plan interventions were followed for nutritional impairment for 3 of 28 sampled residents (Resident #12, #64, and #55) reviewed. The failure of the facility to develop a Comprehensive Care Plan for injuries of unknown origin that could be indicative of abuse with effective interventions and protect residents from further potential injury placed Resident #12 and #64 in Immediate Jeopardy. The failure of the facility to ensure Care Plan interventions were followed for nutritional impairment resulted in actual Harm when Resident #55 sustained severe weight loss. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility was cited F-656 at a scope and severity level of J. The extended survey was conducted on 1/16/2020. The IJ was effective from 11/30/2019 through 1/21/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received 1/21/2020 at 6:05 PM. The corrective actions were validated onsite by the survey team on 1/21/2020 and 1/22/2020 through review of care plan revisions and updates, review of in-service training records, and staff interviews. The findings include: Review of the facility's policy titled, Unexplained Injuries, revised 12/20/2019, showed, .All unexplained injuries, including bruises .and injuries of unknown source .The facility shall modify the resident's plan of care as needed to prevent recurrence or to stabilize, reduce, or remove underlying risk factors contributing to the injury . Review of the facility's policy titled, Weight Assessment and Intervention, dated 12/2019, showed, .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .a. 1 month-5% [percent] weight loss is significant; greater than 5% is severe .b. 3 months-7.5% weight loss is significant; greater than 7.5% is severe .c. 6 months-10% weight loss is significant; greater than 10% is severe .Care Planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate .Individualized care plans shall address .Time frames and parameters for monitoring and reassessment . 1. Review of the medical record, showed Resident #12 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Osteoarthritis, Osteoporosis, Aphasia, Anxiety, Dementia, Depression, and a Pathological Hip Fracture. Review of the Care Plan dated 7/30/2019, showed Resident #12 was totally dependent on staff for all activities of daily living. Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #12 had severe cognitive impairment, no behaviors, walking did not occur, and was totally dependent on staff for all activities of daily living (ADLs). Review of the Incident Report, showed, .11/30/2019 .Incident Location: Unknown .Nursing Description .called to residents [resident's] room by [Named Certified Nursing Assistant (CNA) #5], upon entering .observed resident lying supine with bruising, redness, inflammation and pain to upper left arm .Resident Description: Resident Unable to give Description .Immediate Action Taken .Tylenol 500 mg [milligrams] given crushed PO [by mouth] without difficulty, [Named physician] notified and xray [X-ray] ordered stat [immediately] .upon moving ULE [upper left extremity] resident shows favor with grimace to face and stiffening of BUE [bilateral upper extremities] .Other info [information] .incident of unknown origin .No witnesses found . There was 1 staff statement signed by CNA #5 dated 11/30/2019 and attached to the incident report which showed, .When provide care for [Named Resident #12] She clings her arms to Body and It make [makes] it hard to put on her cloth [clothes] . There were no additional staff statements or interviews, no resident statements or interviews, and no resident assessments included. Review of the Radiology Results Report dated 11/30/2019, showed, .Reason for Study .PAIN IN LEFT SHOULDER .PAIN IN LEFT ARM .PAIN IN LEFT ELBOW .PAIN IN LEFT WRIST .Conclusion .Modest degenerative joint disease of the left shoulder .no fracture or dislocation seen .Grossly intact left humerus .Grossly intact left elbow .Grossly intact osseous appearance of the left forearm .Mild to modest degenerative joint disease of the left wrist .no fracture seen .mild soft tissue swelling . Review of the Weekly Skin Check dated 12/5/2019, showed Resident #12 had, .bruising to left upper arm . Review of the Care Plan dated 7/30/2019, showed a Comprehensive Care Plan was not developed to reflect the injury of unknown origin that was documented in an incident report dated 11/30/2019 and the Care Plan did not document any protective interventions to be implemented. 