**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, email correspondence review, observation, and interview, the facility failed to protect the residents' right to be free from neglect for 3 of 14 (Resident #6, Resident #1, and Resident #12) sampled residents reviewed for abuse and neglect. Resident #6, a vulnerable, cognitively impaired, totally dependent resident who required enteral feeding (method of delivering nutrition directly into the gastrointestinal tract) for nutrition was reviewed for neglect. On 3/20/2025, the nurse documented Resident #6 had a tear on the side of the feeding port of the percutaneous endoscopic gastrostomy (PEG) tube which caused leakage of the feeding onto the bed. Resident #6 did not receive a new PEG tube until 4/7/2025, 19 days after the tear was found, which allowed for leakage of the enteral nutrition for 19 days. Resident #6's weight was 137 pounds (lbs.) on 3/14/2025 and decreased to 117 lbs. on 4/3/2025. Resident #6 sustained a severe weight loss of 14.59 percent (%) in 20 days which delayed healing on her current Stage 3 pressure ulcer/injury (a deep wound that involves full-thickness tissue loss) on the Left Ischial Tuberosity (the bony prominence on the posterior bottom left part of the pelvis). Resident #6 was noted to have a new in-house acquired blister on 4/8/2025, on her right lower back. On 4/16/2025 a new Stage 2 pressure ulcer/injury (partial thickness skin loss involving the epidermis and or dermis) to her coccyx was identified. On 4/30/2025, a new Deep Tissue Injury (DTI) (a pressure-related injury to the soft tissue under the skin) on her left heel was identified. The Registered Dietician confirmed the tear in the feeding tube contributed to Resident #6's severe weight loss Resident #1, a vulnerable, cognitively impaired resident who required 2-person, mechanical lift assistance for transfers sustained a left, distal femur fracture (a break in the lower part of the left thigh bone, just above the knee joint) when staff transferred her without the use of the mechanical lift on 7/4/2025. Resident #1 had a prior improper transfer without the use of the mechanical lift which resulted in a toe fracture (broken bone). The Certified Nursing Assistant (CNA) found Resident #1 sitting in her wheelchair screaming with excruciating pain on 7/4/2025 and attempted to stand Resident #1 up to transfer her to the bed without notifying the nurse for evaluation of Resident #1's pain, which resulted in increased pain. The CNA then picked Resident #1 up and placed her in bed, without the use of the 2-person mechanical lift. The nurse's assessment completed after Resident #1 was placed in the bed revealed bruising and swelling of her left knee. An X-Ray was obtained which revealed Resident #1 had a left distal femur fracture. The facility's failures resulted in Immediate jeopardy for Resident #1 and Resident #6. The facility also neglected to maintain and provide the ordered enteral feeding as scheduled for Resident #12's continuous enteral feed on 8/20/2025. 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) was identified related to the facility's failure to provide necessary goods and services to Resident #1 and Resident #6. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) of F-600 on 8/14/2025 at 10:53 AM. An amended template for F-600 was given to the Administrator and the DON on 8/20/2025 at 11:53 AM, in the Conference Room. The facility was cited at F-600 at a scope and severity of J, which constitutes Substandard Quality of Care. A partial extended survey was conducted from 8/20/2025 through 8/22/2025. An acceptable Removal Plan, which removes the immediacy of the Jeopardy for F-600 was received on 8/22/2025. The Removal Plan was validated onsite by the surveyor on 8/22/2025 through audit review, medical record review, observation, review of education records, and staff interviews. The IJ began on 3/20/2025 and was removed on 8/23/2025. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1.Review of the facility policy titled, Abuse Prevention Program F600, dated 8/2024 revealed, .Residents have the right to be free from abuse, neglect.resulting physical harm, pain.Abuse also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain, physical, mental or psychological well-being.Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.The facility administration and employees are committed to protecting residents from abuse by anyone including, but not necessarily limited to.facility staff.Identification of occurrences and patterns of potential mistreatment/abuse.The reporting and filing of accurate documents relative to incidents of abuse.The implementation of changes to prevent future occurrences of abuse.The current .components of the CMS [Centers for Medicare and Medicaid Services] directed Abuse Condition of Participation .Reporting to the state is per state guidelines. Review of the undated policy titled, KARDEX, revealed .the KARDEX is a vital section that outlines each resident's individualized daily care plan. It provides detailed instructions on various aspects of care, including the resident's daily activities.includes information on the resident's mobility.specific safety needs.and transfer methods.It notes whether the resident can ambulate independently. Review of the facility policy titled, Assessing Falls and Their Causes Guidelines, dated 10/2024, revealed, .The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.Residents must be assessed in a timely manner for potential causes of falls.Relevant environmental issues should be addressed promptly.If a resident has just fallen.nursing staff will record.and evaluate for possible injuries to the head, neck, spine, and extremities.nursing staff will provide appropriate first aid.Documentation will include any observed signs or symptoms of pain, swelling, bruising.An incident report must be completed for residents falls. The incident report form should be completed by the nursing supervisor on duty at the time.no later than 24 hours after the fall occurs. Review of the facility policy titled, .Abuse Prevention Program, Recognizing Signs and Symptoms of Abuse/Neglect (Identification), dated 10/2024, revealed .Neglect occurs when the facility is aware of, or should have been aware of goods and services that a resident (s) requires but the facility fails to provide them to the resident (s), resulting in, or may result in, physical harm, pain.Signs of / Actual Physical Neglect.unexplained weight loss.Possible signs/symptoms.Inconsistent injury explanation. Review of the facility policy titled, .Comprehensive Care Plans, dated 3/2025, revealed .An individualized comprehensive person centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental cultural and psychological needs is developed for each resident.The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS and physicians [physician's] orders. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.Each resident's comprehensive care plan is designed to.Incorporate identified problem areas.The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans.At least quarterly.The IDT [Interdisciplinary Team] will outline services in the comprehensive care plan that meet professional standards of quality or accepted standards of clinical practice. Review of the facility policy titled, Enteral Nutrition ., dated 5/2025, revealed .Adequate nutritional support through enteral feeding will be provided to residents as ordered.A dietitian will assess residents who are receiving enteral feedings, and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings and to prevent complications associated with enteral feedings and to prevent complications associated with enteral feedings.Enteral feeding orders will be written to ensure consistent volume infusion. The following information will be included to ensure that the full volume will be infused, regardless of any interruption of feeding.Rate of infusion.Total calories per day.Total daily volume to be infused (number of ml (milliliter) per day).Central supply or Food Service Manager will be responsible for ordering all tube feeding supplies. Review of the facility policy titled, Wound Care Guidelines, dated 6/2025, revealed .The purpose of this procedure is to provide guidelines for the care of wounds and to promote healing. Review of the facility policy titled, Exercise of Rights/Resident Rights ., dated 11/2024, revealed .Our residents have the right to a dignified existence.access to persons and services inside and outside the facility.Our residents have equal access to quality care.Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.Staff shall treat cognitively impaired residents with dignity and sensitivity. Review of the facility policy titled, Change in a Resident's Condition or Status ., dated 10/2024, revealed .The facility staff shall promptly notify the resident, his or her Attending Physician, and resident representative of changes in the resident's medical.condition and/or status.The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician.A need to alter the resident's medical treatment significantly.A need to transfer the resident to a hospital/treatment center.There is change in the resident's level of care status. Review of the facility policy titled, Pressure Injury/Skin Breakdown-Clinical Guidelines, dated 6/2025, revealed .The nursing staff will complete an evaluation of the skin.Based upon need and the results of the evaluations the staff will implement interventions for the prevention and care of skin issues.Nutritional supplementation should be based on realistic appraisal of need and identification of medical conditions and factors that affect.weight.and overall nutritional balance. Review of the facility policy titled, Quality of Life-Activities of Daily Living ., dated 4/2025, revealed .The community environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being.Residents whom are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition.Residents are provided with appropriate care.Utilize ADL [activities of daily living] reports, paper or electronic to assess ADL decline.Update care plan appropriately and interventions as needed. Review of the facility policy titled, Accidents and Incidents - Investigating and Reporting ., dated 10/2024, revealed .All accidents or incidents involving residents, employees.The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.The following data, as applicable, shall be included.nature of the injury.circumstances surrounding the accident or incident.condition of the injured person.disposition of the injured.Any corrective action taken.The Director of Nursing.shall review and complete.The Administrator shall review. 2. Review of the medical record revealed Resident #6 was admitted on [DATE], with diagnoses which included Encephalopathy, Aphasia, Dysphagia, and Cognitive Communication Deficit. Review of the Medication Administration Record (MAR) dated 3/2025, revealed Resident #6 had scheduled continuous enteral feed for Jevity (calorically dense, fiber-fortified nutrition that provides balanced nutrition for long term tube feeding) 1.5 at 55 milliliter (ml)/Hour via (by way of) PEG tube. Resident #6's enteral feed order revealed to turn off the pump at 11:00 AM and turn the pump back on at 1:00 PM. Review of the Weights and Vitals Summary revealed Resident #6 weighed 137 lbs. on 3/14/2025. Review of the Progress Notes for Resident #6 dated 3/20/2025, revealed .Peg [PEG] tube.needs to be replaced due to tear on the side at the port. Tape use [used] to secure the spike [the end of the tubing connected to the residents PEG tube] into the port. Review of the Skin & (and) Wound Evaluation for Resident #6 dated 3/24/2025, revealed a Stage 2 pressure ulcer to the Resident's Left Ischial Tuberosity which measured 2.0 centimeter (cm) in Length (l) by 2.5 cm width (w) by 0 depth (d) which equaled a total area of 3.7 cm2 (centimeter squared a unit used in the measurement of area). Review of the Weights and Vitals Summary revealed Resident #6 weighed 117 lbs. on 4/3/2025. Review of the Progress Notes for Resident #6 dated 4/3/2025, revealed .NP [Nurse Practitioner] spoke with this residents' RP [Resident's Responsible Party] regarding weight loss and slow decline in status. Review of Hospital #3's After Visit Summary dated 4/7/2025 revealed Resident #3's Peg tube was replaced. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 had poor short term and long-term memory. Resident #6 was dependent on staff for all activities of daily living. Resident #6 had an unplanned weight loss during the assessment reference period. Resident #6 received all nutrition through her PEG tube. Resident #6's pressure ulcer declined from Stage 2 to a Stage 3. Review of the medical record revealed Resident #6 was diagnosed with Abnormal Weight loss and Protein-Calorie Malnutrition on 4/8/2025. Review of the MAR dated 4/2025, revealed Resident #6 had scheduled continuous enteral feed for Jevity 1.5 at 55 ml/hour via PEG tube from 4/1/2025 through 4/8/2025. Resident #6's enteral feed was changed on 4/8/2025 to Jevity 1.5 at 65 ml/hour via PEG tube. Resident #6's enteral feed order revealed to turn off pump at 11:00 AM and turn pump back on at 1:00 PM Review of the NP Progress Notes dated 4/8/2025, revealed .Follow up.Prior unintended weight loss of 20lbs [20 lbs] .Patient [Resident #6] was found to have a dysfunctional PEG tube and it has since been replaced. She has also been moved to a room closure [closer] to nursing station for closer monitoring.Abnormal weight loss: PEG tube replaced. Will continue to monitor intake and feeding schedule . Review of the Skin & Wound Evaluation for Resident #6 dated 4/8/2025, revealed a new in-house pressure ulcer on her right lower back measuring 1.0 cm (l) by 1.5 cm (w). Review of the Nutrition Note dated 4/8/2025, revealed .A nutritional assessment was completed on this date for [Named Resident #6]. Resident's current weight.117.2 - 4/4/2025.Resident has had a weight change over the last 30 days. weight down 20# [20 lbs.] in 30 days, 14.5 % loss significant. Resident's current diet order .NPO [nothing by mouth] .Resident has stage II [2] pressure injury [ulcer] .per most recent skin report.Resident has skin concern(s) per most recent skin report.Enteral regimen has been unchanged since January and weight had been stable with gradual gain noted. Prostate [liquid protein].was added in March. Multiple pressure wounds noted, new area noted today. Labs reviewed.Peg tube was replaced 4/7 [4/7/2025] d/t [due to] split in tube.Rec [recommendation] to increase enteral [feeding] to Jevity 1.5 @ [at] 65ml/hr [hour] x [times] 22 hours. Review of the Skin & Wound Evaluation for Resident #6 dated 4/9/2025, revealed the pressure ulcer to the Left Ischial Tuberosity had progressed to a Stage 3 area. The Stage 3 pressure area had increased in size to 2.9 cm (l) by 3.2 cm (w) by 1.3 cm (d) which equaled a total area of 7.1 cm2. Review of the Skin & Wound Evaluation for Resident #6 dated 4/16/2025, revealed a new in- house acquired Stage 2 pressure ulcer on the coccyx that measured 2.9 cm(l) by 6.3 cm (w) by 0.1 cm (d) which equaled a total area of 13.1 cm2. Review of the Order Summary Report for Resident #6 revealed, .May substitute feeding formula as needed. Jevity 1.2 for 1.5.active.4/26/2025. Review of the Skin & Wound Evaluation for Resident #6 dated 4/30/2025, revealed a new in-house acquired Deep Tissue Injury (intact skin that is purple or maroon in color, with a blood-filled blister or other evidence of damage) on the left heel that measured 3.8 cm (l) by 2.5 cm (w) by 0 cm (d) which equaled a total area of 7.1 cm2. Review of an email sent by the Director of Nursing to the Director of Food Hospitality and Nutrition dated 7/17/2025, revealed .I have had a third feeding pump to malfunction. I notified the manufacturer a few months ago. I sent two back. The issues I have found have been inaccurate history recordings and not infusing properly. A return email from [Named Supply Company Representative] dated 7/30/2025, revealed, .I'm doing a day trip.tomorrow. I can be at your facility between 10-10:30 to dive into the pump issue. During an interview on 8/15/2025 at 11:45 AM, CNA U stated, .[Named Resident #6 ] is total assist with everything.she doesn't eat by mouth she has a feeding tube.she has had weight loss.the tube would not stay connected and the feeding would be all over the bed.they [nursing staff] tried to say the resident was doing it but I don't think she is capable of doing that.the tube had a split in it so there was no suction to it.I had brought it to the nurses attention that it was going all over the bed.I know it went on for over a month. Call placed to Licensed Practical Nurse (LPN) V (nurse who noted the tear in the PEG on 3/20/2025) on 8/15/2025 at 11:54 AM, left message for a return call. LPN V did not return the call. During a telephone interview on 8/18/2025 at 12:09 PM, Wound Care Nurse #2 stated, .[Named Resident #6] had a stage one [pressure ulcer] on admission to her coccyx.she started losing weight because the feeding would not stay connected.feeding would be on the bed, I would have to find a CNA to help me clean her up when I went to do wound care.about a month before the facility sent her out to get the tube fixed.a PRN [as needed] nurse documented that the tube had a slit in it and the tube was being taped.the Unit Manager was made aware.losing weight developing more wounds.the family came up there [to the facility] often they were very unsatisfied with her care and talked to the DON. During a telephone interview on 8/18/2025 at 12:23 PM, the Registered Dietician (RD) stated, .she [Resident #6] had a significant weight loss on my 4/8/2025 [referring to her progress note] review.20 lbs. in 30 days.she had her PEG tube replaced.and her weight started going up.the PEG tube had a split in the tube.it is possible formula was leaking out.I seen the split noted in the nurse note for 3/20/2025, so the PEG tube needed replaced.PEG was replaced on 4/7/2025.I don't know why it took that long.since the tube was replaced, her weight has improved.I don't remember no [a] formal meeting about her weight loss .prior to the significant weight loss, her weight had been pretty stable without any significant loss.4/8 [4/8/2025] note I do note a pressure wound and on 3/14/2025, I added a protein supplement for her. During an interview on 8/18/2025 at 1:30 PM, LPN S stated, .[Named Resident #6] had a split in her peg tube .I don't recall why it wasn't changed sooner .I think once they found out they got it fixed . During a telephone interview on 8/18/2025 at 2:03 PM, CNA T stated, .she [Resident #6] had some weight loss, yes .we were out of Jevity 1.5 we were going all over the building trying to find some .they gave her Glucerna [nutritional supplement for diabetics] .the Unit Manager poured the Glucerna in the Jevity bottle .I don't know when her peg tube was taped up .her brother is the one that brought it to everyone's attention, he took pictures of it . During an interview on 8/18/2025 at 3:10 PM, the Unit Manager stated, .they [RD/NP] assumed the weight loss was from the feeding and they changed her [Resident #6] feeding .[Named LPN V] never told anybody about the tear in the PEG tube .she forgot to say anything .[Family Member (FM) W] found the hole in her tube and the tape wrapped around it .he showed me .we got her sent out to get it [tube] replaced that same day .the order is on 4/7/2025 to send her out, I thought we sent her out before then .the DON reviews the nurses notes .[Named LPN V] taped it [slit in tube] up .it was never reported to me .[FM W] said it was leaking and it did have tape on it .it did have a hole in it .the slit was actually in the tube .from what I saw .