2. Review of the medical record, showed Resident #64 was admitted to the facility on [DATE] with diagnoses of Dementia, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Transient Cerebral Ischemic Attack. Review of the Care Plan revised 12/8/2019, showed Resident #64, .has an ADL self care deficit .Interventions .The resident is totally dependent on (1) staff to provide bath/shower .The resident requires extensive assistance by (1) staff to turn and reposition in bed .The resident is totally dependent on (1) staff for dressing .The resident requires extensive assistance by (1) staff to eat .The resident is totally dependent on (1) staff for personal hygiene and oral care .The resident is totally dependent on (1) staff for toilet use .The resident is totally dependent on (1) staff for transferring .The resident has potential/actual impairment to skin integrity due to fragile skin such as Skin Tears and Bruising . Review of the quarterly MDS dated [DATE], showed Resident #64 had severe cognitive impairment per the staff assessment, no behaviors, required staff assistance for all ADLs, and received anticoagulant medications daily for the past 7 days. The Physician's Orders signed 12/13/2019, showed an order for the anticoagulant, Eliquis 2.5 milligrams to be administered orally every 12 hours starting on 11/11/2019. The Eliquis order was changed to once daily on 12/18/2019. Review of the Incident Report dated 12/18/2019, showed, .Location .Resident's Room .Nursing Description .Resident was lying in bed when this nurse entered the room and was covering resident up, resident had hand lying on his neck, when resident moved his hand this nurse observed purple colored marks .when asked CNA she states that resident has had that area around his neck for a long time, after assessing area the resident was observed with his hand resting back around his neck in the discolored area .Resident Description .Resident Unable to give Description .Mobility .Bedridden .purple bruising noted around the front of resident's neck .No Witnesses found . There was 1 staff statement signed by CNA #3 and dated 12/19/2019 attached to the incident report, which showed, .I have seen the discoloration around [Named Resident #64] neck for several weeks never thought anything about it except when I clean him I always have to remove his hand from around his neck . There were no additional staff statements or interviews, no resident statements or interviews, and no resident assessments included. Review of the Care Plan revised 12/8/2019, showed a Comprehensive Care Plan was not developed to reflect the bruising around Resident #64's neck and chest that was documented on 12/18/2019 on the incident report, and there was no documentation of any protective measures implemented. The Care Plan did not address the use of anticoagulant medications. During an interview conducted on 1/17/2020 at 4:02 PM, the MDS Coordinator was asked if Care Plans should reflect the current status of the residents. The MDS Coordinator stated, Yes. The MDS Coordinator was asked if Resident #12's Care Plan should reflect her arm and shoulder injury. The MDS Coordinator stated, Yes. The MDS Coordinator was asked if the bruising to Resident #64's neck and chest area should be addressed on the Care Plan. The MDS Coordinator stated, Yes. The MDS Coordinator was asked if the steps taken to prevent further injuries should be reflected in the Care Plans. The MDS Coordinator stated, I didn't put it on the Care Plan. [Named LPN #2] called and told me about it .I don't even know if anybody but her knew about it . The MDS Coordinator was asked if it should be documented on the Care Plan. The MDS Coordinator stated, Yes. It should be. The MDS Coordinator was asked if the use of the anticoagulant medication, Eliquis, should be documented on the Care Plan. The MDS Coordinator stated, It should be. The failure of the facility to develop Comprehensive Care Plans for injuries of unknown origin that could be indicative of abuse with effective interventions and protect residents from further potential injury placed Resident #12 and #64 in Immediate Jeopardy. Refer to F-610 3. Review of the medical record, showed Resident #55 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure, Dysphagia, Cognitive Deficit, Hypertension, Depression, Psychosis, and Dysthymic Disorder. Review of the Care Plan dated 9/1/2019, showed Resident #55 had .Potential for impaired nutrition .Interventions .supplements to be given as ordered .Refer to .RD [Registered Dietitian] as needed . Review of the quarterly Minimum data set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment, a height of 66 inches, a weight of 134 pounds, and a weight loss of 5% or more in the past month or 10% or more in the last 6 months, and was not on a physician-prescribed weight-loss regimen. Review of the Weights and Vitals Summary showed the following weights for Resident #55: a. 7/1/2019 144 pounds (lbs) b. 7/3/2019 151 lbs c. 7/9/2019 155 lbs b. 8/1/2019 156 lbs c. 9/2/2019 152 lbs d. 10/1/2019 138 lbs (severe weight loss of 9.21% in 1 month, and 10.96% in 3 months) e. 11/6/2019 134 lbs (severe weight loss of 14.1% in 3 months) f. 12/19/2019 134 lbs (severe weight loss of 11.84% in 3 months) g. 1/6/2019 132.2 lbs (severe weight loss of 14.7% in 6 months) h. 1/17/2020 128.2 lbs (7.1% weight loss in 3 months, and severe weight loss of 17.29% in 6 months) Review of the Physician's Order dated 7/1/2019, showed, .4 oz [ounces] mighty shake [milkshake with increased calories] Q [every] day @ [at] 3 pm R/T [related to] weight loss concerns . Review of a Nurse's Note dated 7/1/2019, showed, .4 oz mighty shake q day at 3 pm r/t weight loss concerns per dietary rec [recommendations] . Review of a Nutrition Note dated 7/11/2019, showed, .receiving 30 ml [milliliters] liquid protein BID [twice a day] .Recommend to continue current diet and