[LPN V] was only one reported .I don't know how long it had been that way .the DON was told she [Resident #6] does have a slit in it [tube] and it had been leaking . During a telephone interview on 8/18/2025 at 3:50 PM, NP #1 stated, .the PEG tube, the fluid wasn't running through it .wasn't getting her [Resident #6] nutrition .I do recall that .she had a couple of issues with her tubing .I don't remember exactly .that was contributing to the weight loss .the machine [feeding pump] was beeping a lot .I don't know how long that went on .I don't recall the nurse that told me about it .there were a lot of wounds .the enteral feed was noted on the bed . During an interview on 8/18/2025 on 4:08 PM, FM W stated, .in October 2024 she [Resident #6] had one bed sore on her bottom, the wound nurse then healed it up .she kept getting bed sores .I walked in and found the tube leaking, feeding all over the bed .the cover was brown .I found it [slit in tube] in April it was taped up all around .they moved her closer to the desk .the [Named DON & Administrator] put her on 1 on 1 for a month .during that time she didn't have a bed sore or anything .they were switching her feedings around and I could tell because the feeding would be a different color when I came in .During the interview FM W showed this surveyor a picture dated 4/7/2025 at 10:32 AM of Resident #6's PEG tube which revealed a hole in the connection at the end of her tube. During an interview on 8/18/2025, at 5:15 PM, the MDS Coordinator was asked why Resident #6 had a significant change assessment completed on 4/8/2025. The MDS Coordinator stated, .due to weight loss .the reason was unknown until they [facility] done [did] an investigation .monitored the [Named feeding pump] pumps and ordered new ones .we had faulty pumps .labs [laboratory values checked] were done to look for an underlying cause .sent her out to get a new [feeding] tube it was leaking .I am not sure when the leaking started .they were unsure about the weight loss but thought that may have had something to do with it .she had a stage 2 pressure ulcer that declined to a stage 3 pressure ulcer . During an interview on 8/18/2025, at 5:24 PM, the DON was asked if the damaged feeding tube contributed to Resident #6's weight loss. The DON stated, .4/3 [2025] the Restorative CNA weighed her and it [Resident #6's weight] was 117 lbs .she did look thinner, we reweighed her again the weight was the same .I had been auditing the pumps .Friday we have PAR [Patient at Risk] days .I would audit the pump .the first time I saw the split was on 4/3/2025 .the nurses never notified me the PEG was leaking .she is a nurse why didn't she notify the physician, no need to call me .new PEG tube on 4/7 [2025] . The DON was asked if she observed the split on 4/3/2025, why did it take until 4/7/2025 for Resident #6 to get a new PEG tube. The DON stated, .we got her out as soon as we could . The DON was asked if a resident's PEG tube should have a hole/tear in it. The DON stated, .Absolutely not, it was so minute .one CNA had said it was leaking .where you connect the tubing .nothing about it not flushing that I recall .I missed it in the notes .4/3 [2025] was when I first knew .I did not think it contributed to her weight loss .it could leak some of her nutrition out but it was so minute . The DON was asked if a different enteral formula was ever used for Resident #6. The DON stated, .the Unit Manager was on the floor late one afternoon and she poured Jevity 1.2 in it .I got on to her about it .I think we got a doctor order to substitute with the other Jevity .I done [did] an investigation about this .because it was a large weight loss .the nurse put in the notes about the slit in the tubing 3/20/2025 . The DON was asked if the family had ever called her about the feeding color looking different. The DON stated, .he called me at midnight .the feeding came in late that night .4/25 [2025] we replaced the pumps, 4 times I had voiced a complaint to the company about them .[Named LPN V] did not report it [slit in the tube] to the oncoming nurse [on 3/20/2025] .4/3/2025 is when we knew .I will have to look at that on why she didn't go out right then .we got right on it . Observation in Resident #6's room on 8/19/2025 at 8:20 AM, revealed the Resident's enteral feed bottle of Jevity 1.5 was completely empty and the enteral tubing line was clear without any feeding in the line. During an interview on 8/19/2025 at 8:30 AM, RN F stated, .I normally catch it [referring to the enteral feed for Resident #6] in time . During an interview on 8/21/2025 at 10:30 AM, CNA U stated, .her wounds were smaller, but they became larger when she was losing weight . During an interview on 8/21/2025 at 4:50 PM, Regional Director of Clinical Services #1 was asked if the facility had an Intake and Output (I & O) for Resident #6. She stated, I will look. Regional Director of Clinical Services #1 came back to the surveyor and stated, .We didn't have an I & O for [Named Resident #6] . During an interview on 8/27/2025 at 11:12 AM, the Unit Manager reviewed the picture FM W had provided. The Unit Manager stated, .that is not the area where I seen [saw] the tape .I seen the tape around the tubing, around another hole in the tubing below that area . During a telephone interview on 8/27/2025 at 2:22 PM, the Medical Director (MD) was asked what a nurse should do if a resident has a tear in their feeding tube. The MD stated, .report it to us, send [the resident] to the ER [Emergency Room] . The MD was asked if Resident #6's weight loss was discussed in the Quality Assurance Performance Improvement (QAPI) meeting. The MD stated, .Yes, yes, right and we changed the tube to solve the problem . 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnosis which included Major Depressive Disorder, Hypertension, Dysphagia, Abnormalities of gait and mobility, Psychosis, and other lack of coordination. Review of the Physical Therapy evaluation and Plan of Treatment for Resident #1 dated 5/1/2025 revealed impaired physical mobility and total dependence with transfers. Review of the Annual MDS dated [DATE], revealed Resident #1 had a BIMS score of 6, which indicated severe cognitive impairment. Resident #1 was dependent on staff for toileting, bathing, lower body dressing, sit to stand, chair/bed-to chair transfer, and walking 10 feet was not attempted. Resident #1's MDS did not reflect the use of a mechanical lift. Resident #1 had impairment to one side of her lower extremity. Resident #1 had no falls since the prior assessment. Review of the care plan revealed, .Focus.[Named Resident #1] has an ADL Self Care Performance Deficit r/t [related to] Stroke and Hemiplegia.Revision on: 05/05/2025.Interventions.TRANSFER: [Named Resident #1] requires times 2-person total Mechanical.lift with medium sling for transfers. Date Initiated: 05/08/2014 Revision on: 05/13/2025. Review of the Incident Description for Resident #1 dated 7/4/2025, revealed .10:00 [AM].Nursing Description.bruise noted on l [left] knee, pt [patient] reported pain when positioned to perform peri [perineal] care.Injury Type.Abrasion.Injury Location.Left Knee (front). Review of the facility investigation revealed a written statement completed by RN F dated 7/4/2025, which stated, .CNAs asked me to look at patient [Named Resident #1]. I walked to her room and she was yelling Ow it hurts. Swelling of left knee, light bruise noted on assessment. Pt repositioned w/[with] pillows under knee. Call [Named on call company].Hospice, DON, Manager. Review of the Radiology Results Report for Resident #1 dated7/5/2025, revealed .KNEE 1 OR 2 VIEWS.Reason for Study.PAIN IN LEFT KNEE.FINDINGS: There is a moderately displaced fracture of the distal femoral metaphysis [portion of the thigh bone located just below the knee joint] with adjacent soft tissue swelling.There are moderate degenerative changes. Bones are osteopenic. CONCLUSION: Fracture of the distal femur. Review of the MAR for Resident #1 dated 7/2025, revealed Morphine Sulfate Oral Solution 10 milligram (mg)/ 5 ml (milliliter) with a start date of 7/5/2025. The nurse noted a pain level of 10 on 7/5/2025 (pain scale 1-10 with 10 being the highest level of pain). Review of the care plan revealed, .Focus.Potential for pain R/T fx [fracture] left femur.Place overbed table away from resident's leg. Put water on bed side table with in reach.Date Initiated: 07/05/2025. Review of the facility investigation completed by the Administrator dated 7/5/2025, revealed, .DESCRIPTION OF INCIDENT.[Named Resident #1] responds to name. Disoriented to time, place, and situation. Long and short term memory are impaired. Communicates with simple words.Does not speak much. Requires assistance of one person to shower, dress, and have personal hygiene needs met.Requires assistance of two people to transfer by mechanical lift now. She did transfer with one person assist as she was able to stand and pivot.12 falls since her admission in 2014.On 7/4/25 [2025] at 10:01 AM, resident c/o [complained of pain] when staff was changing brief. [Named RN F] was summoned to the room to assess resident.observed edema to left knee.called the NP to report findings. New orders given for ice and pain medication.notified [Hospice #1].Hospice nurse enroute to the facility to assess resident at 10:20 [AM] on 7/5/24 [2024]. The x-ray results were received and it indicated a fracture of the left distal femur.She has had several fractures in the past. Left femur fracture with repair, exact date unknown.Upon observation of [Resident #1] in the bed as she was positioned the day the pain began, I, [Named DON], observed the over bed table next to her bed. The left knee was on the side of the bed next to the over bed table. The corner of the table lined up with the bruise and abrasion on her left knee. If a staff member pushed the table over her unaware that they hit her knee, it would hit her knee and possible [possibly] cause a fracture of the left femu

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a resident's right to be free from abuse and neglect for 6 of 15 sampled residents (Resident #1, #2, #3, #4, #5, and #14) reviewed for abuse. The facility's failure to ensure a resident's right to be free from abuse and neglect resulted in Immediate Jeopardy when the facility failed to assess and provide timely treatment for an injury of unknown origin that resulted in a fracture for Resident #5; and a fall that resulted in a fracture for #14; and failed to prevent, identify, and monitor Resident #1 resulting in multiple resident-to-resident altercations with Resident #2 and #3. The facility's failure to provide supervision and ensure a safe environment resulted in Immediate Jeopardy for Resident #1, #2, #3, #4, #5, and #14. 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 Interim Administrator and Interim Director of Nursing (IDON) were notified of the Immediate Jeopardy (IJ) for F-600 on 11/21/2022 at 5:43 PM, in the Conference Room. The Interim Administrator and Regional Vice-President were notified of the second Immediate Jeopardy (IJ) for F-600 on 12/7/2022 at 5:31 PM. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and a severity of J, which is Substandard Quality of Care. A partial extended survey was conducted from 12/12/2022 through 12/13/2022. The Immediate Jeopardy existed from 8/19/2022 through 12/13/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/13/2021 at 8:42 AM, and was validated onsite by the surveyors on 12/14/2022 through review of root cause analysis, in-services, audits, and staff interviews conducted. The findings include: 1. Review of the facility's policy titled, .Abuse Investigations ., revealed .Reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse .neglect or injury of unknown source be reported, the Administrator, or his/her designee will appoint a member of management to investigate the alleged incident .The individual conducting the investigation will, at a minimum .Review the completed documentation forms .Interview the person(s) reporting incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate) .Interview the resident's roommate .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .the QA [Quality Assurance] team should evaluate the following .a. Changes that may need to be made to prevent further occurrences; b. Defining how care will be changed or improved to protect residents; c. Immediate and ongoing training needs and staff competency as needed; d. Identification of staff member(s) whom will carry out a-c; e. Identification of QAPI [Quality Assurance and Performance Improvement] team member whom will monitor the above . Review of the facility's Charge Nurse JOB DESCRIPTION, dated 6/2021, revealed .Perform administrative duties such as the documenting of: nurses' notes, doctors' orders .reports, evaluations .charts, resident assessments and care plans .Report accidents and incidents when they occur, including all complaints and grievances made by residents and/or their families . Review of the facility's policy titled, .Abuse Prevention Program, Screening of Employees, dated 8/2022, revealed .The facility administration and employees are committed to protecting residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers .family members .friends, visitors, or any other individual . Review of the facility's policy titled, .Abuse Program: Training, Reporting and Response, Covered Individual Responsibilities, dated 10/2022, revealed .The facility, through the Administrator or their designee, will report alleged violations related to .neglect, or abuse, including injuries of unknown source .the results of all investigations to the proper authorities within prescribed time frames . Review of the facility's electronic health record (EHR) neurochecks protocol revealed neurochecks were to be completed every 15 minutes times (x) 4, every 30 minutes x 4, every 1 hour x 2, then every shift x 72 hours. 2. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Dementia, Diabetes, Osteoarthritis, Psychosis, Scoliosis, and Anxiety. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment, and required extensive assistance for activities of daily living (ADLs). Review of the Nurse Practitioner Progress Note dated 8/20/2022 at 8:05 AM, revealed .notified by nurse .resident complains of pain in L [left] shoulder .Will get STAT [urgent] xray of L shoulder. If abnormal pt [patient] will need FTF [Face to face] . Review of the Nursing Note dated 8/20/2022 at 8:21 AM, revealed .This nurse [Licensed Practical Nurse (LPN) #2] was called to resident's room by CNA [Certified Nursing Assistant #1] asking me to assess resident arm d/t [due to] complaints of pain. Upon entering room, this nurse observed resident lying in bed with L arm cradled to side of body. Resident [Resident #5] stated her arm was 'hurting real [really] bad' when asked where she was hurting resident stated her shoulder while guarding her L arm. Limited ROM [Range of motion] noted. When this nurse asked resident what happened she stated there was 'a girl that worked with them (referring to the CNA at bedside) that was real rough.' This nurse notified unit manager on duty, DON [Director of Nursing] and telehealth contacted at this time. Orders given to STAT x-ray L shoulder and notify telehealth with results. Review of the Nursing Note dated 8/20/2022 at 2:45 PM, [Named mobile X-ray company] in facility to complete ordered x-rays . Review of the Nursing Note dated 8/20/2022 at 9:12 PM, revealed .X ray result indicates left shoulder humeral fracture .Resident was transferred to [named hospital] at 9:20pm [9:20 PM] . Review of the Nursing Note dated 8/21/2022 at 4:45 AM, revealed .Return with injury to L humeral, swollen, warm to touch, sling placed. Follow up appointment with [named Orthopedic Clinic] .within a week . Observations in the resident's room on 11/17/2022 at 10:05 AM, 2:53 PM, and 11/21/2022 at 5:21 PM, revealed Resident #5 was lying in bed, her bed was against the wall on the right side, the call light was in reach, no side rails were present, no odors were noted, and the resident appeared thin and frail. Observation on 11/29/2022 at 9:17 AM, revealed Resident #5 was in bed, the head of her bed was raised, she was awake and alert, her call light was in reach. During an interview conducted on 12/5/2022 at 4:15 PM, CNA #1 was asked about Resident #5's incident. CNA #1 stated, I went in to dry [named Resident #5] she didn't say nothing when I flipped her toward the wall then I turned her back toward me she said 'oh' I asked her what's wrong. [Named Resident #5] said 'I'm hurting, my arm.' I asked her what happened to you she said 'that girl beat the [expletive] out of me' I ran out of the room for the nurse. I got [named LPN #1] and told him [named Resident #5] said her arm hurt that a girl beat the [expletive] out of her. So, we went into her room. He asked her and she told him the same thing. I said what you going to do before I leave. He said I'm going to order an x-ray. He said for me to go on home he would handle it. The next morning [8/20/2022] when I came in .I had the same section. I went in and asked [named Resident #5] how you doing today. She said her arm still hurt. I ran got the other nurse, [named LPN #2]. Told her to check on [name Resident #5] her arm still hurts. Told her [named LPN #1] was supposed to got an x-ray last night [8/19/2022]. [Named LPN #2] pulled the cover back, and she said, 'I think her arm is broke'. I told her about telling [named LPN #1] the night before [8/19/2022], and evidently didn't order the x-ray he said he was going to order. The left arm was purple in color at the upper arm. [Named LPN #2] went got 2 other nurses, and they came in the room. They said to get x-ray ordered. [Named Resident #5] stated the white girl beat her. She is sometimes oriented. She recognizes me and I talk with her regularly. This is the first time I ever heard her say something like this had happened. During an interview conducted on 12/6/2022 at 10:15 AM, LPN #2 was asked about the incident with Resident #5. LPN #2 stated, .I came in to work on 8/20/2022 at about 7:30. [Named CNA #1] came to me and stated she had reported to [named LPN #1] the night before [8/19/2022] that [named Resident #5] had been complaining of arm pain. The resident was still complaining the next morning of arm pain and [named CNA #1] came to get me. I assessed the resident's arm. I got [named LPN #6] to come assess resident's arm. Her arm had bruising at the bicep area of her arm, and the shoulder area didn't look right. We contacted telehealth and got an order for x-ray and notified the DON and Administrator. It was a STAT order for x-ray. They came and done the x-ray. We got a phone call and fax alert with the result of x-ray. I relayed the results to telehealth doctor, and they gave orders to send her [Resident #5] to the ER [Emergency Room]. I believe it was on my shift I sent her out to ER. She was complaining of pain . LPN #2 was asked if Resident #5 told her what happened to her arm. LPN #2 stated, [Named Resident #5] told me the 'big white, fat, bi*** shook' her. I wasn't here the day before [8/19/2022] .[Named CNA #4] does fit that description . During an interview conducted on 12/6/2022 at 10:49 AM, LPN #6 was asked about the incident with Resident #5. LPN #6 stated, [Named LPN #2] came got me and wanted me to look at her [Resident #5's] arm. Her left arm was bruised and didn't look right. I instructed to call [named former DON] and tell her it's an injury of unknown origin. [Named Resident #5] said 'that girl hurt my arm, she was stout as a bull, and she hurt my arm.' I told [named LPN #2] to call telehealth, family, and doctor, and let them know. They came and did X-ray .I know she did go to the hospital . During a telephone interview conducted on 12/8/2022 at 9:35 AM, CNA #4 was asked about the incident with Resident #5. CNA #4 confirmed the former DON called her about the bruising found on Resident #5. CNA #4 confirmed she was 1 of the 2 white CNAs and stated, .possibility I worked, I don't remember working with her that day . During a telephone interview conducted on 12/8/2022 at 12:40 PM, the former Administrator was asked about the incident with Resident #5. The former Administrator stated, I do remember that. An abuse incident should have been done. [Named Resident #5] described [Named CNA #4], but she didn't work with her in that time frame. The doctor had seen her on Wednesday, and she told us on Friday .I spoke with MD [Medical Doctor] and FNP [Family Nurse Practitioner] .and she didn't have any problem of pain. The person she described didn't work in that time frame. We looked at the schedule to see what staff worked .had diagnoses of fractures in past. We did see that she had comorbidities and we noted she had a turtleneck on. She could have been injured putting on that tight turtleneck. We concluded unsubstantiated abuse, but she had a fracture from manipulating her arm, instead of intentionally hurting her . During a telephone interview conducted on 12/14/2022 at 8:44 AM, LPN #1 was asked about the incident with Resident #5's injured arm. LPN #1 confirmed his statement dated 9/8/2022 was true, and that Resident #5 did not have any falls on his shift. LPN #1 stated, I was told by the nurse when I came on, that she [Resident #5] had a fracture per x-ray . Resident #5 first said she was in pain and alleged abuse by a staff member on 8/19/2022 at about 7:00 PM, to CNA #1. CNA #1 alleged she reported the allegation to LPN #1 that night. LPN #1 did not document an assessment of Resident #5, did not do an incident report, and did not report the allegation of abuse. CNA #1 reported the same to LPN #2 on 8/20/2022, about 12 hours later. Resident was given Tylenol for the pain on 8/20/2022 at 8:00 AM, an X-ray was obtained at 2:45 PM on 8/20/2022, and results showed left humerus fracture. Tylenol was given again at 8:39 PM on 8/20/2022, when Resident #5 was transferred out to a hospital for the fracture. Therefore, Resident #5 suffered with the fracture for over 24 hours with only two doses of Tylenol for pain before being sent out to the hospital. This resulted in an Immediate Jeopardy for neglect of Resident #5. 3. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Schizophrenia, Dementia with Behavioral Disturbance, Chronic Kidney Disease, Seizures, Malnutrition, and Chronic Hepatitis C. Review of the quarterly MDS dated [DATE], revealed Resident #1 had severely impaired cognition, physical behaviors directed towards others on 4-6 of 7 days, and verbal behaviors directed towards others on 1-3 of 7 days. Review of the Care Plan revised 9/9/2022, revealed .History of Exhibits violent angry outburst and behavior problems towards staff and other residents .Violent outburst on 2 other residents .Sent to [named hospital] and returned .Placed on One-on-one supervision/care . Review of the Nurses Note dated 9/20/2022 at 5:17 AM, revealed, .Res [Resident] did get up and wonder [wander] periodically and push on exit door handles. No one on one personnel avail [available] for res [resident] and staff safety. DON [Director of Nursing] notified . Review of the Nurses Note dated 9/21/2022 at 12:20 AM, revealed .No one on one personnel avail for res and staff safety .DON notified . Review of daily assignment sheets for 9/8/2022-12/2/2022 revealed the following: a. One (1) CNA [Certified Nursing Assistant] was assigned to the Gardens [secure locked unit] from 7:00 PM-7:00 AM, and no one was assigned to provide one on one supervision for Resident #1 on 9/8/2022, 9/10/2022, 9/15/2022, 9/22/2022, 9/24/2022, and 9/27/2022. b. Two (2) CNAs were assigned to the Gardens from 7:00 PM to 7:00 AM and no one was assigned to provide one on one supervision for Resident #1 on 9/9/2022, 9/11/2022, 9/14/2022, 9/16/2022, 9/19/2022, 9/23/2022, 9/25/2022, 9/26/2022, 10/2/2022, 10/14/2022, 10/23/2022, 10/24/2022, 11/11/2022, 11/12/2022, 11/15/2022, and 11/30/2022. c. No one was assigned to provide one on one supervision for Resident #1 from 3:00 PM-7:00 PM on 10/31/2022. d. No one was assigned to provide one on one supervision for Resident #1 from 7:00 AM-7:00 PM on 12/2/2022. Review of the Incident Report dated 11/10/2022 at 2:15 PM, revealed Resident #1 was observed lying on his back on the hallway floor and Resident #2 was on top of him. Resident #2 had his hands around Resident #1's throat. 4. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE], with diagnoses of Alzheimer's, Hypertension, Depression, and Dementia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 had a BIMS of 3, which indicated severe cognitive impairment, and no behaviors were coded. Review of a witness statement signed by CNA #5 and dated 9/7/2022, revealed CNA #5 was giving shift report to CNA #6 on 9/7/2022 at approximately 6:55 PM. Resident #3 walked toward Resident #1 who was sitting in a chair in the Day Room, Resident #1 reached up and struck Resident #3 with his closed fist on her left jaw. CNA #6 stepped in between the residents and CNA #5 took Resident #3 to a safe area. The CNAs reported the incident to LPN #3. Observation in the Day Room on 11/17/2022 at 10:21 AM, revealed Resident #3 was fully clothed, sat in a wheelchair, and watched television. Observation in the Resident's Room on 11/28/22 at 10:27 AM, revealed Resident #3 was in bed, her eyes were closed, and she appeared to be asleep. Observation in the Resident's Room on 12/6/22 at 2:56 PM, revealed Resident #3 was in bed, her head was covered with a wrap, and she was turned toward the wall. 6. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia, Hypertension, and Malnutrition. Review of the quarterly MDS assessment dated [DATE], revealed Resident #4 had severe cognitive impairment. Review of an Incident Audit Report dated 9/7/2022, revealed .Incident Description .9/07/2022 [9/7/2022] .20:45 [8:45 PM] .Writer [LPN #3] standing at med [medication] cart passing medication when writer observed res [Resident #1] walking up behind res [Resident #4] .Res [Resident #1] struck res .[Resident #4] .in the rear right side of his neck with a closed fist. Writer immediately jumped in between the residents and redirected res .Resident #1] .away from res [Resident #4] .Writer walked down to his room and put cna [CNA] as one on one with res. [Resident #1]. Writer went back and assessed resident [Resident #4], Res [Resident #4] had no obvious signs of injury and made no faces of pain or any complaints . Observation in the Day Room on 11/17/22 at 10:23 AM, revealed Resident #4 was fully clothed, sat in a chair, and played with the drawstring of his pants. Observation on the Secure Unit hall on 11/29/22 at 9:14 AM, revealed Resident #4 was fully clothed, sat in a chair, his eyes were closed, and he appeared to be asleep. Observation in the Activity Room on 12/2/22 at 10:45 AM, revealed Resident #4 interacted with other residents. During an interview conducted on 11/17/2022 at 9:15 AM, the Interim Administrator confirmed staff was not providing one on one care for Resident #1 at the time of the incident on 11/10/2022. During an interview conducted on 11/17/2022 at 1:47 PM, CNA #2 confirmed she was scheduled to sit one on one with Resident #1 on 11/10/2022 from 7:00 AM-7:00 PM. CNA #2 was asked what time she arrived. CNA #2 stated, About 2 [2:00 PM] .I clocked in, put my belongings up in the breakroom in the Gardens, then used the restroom in the breakroom, and, literally, we heard the commotion . CNA #2 was asked if she saw anyone sitting outside Resident#1's room when she arrived. CNA #2 stated, No, there was no one out there . CNA #2 was asked if there were there any papers on the table. CNA #2 stated, No, it wasn't there. I had to ask for it [1:1 Monitoring Sheet] . CNA #2 was asked who was supposed to be sitting with him before she arrived. CNA #2 stated, That I'm not for sure .they knew I was running late and expected somebody to be there when I arrived .they always said that somebody needs to be with him .so I thought by me running late, they would have somebody there. CNA #2 was asked what she saw when she heard the commotion and came out of the break room. CNA #2 stated, [Named Resident #2] was on top of [named Resident #1] saying 'he hit me .he hit me in the back of my head' . CNA #2 was asked if she had ever seen Resident #1 be aggressive toward anyone. CNA #2 stated, Yes .He will get angry toward me to the point where I'm literally scared, and I have seen him get mean and holler at other residents or staff, and I did see him hit one of our other staff members before .it can be like a light switch. He will be sweet one second and then just flip. You never know when he will get in that mood . During an interview on 11/17/2022 at 2:20 PM, LPN #6 was asked who was sitting with Resident #1 when CNA #2 arrived on 11/10/2022. LPN #6 stated, No one, [named the Scheduler] said [named CNA #2] was going to be late .we had to just watch out for him .do the best we could. LPN #6 was asked if anyone was with him when the incident happened. LPN #6 stated, No . LPN #6 was asked if she asked the Scheduler when she realized CNA #2 was going to be late. LPN #6 stated, I did, I was like who is coming in .She said she was going to talk to .the Restorative Aide to come sit with him until CNA #2 came in. LPN #6 was asked if the Restorative Aide came to sit with him. LPN #6 stated, No. LPN #6 was asked if he was ever alone. LPN #6 stated, Yes ma'am. We would just check .he was sleeping, which made it easy for us to watch . LPN #6 was asked if she saw the altercation between Resident #1 and Resident #2. LPN #6 stated, No. During an interview on 11/17/2022 at 2:37 PM, the Nurse Practitioner (NP) was asked if Resident #1 was supposed to have someone with him at all times. The NP stated, Yes, he's on 1 on 1 supervision .it was my understanding that no one was actually assigned to him that day. They were having to more or less take turns watching him. I wasn't aware at the time .but there was no one assigned to him that day . During an interview conducted on 11/21/2022 at 2:43 PM, LPN #3 confirmed Resident #1 was placed on 1:1 monitoring on 9/8/2022 after 2 altercations with other residents. LPN #3 stated, .I said look this guy just can't keep walking around here hitting people . LPN #3 was asked if staff was provided to sit 1 on 1 with Resident #1 on 9/20/2022. LPN #3 confirmed no one was available to sit with Resident #1. LPN #3 stated, .That was like my last resort of asking them over and over again, and nobody was doing nothing . LPN #3 was asked what the DON said when she was notified. LPN #3 stated, She told me that she would get somebody, or she would call the staffing person .but nothing ever happened .I had one CNA I had to take off the floor. I had 2, I had 1 do the 1 on 1. One CNA would get a section and 1 on 1 [assigned to take care of the men and provide one on one care for Resident #1] and the other CNA had the women. LPN #3 was asked what if the CNA that was assigned to take care of the men and sit one on one with resident #1 had to take care of someone else. LPN #3 stated, The rationale was he was asleep through the night . LPN #3 was asked if there were other times when Resident #1 was left alone. LPN #3 stated, Oh yeah absolutely, when she was making rounds .I knew that still wasn't adequate, so that's why I started documenting . LPN #3 was asked if the same issue was present with no staff scheduled for 1 on 1 supervision for Resident #1 on 9/21/2022. LPN #3 stated, Yes ma'am, the same issue. Then what they started doing was, once they realized that I was documenting, they started scheduling 1 on 1 for my shift only .they brought somebody in. They did it right once I started documenting, so when I wasn't working or on the weekends .the only reason I know is because I picked up [weekend shifts] .you've got 2 CNAs on the hall .it's impossible, because that means she [the CNA providing 1 on one supervision for Resident #1] wouldn't have cared for anybody else. LPN #3 was asked if the facility provided any special education for providing 1 on 1 supervision for Resident #1. LPN #3 stated, No, it was just like they didn't want to do 1 on 1, but if they had to it was just like grab somebody and sit with him .with [Resident #1] you need somebody who understands his disability, his dementia, and triggers, and be proactive in stopping triggers .to keep him from becoming violent, if they had taken the time to do it right .they could've . LPN #3 was asked if it was safe for the other residents for Resident #1 to be left unsupervised. LPN #3 stated, Oh, absolutely