supplements . Review of the August 2019 Medication Administration Record (MAR), showed Resident #55 had orders for, .PROVIDE GOLD [liquid protein supplement] 30ML BY MOUTH TWICE DAILY .Started 10/23/18 . The MAR documented the Provide Gold was administered twice daily from 8/1/2019-8/19/2019. There was no documentation Provide Gold was administered after 8/19/2019. Review of the August 2019 MAR, showed Resident #55 had orders for, .HOUSE SUPPLEMENT [liquid supplement with increased calories] 120ML BY MOUTH THREE TIMES DAILY .Started 10/23/18 . The MAR documented the House Supplement was administered 3 times daily from 8/1/2019-8/19/2019. There was no documentation the House Supplement was administered after 8/19/2019. Review of the August 2019 MAR, showed there was no documentation the Mighty Shake was administered to Resident #55. Review of the medical record showed, there was no documentation the House Supplement, protein supplement, or the Mighty Shakes had been discontinued by the physician. Review of the Nutrition Note dated 9/19/2019, showed Resident #55, .has now lost 4 lbs in a month .gets a Mighty shake at afternoon snack . Review of the Nutrition Note dated 10/3/2019, showed Resident #55, .has had a 10% weight loss in last 6 months .gets Mighty shakes at afternoon snacks .significant weight loss . Review of the September 2019, October 2019, November 2019, December 2019, and January 2020 MARs, showed there was no documentation the House Supplement, Mighty Shake, or the Provide Gold were administered. The facility was unable to provide documentation the RD did any further assessments after 10/3/2019 on Resident #55. Resident #55 sustained severe weight loss on 10/1/2019 and continued to lose weight. Observation in the resident's room on 1/16/2020 from 1:45 PM to 2:30 PM, showed Resident #55 did not receive a supplement. During an interview on 1/16/2020 at 3:22 PM, CNA #10 (Restorative Aide) was asked about the process of obtaining weights. CNA #10 stated, .try to weigh consistently on the same day .if 3 pound difference up or down I reweigh then . CNA #10 was asked how often were the scales recalibrated. CNA #10 stated, .I am not sure, when I started in December [Named DON] stated the scales had just been recalibrated . CNA #10 stated that she does not enter the weights into the Electronic Medical Record, the nurses enter the weekly weights into the record. CNA #10 stated, .I understood that the previous restorative person had inconsistent weights, not weighing on the same wheelchair, scale, or lift . There was no documentation of reweights in the medical record. During an interview on 1/16/2020 at 3:57 PM, Certified Nursing Assistant (CNA) #1 was asked who administered Resident #55's nutritional supplements. CNA #1 stated, The nurse brings it to him. During an interview conducted on 1/16/2020 at 4:00 PM, Licensed Practical Nurse (LPN #2) was asked who administered Resident #55's nutritional supplements. LPN #2 stated, The CNAs bring it to him. During an interview conducted on 1/21/2020 at 2:10 PM, the RD and LPN #2 were asked where to find documentation the supplements were administered. The RD and LPN #2 confirmed the orders for supplements had never been transcribed when the facility changed to electronic medical records in August, 2019, and the orders were never entered into the electronic medical record for administration. The RD confirmed she had not followed up to ensure her recommendations were followed. During an interview on 1/19/2020 at 4:47 PM, the RD stated that there had been concerns with calibrating the scales. The RD stated she had gone to the DON because there had been problems with the weights. The RD stated, .after you get them [weights] you have to wait and see if they're [staff are] reweighing .it has been a source of frustration . The facility was unable to provide documentation the mighty shakes, house supplements, or protein supplements were administered after 8/19/2019. The failure of the facility to follow the Care Plan interventions to provide supplements caused actual Harm when Resident #55 sustained severe weight loss. The survey team verified the Removal Plan by: 1. These residents' care plans were reviewed, interventions were made to the care plans, and revised interventions were input into the residents' record. In-service education was conducted with staff on implementation and revision of care plans, implementing interventions, and documenting the effectiveness of the interventions. The survey team verified the corrective action through review of care plans and interviews with staff on all shifts. 2. The DON, or designee, will conduct random audits of 10 residents weekly for 4 weeks, 15 residents bi-weekly for 2 months, and then 20 residents monthly for 2 months for care planning and putting interventions into place. Findings of this audit will be discussed and monitored in the monthly Quality Assurance meeting until substantial compliance is met. The survey team validated the corrective action through review of the audit tools and staff interviews. Noncompliance of F-656 continues at a scope and severity of D for monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.