not. During an interview conducted on 11/21/2022 at 3:54 PM, the Interim Administrator confirmed the 1:1 Monitoring sheets were incomplete. The Interim Administrator stated, .Originally, we thought she was sitting with him when technically, when she came to work, she put her stuff down and went to the bathroom, she had not technically gone to sit with him yet .basically what we failed to do was follow the resident's plan of care .we determined that the resident's POC [Plan of Care] was not followed per doctor's orders .resulted in physical altercation [with Resident #2] . During an interview conducted on 12/1/2022 at 12:00 PM, the Medical Director confirmed he was not aware there were days the facility did not have staff to provide 1 on 1 monitoring for Resident #1, and that Resident #1 always needed staff supervision. During a telephone interview on 12/1/2022 at 3:13 PM, the Regional Nurse Consultant (RNC) confirmed she was not part of the determination to place Resident #1 in 1 on 1 monitoring indefinitely. The RNC stated, .Have a task in POC [Point of Care CNA documentation system] which, to my understanding, they did not utilize .they were using paper .the 1 on 1 documentation .should have been in POC .I wasn't aware until sometime in October that he had been on 1 on 1 for this extended period of time . The RNC confirmed that she was not aware there were days the facility did not provide staff for 1 on 1 monitoring until 11/10/2022, when she saw the resident-to-resident incident submitted. The RNC stated, .that's not a resident-to-resident, that's a report under neglect, because he was care-planned for 1 on 1 .if there was a staffing issue .supposed to notify [named interim Administrator] and then [named IDON] to obtain a replacement . 5. Review of the closed medical record, revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Dementia with Psychotic Disturbance, Diabetes, Epilepsy, Schizoaffective Disorder, and Speech Disorder. Review of the annual MDS assessment dated [DATE], revealed Resident #2 had a BIMS of 11, which indicated moderate cognitive impairment. Review of the Incident Report dated 8/21/2022, revealed Resident #2, who had highly impaired vision, ran over Resident #1's foot accidentally. Resident #1 hit [Resident #2] on the back of the head with his open hand. Review of the Incident Report dated 8/28/2022 at 6:56 PM, revealed Resident #1 was observed lying on the Day Room floor in a sleeping position with a scratch on the left side of his face. There was blood on the floor. Resident #2 was in his wheelchair, his lip was bloody, and he was holding onto Resident #1's arm, holding him on the floor. The altercation was unwitnessed and neither resident was able to tell staff what happened. Review of the Nursing Noted dated 11/10/2022 at 3;09 PM, revealed Resident #1 was observed lying on the floor, Resident #2 was on top of Resident #1 and had his hands around Resident #1's throat. Resident #2 was yelling He hit me in my head. During an interview conducted on 12/7/2022 at 9:03 AM, the MDS Coordinator was asked about the incident between Resident #1 and Resident #2. The MDS Coordinator confirmed the Care Plan for Resident #1 was not being followed for 1 on 1 monitoring, which resulted in an altercation between Resident #1 and Resident #2 on 11/10/2022. The facility failed to follow the Care Plan to monitor Resident #1 after the incident with Residents #3 and #4, and he later assaulted Resident #2. 6. Review of the closed medical record, revealed Resident #14 was admitted to the facility on [DATE], with diagnoses of COVID-19, Cerebral Infarction, Dementia, Alzheimer's Disease, Osteoporosis, Anxiety, and Vitamin D Deficiency. Review of the quarterly MDS assessment dated [DATE], revealed Resident #14 had a BIMS of 4, which indicated severe cognitive impairment. Review of the Nursing Note dated 10/27/2022 at 6:15 AM, revealed .[Named Resident #14] observed sitting on floor by his wheelchair .stated he was attempting to walk .Staff reeducated resident about att [attempting] to ambulate without asst [assistance] .DON [Director of Nursing] notified . Review of the fall Incident Report dated 10/27/2022, revealed Resident #14 sustained an unwitnessed fall with no injuries. Review of the fall investigation dated 10/27/2022, revealed the only neurochecks were completed on 10/27/2022 at 7:32 AM, 7:47 AM, and 8:02 AM. Neurocheck assessments were not completed for 72 hours per the facility's protocol for unwitnessed falls. Review of the Nursing Note dated 10/28/2022 at 7:07 AM, revealed .Therapy .went in res [resident's] rm [room] to perform exercise .Res complained of pain when therapy att [attempted] to get him up .advised oncoming nurse .MD [medical doctor] notified .bilat [bilateral] x-ray . Review of the telehealth Progress Notes dated 10/28/2022 at 1:48 PM, revealed .resident c/o [complained of] L hip pain .had a fall on 10/27/2022 at 0630 [6:30 AM] .Patient highly confused. Nurse states patient normally gets up to eat and do activities but refusing to get out of bed .decreased ROM to L hip .ASSESSMENT/DIAGNOSIS PLAN NOTES .Pain in left hip .STAT xray left hip 2 views . Review of the Physician's Order dated 10/29/2022, revealed a bilateral hip x-ray was ordered. The order was not entered into the electronic health record (EHR) as STAT and was not entered on the day the order was given [10/28/2022]. Review of the Nursing Note dated 10/29/2022 at 3:09 PM, revealed .[named mobile radiology company] completed hip xray. awaiting results at this time. Review of the Nursing Noted dated 10/31/2022 at 9:30 AM, showed the x-ray results revealed Resident #14 had a left hip fracture with moderate displacement. Facility notified the provider who gave an order to send the resident to the emergency room. Review of the Nursing Note dated 10/31/2022 at 10:25 AM, revealed Resident #14 was transferred to the emergency room for treatment of his left hip fracture [4 days after the fall]. During an interview conducted on 11/22/2022 at 12:16 PM, LPN #2 confirmed she worked 10/28/2022, the day following Resident #14's fall. LPN #2 stated, .Friday [10/28/2022] morning I come [came] back in to work and was told .he was complaining of pain and refusing to get up .[named LPN #3] said he had called telehealth .was just needing help getting the x-ray ordered through the mobile x-ray company .he said he needed help calling and we don't call, we do it all online .the password wasn't valid, and I couldn't log on to [named the mobile x-ray site] .when [named LPN #6] come [came] in, I asked her for the password, so we could get it ordered .[named LPN #6] took over the whole situation . During an interview conducted on 11/23/2022 at 9:39 AM, the Physical Therapist stated, .went in to do his [Resident #14] treatment, he had been able to sit, stand and transfer .he couldn't stand .because of pain .went and found [named LPN #3] .walked down with me and did assess him .[Resident #14] moaned and verbally complained about his left hip which was uncharacteristic of him .he would move his right side and say see no pain here, it's [pain] just right here .indicated his left upper leg . During an interview conducted on 12/1/2022 at 12:00 PM, the Medical Director confirmed that facility staff should fully follow physician's orders and should have followed up on R[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, review of daily assignment sheets, time detail reports, Safety Check Log (1:1 Monitoring logs), and interview, the facility failed to implement care plan interventions for 1:1 monitoring for 1 of 18 (Resident #1) sampled residents which resulted in an Immediate Jeopardy when Resident #1, a severely cognitively impaired resident with a history of aggression and physical altercations, was left unattended by staff on 11/10/2022 and struck another resident (Resident #2) in the head, initiating an altercation. Immediate Jeopardy (IJ) is a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, severe injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy on 12/8/2022 at 10:07 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-656. The facility was cited at F-656 at a scope and severity of J. A partial extended survey was conducted from 12/12/2022 through 12/13/2022. The IJ was effective 8/19/2022 through 12/13/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/13/2021 at 8:42 AM, and was validated onsite by the surveyors on 12/14/2022 through review of root cause analysis, in-services, audits, and staff interviews conducted. The findings include: 1. Review of the facility's policy titled, Using the Care Plan, dated 5/2022 revealed, .The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident . 2. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Dementia with Mood Disturbance/Behavioral Disturbance/Psychotic Disturbance, Seizures, Hypertension, and Chronic Hepatitis C. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severely impaired cognition, physical behaviors directed towards others on 4-6 of 7 days and verbal behaviors directed towards others on 1-3 of 7 days. Review of the Care Plan dated 4/8/2022 revealed, .History of Exhibits violent angry outburst and behavior problems towards staff and other residents .9/8/22 Violent outburst on 2 other residents .Sent to [named hospital] and returned .Placed on One-on-one supervision/care .revised 9/9/2022 . Review of the telehealth Physician's Progress Note dated 9/7/2022 at 9:28 PM, revealed, .pt [patient - Resident #1] having severe psychosis. assaulted 2 other residents. agree w/ [with] RN [Registered Nurse] that patient should go under 48 hours psych [psychiatric] watch . Review of the Nurses Note dated 9/9/2022 at 2:03 AM revealed, Resident is on one on one [supervision] at this time. Review of the Nurses Note dated 9/20/2022 at 5:17 AM revealed, Res [Resident #1] sleep most of shift, no behaviors noted. Res did get up and wonder [wander] periodically and push on exit door handles. No one on one personnel avail [available] for res [resident] and staff safety. DON [Director of Nursing] notified . Review of the Nurses Note dated 9/21/2022 at 12:20 AM revealed, Res sleep most of shift, no behaviors noted. No one on one personnel avail for res and staff safety DON notified . Review of the daily assignment sheet dated 11/10/2022 revealed Certified Nursing Assistant (CNA) #2 was assigned to work on the Garden's Hall (secure unit), where Resident #1 resided, from 7:00 AM -7:00 PM with 2 other CNAs. Review of time detail report dated 11/10/2022 revealed CNA #2 clocked in at 1:52 PM. Review of the Nurses Note dated 11/10/2022 at 2:49 PM revealed, .Resident observed laying in hallway floor on back with resident .[Resident #2] laying on top of him .while on floor resident .[Resident #2] was observed with hands around [named Resident #1] neck . There was no documentation Resident #1 was on 1:1 staff observations during this time. Review of the medical record revealed Resident #1 was transferred to the emergency room (ER) evaluation on 11/11/2022 and readmitted to the facility on [DATE]. Review of the Physician's Progress Note dated 11/15/2022 at 7:18 PM revealed, .readmitted after an altercation with another resident on last week. Resident was being attacked by another resident [Resident #2] after the other resident stated [named Resident#1] hit him on his head .He is being supervised by staff, as he has been on 1:1 supervision for some time due to his attacks towards other residents in the past . 3. Review of daily assignment sheets from 9/8/2022-12/2/2022 revealed the following: On 9/8/2022, 9/10/2022, 9/15/2022, 9/22/2022, 9/24/2022, and 9/27/2022 there was one (1) CNA assigned to the Gardens Hall (Secure Unit) from 7:00 PM-7:00 AM, and there was no staff assigned to be on 1:1 with Resident #1. On 9/9/2022, 9/11/2022, 9/14/2022, 9/16/2022, 9/19/2022, 9/23/2022, 9/25/2022, 9/26/2022, 10/2/2022, 10/14/2022, 10/23/2022, 10/24/2022, 11/11/2022, 11/12/2022, 11/15/2022, and 11/30/2022 there were 2 CNAs assigned to the Gardens Hall from 7:00 PM to 7:00 AM, and no staff was assigned to be on 1:1 with Resident #1. No staff was assigned to be on 1:1 with Resident #1 from 3:00 PM-7:00 PM on 10/31/2022. No staff was assigned to be on 1:1 with Resident #1 from 7:00 AM-7:00 PM on 12/2/2022. 4. Review of the 1:1 Monitoring Sheets dated 9/8/2022-11/21/2022, revealed there was no documentation Resident #1 was being observed 1:1 on the following dates: (a) On 9/17/2022, 9/21/2022, 9/23/2022, 9/24/2022, 9/25/2022, 9/26/2022, 11/6/2022, and 11/10/2022. (b) On 10/22/2022 and 10/24/2022 from 7:00 AM to 7:00 PM. (c) On 11/1/2022 from 3:00 AM through 7:00 AM. (d) On 11/5/2022 from 7:00 AM through 11:59 PM. 5. During an interview conducted on 11/17/2022 at 9:15 AM, the Interim Administrator confirmed staff were not providing 1:1 care to Resident #1 at the time of the incident on 11/10/2022. During an interview conducted on 11/17/2022 at 1:47 PM, CNA #2 confirmed she was scheduled to observe 1:1 with Resident #1 on 11/10/2022 from 7:00 AM-7:00 PM. CNA #2 was asked what time she arrived. CNA #2 stated, About 2 [2:00 PM] .I clocked in, put my belongings up in the break room in the Gardens [Secure Unit], then used the restroom in the break room and literally we heard the commotion . CNA #2 was asked did you see anyone sitting outside Resident #1's room when you arrived. CNA #2 stated, No there was no one out there .a chair and an overbed table. CNA #2 was asked were there any papers on the table. CNA #2 stated, No it wasn't there I had to ask for it [1:1 Monitoring Sheet] . CNA #2 was asked who was supposed to be sitting with him before you arrived. CNA #2 stated, That I'm not for sure .they knew I was running late and expected somebody to be there when I arrived .they always said that somebody needs to be with him .so I thought by me running late they would have somebody there. CNA #2 was asked when you heard the commotion and came out of the break room, what did you see. CNA #2 stated, [Resident #2] was on top of [Resident #1] saying he hit me, he hit in the back of my head . CNA #2 was asked if she ever saw Resident #1 be aggressive toward anyone. CNA #2 stated, Yes .He will get angry toward me to the point where I'm literally scared, and I have seen him get mean and holler at other residents or staff; and I did see him hit one of our other staff members before .it can be like a light switch. He will be sweet one second and then just flip. You never know when he will get in that mood . During an interview conducted on 11/17/2022 at 2:20 PM, Licensed Practical Nurse (LPN) #6 was asked who was sitting with Resident #1 when CNA #2 arrived on 11/10/2022. LPN #6 stated, No one, [named the Scheduler] said [CNA #2] was going to be late .we had to just watch out for him to do the best we could. LPN #6 was asked if anyone was with him when this incident happened. LPN #6 stated, No . LPN #6 was asked when she realized CNA #2 was going to be late, if she informed the Scheduler. LPN #6 stated, I did, I was like who is coming in .She said she was going to talk to .the Restorative Aide to come sit with him until CNA #2 came in. LPN #6 was asked if the Restorative Aide came. LPN #6 stated, No. LPN #6 was asked if Resident #1 was alone at times. LPN #6 stated, Yes ma'am, we would just check .he was sleeping which made it easy for us to watch . LPN #6 was asked if anyone saw the altercation between Resident #1 and Resident #2. LPN #6 stated, No. During an interview conducted on 11/17/2022 at 2:37 PM, the Nurse Practitioner (NP) was asked if Resident #1 was supposed to have someone with him at all times. The NP stated, Yes, he's on one to one supervision .it was my understanding that no one was actually assigned to him that day, they were having to more or less take turns watching him. I wasn't aware at the time, but when I came to break up the altercation, the older CNA said something about maybe we were changing shifts .when the on-coming is coming on, the one leaving shouldn't leave his side, and I educated them about that .but there was no one assigned to him that day . During an interview on 11/21/2022 at 9:44 AM, the Interim Director of Nursing (IDON) confirmed the 1:1 Monitoring sheet documentation was incomplete. The IDON stated, .They are very random, they are not complete .I just collected what we had .I put them in order .obviously I saw that was not being done correctly . During an interview on 11/21/2022 at 10:10 AM, the Scheduler was asked if CNA #2 called and told her she was going to be late on 11/10/2022. The Scheduler stated, She texted my phone and told me she would be late, something about court. I told the nurse .she's going to be late .I was on a cart working . The Scheduler was asked if she knew what time CNA #2 arrived. The Scheduler stated, No, ma'am, I don't have access .that day [named CNA #2] was one on one . The Scheduler was asked who was one on one with Resident #1 until CNA #2 arrived. The Scheduler stated, I can't answer that, because I was on a cart on this side. The Scheduler was asked if she told anyone that she would send the Restorative Aide around to sit one on one with Resident #1. The Scheduler stated, No, I did not .if I'm on a cart, I don't do anything dealing with the staffing part, the staffing is already done .I just know I told the nurse that morning she was going to be late. The Scheduler was asked what her plan was for one on one with Resident #1. The Scheduler stated, I always tell the nurse, there's a unit manager back there, and there's a nurse and we can all help out .that's the way it's supposed to be . The Scheduler was asked if she knew what time she was told that CNA #2 had not made it to work yet. The Scheduler stated, .I was thinking it was around 11, I was in the Dining Room . The Scheduler was asked if she notified anyone that nobody was 1:1 with Resident #1 at that point. The Scheduler stated, No ma'am. During an interview conducted on 11/21/2022 at 2:43 PM, LPN #3 confirmed Resident #1 was placed on 1:1 monitoring on 9/8/2022 after 2 altercations with other residents. LPN #3 stated, .I said look this guy just can't keep walking around here hitting people . LPN #3 was asked they did not provide you staff to sit 1:1 on 9/20/2022. LPN #3 stated, That's correct .that was like my last resort of asking them over and over again and nobody was doing nothing . LPN #3 was asked when you notified the DON, what did she tell you. LPN #3 stated, She told me that she would get somebody or she would call the staffing person .but nothing ever happened .I had one CNA, I had to take 1 off the floor. I had 2, I had one do the 1 on 1. One CNA would get a section and 1 on 1 [assigned to take care of the men and provide 1:1 supervision for Resident #1] and the other CNA had the women. LPN #3 was asked what if the CNA assigned to men and 1:1 for Resident #1 had to take care of somebody else. LPN #3 stated, The rationale was he was asleep through the night, but I was trying to tell them [didn't have 1:1 staff]. LPN #3 was asked were there times when Resident #1 was left alone. LPN #3 stated, Oh yeah absolutely, when she was making rounds .I knew that still wasn't adequate, so that's why I started documenting . LPN #3 was asked if on 9/21/2022 there was the same issue with no staff scheduled for 1 on 1. LPN #3 stated, Yes ma'am, the same issue. Then what they started doing was once they realized that I was documenting, they started scheduling 1 on 1 for my shift only .they brought somebody in. They did it right once I started documenting, so when I wasn't working or on the weekends .the only reason I know is because I picked up [weekend shifts] .you've got 2 CNAs on the hall .it's impossible because that means she wouldn't have cared for anybody else. LPN #3 was asked did the facility provide any special education for 1 on 1. LPN #3 stated, No, it was just like they didn't want to do 1 on 1 but if they had to it was just like grab somebody and sit with him .with [Resident #1] you need somebody who understands his disability, his dementia, and triggers, and be proactive in stopping triggers .to keep him from becoming violent, if they had taken the time to do it right .they could've . LPN #3 was asked was it safe for the other residents for Resident #1 to be left unsupervised. LPN #3 stated, Oh, absolutely not. During an interview conducted on 11/21/2022 at 3:54 PM, the Interim Administrator confirmed the 1:1 Monitoring sheets were incomplete. The Interim Administrator stated, .Originally, we thought she was sitting with him when technically when she came to work, she put her stuff down and went to the bathroom, she had not technically gone to sit with him yet .basically what we failed to do was follow the resident's plan of care .we determined that the resident's POC [Plan of Care] was not followed per doctor's orders .resulted in physical altercation [with Resident #2] . During an interview conducted on 11/22/2022 at 11:15 AM, LPN #4 confirmed she was working on 11/10/2022. LPN #4 was asked when she was made aware that there was not a staff member for 1:1 for Resident #1. LPN #4 stated, .I was in meetings, so I think it was at the care plan meeting I was made aware the aide hadn't made it in yet and the [Scheduler] was made aware, also the DON .it was told that they were going to get someone to cover the 1 on 1 .the nurse on the unit told me the [Scheduler] was going to send someone down to take care of the 1 on 1 .I had to take care of PAR [the Patients at Risk meeting]. LPN #4 was asked what time the care plan meeting started. LPN #4 stated, Right after morning meeting, don't know if we were done early or late .It [the altercation] happened during PAR and the nurse called me down there and told me what had took place, I left PAR . LPN #4 was asked if PAR took place right after the care plan meeting. LPN #4 stated, PAR happens at 1:30 [PM]. Care Plan depends on how many residents there are on care plan . LPN #4 was asked what she did when she arrived on the hall. LPN #4 stated, Trying to figure out why it occurred, and the aide that was supposed to be in 1 on 1 wasn't down there when it happened .They had me down there thinking she was sitting with him .I wasn't aware of that part .I was thinking she was down there sitting with him and had to get up and go to the restroom .I wasn't aware that she had just come in and put her stuff down . LPN #4 was asked as the Unit Manager should she have been aware no one was sitting 1:1. LPN #4 stated, Yes ma'am. LPN #4 was asked if Resident #1 should be left alone at any time. LPN #4 stated, No ma'am. During an interview conducted on 11/29/2022 at 1:38 PM, the former DON denied having been notified of not having staff to provide 1:1 monitoring for Resident #1 on 9/20/2022 and 9/21/2022. The former DON was asked how did you ensure staff were competent to provide care and 1:1 monitoring of a combative, aggressive resident. The former DON stated, We have a [computer] course on de-escalating patients and our log that they're checking on him to make sure and documenting where he is . The former DON was asked what training was provided to staff regarding how to complete or fill out the 1:1 Monitoring tool. The former DON stated, I think it's pretty self-explanatory . The former DON was asked did you monitor those tools to ensure they were completed. The former DON stated, Truly, honestly I left that to be on the nurses. The former DON was asked were you aware there was no coverage for 1:1 for Resident #1 on 11/10/2022. The former DON stated, No .I did not know about it until after the incident . During an interview conducted on 12/1/2022 at 3:13 PM, the Regional Nurse Consultant (RNC) was asked were you aware there were days Resident #1 did not have 1 on 1 monitoring. The RNC stated, Not until November 10th when I saw a resident to resident be submitted that [named the Interim Administrator] and I had a conversation .that's not a Resident to Resident, that's reportable under neglect because he was care planned for 1 on 1 .if there was a staffing issue .supposed to notify [named interim Administrator] and then [named IDON] to obtain a replacement . During an interview conducted on 12/5/2022 at 9:55 AM, the Interim Administrator confirmed they could not find any de-escalation training that was completed prior to 12/2/2022. During an interview conducted on 12/7/2022 at 9:03 AM, the MDS Coordinator confirmed Resident #1's care plan was updated to include 1:1 monitoring on 9/9/2022 and the care plan was not being followed on 11/10/2022 when the incident between Resident #1 and Resident #2 occurred. The MDS Coordinator was asked should the care plan be followed. The MDS Coordinator stated, Absolutely. The MDS Coordinator was asked should Resident #1 be on continuous 1:1 monitoring. The MDS Coordinator stated, Yes. Refer to F-689 The surveyors verified the removal plan by review of root cause analysis, in-services, audits, and staff interviews conducted: NP educated the 2 CNAs involved with Resident #1 on one-to-one supervision. Surveyors verified by interview. RNC in-serviced RN/IDON and LPN Nurse Manager on Abuse Prevention Program, Recognizing Signs and Symptoms of Abuse/Neglect (Identification) to include notification of Admin (Administrator)/DON when staffing changes occur with 1:1. Nursing staff educated not to leave 1:1 resident without staff replacement. Charge Nurses educated to new protocol for 1:1 and notification. Surveyors verified by review of in-service documentation and interview. DON/Nurse Manager in-serviced staff on Abuse Prevention Program, Recognizing Signs and Symptoms of Abuse/Neglect (Identification) to include notification of Admin/DON when staffing changes occur with 1:1. Nursing staff to be educated not to leave 1:1 resident without staff replacement. Charge Nurses educated to new protocol for 1:1 and notification. Surveyors verified by review of in-service documentation and interview. RNC in-serviced RN/IDON and LPN Nurse Manager on use of crisis intervention technics, tips on managing challenging behaviors, and redirecting a client with challenging behaviors. Surveyors verified by review of in-service documentation and interview. DON/Nurse Manager in-serviced staff on use of crisis intervention technics, tips on managing challenging behaviors, and redirecting a client with challenging behaviors. This training started on 11/23/22. Additional staff will be in-serviced prior to working their next shift. Surveyors verified by review of in-service documentation and interview. Charge Nurse will sign at the end of each shift to verify documentation is complete. Surveyors verified by review of documentation. Medical Records will collect and audit 1:1 sheets routinely and scan into the electric record. Surveyors verified by interview. All new behaviors will be reviewed Monday through Friday during clinical start up for redirection/appropriate intervention and discuss and provide education according to needs. Surveyors verified by interview. DON implemented protocol and placed at NS (Nurses Station). All one-on-one orders for supervision are placed as a doctor's order on POC/PCC MAR (Point of Care CNA Documentation/Point Click Care Medication Administration Record). Surveyors verified by review of protocol and interview. QAPI (Quality Assurance Performance Improvement) was conducted November 18, 2022, with IDT (Interdisciplinary Team) and Medical Provider representative and completed RCA [Root Cause Analysis]. Surveyors verified by review of QAPI minutes. New staff will be educated on 1:1 process, crisis intervention and behavioral training upon hire. Surveyors verified by interview. QAPI will be held again 12/8/22 with Governing Body to discuss deficiency, education, systemic changes, and monitoring moving forward. Surveyors verified by review of QAPI minutes. Audit of Staffing sheets to be done 3 times (x) a week to assess compliance of assignment(s) of 1:1 weekly x 4 weeks then 1 x weekly for 8 weeks. Results of the audits will be submitted to the QAPI Committee for review and recommendation(s). Surveyors verified by review of audits and interview. DON/Nurse Manager will audit staff knowledge regarding behavioral scenarios and how to respond. Choosing 2 staff members 3 times a week x 4 weeks then 2 staff members 1 time a week x 8 weeks. The results of those audits will be sent to QAPI for eval and review. Surveyors verified by review of audits and interview. The facility's noncompliance of F-656 continues at a scope and severity of D for monitoring the effectiveness of the 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, job description review, medical record review, observation, and interview, the facility failed to ensure that residents were provided appropriate care and services to meet the residents' physical, mental and/or psychosocial needs in a timely manner for 2 of 18 sampled residents (Resident #5 and #14) reviewed for quality of care. This resulted in Immediate Jeopardy (IJ) when Resident #5 complained of pain and abuse by a staff member and no one addressed this abuse allegation and injury until the next day; and when staff failed to acknowledge and implement an immediate (STAT) physician's order, follow up on radiology results, transfer a resident to the hospital in a timely manner, and provide pain relief for Resident #14. The facility's failure to provide appropriate care and services resulted in Immediate Jeopardy for Resident #5 and #14. 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 Interim Administrator and Regional Vice-President were notified of the Immediate Jeopardy (IJ) for F-684 on 12/7/2022 at 5:31 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-684. The facility was cited at F-684 at a scope and a severity of J, which is Substandard Quality of Care. A partial extended survey was conducted from 12/12/2022 through 12/13/2022. The Immediate Jeopardy existed from 8/19/2022 through 12/13/2022. An acceptable Removal Plan which removed the immediacy of the jeopardy was received on 12/13/2022 at 10:44 PM, and was validated onsite by the Surveyors on 12/14/2022, through review of root-cause analysis, in-services, audits and staff interview conducted. The findings include: 1. Review of the facility's policy titled, Request for Diagnostic Services . dated 5/2022, revealed, All requests for diagnostic services must be ordered by a physician .Orders for diagnostic services will be promptly carried out as instructed by the physician's order .Emergency requests must be labeled .stat .to assure that prompt action is taken . Review of the facility's policy titled, .Pain Clinical Protocols and Guidelines dated 10/2022, revealed, .Pain management will be provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences .Through established assessments, the nursing staff will identify individuals who have pain or who are at risk for having pain .This includes a review of each person's known diagnoses and conditions that commonly cause or predispose to pain .It also includes a review for any treatments that the resident currently is receiving for pain, including complementary treatments .The nursing staff will assess each individual for pain .whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain .Through the assessment process, the nursing staff will attempt identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain .Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level .The staff will observe the resident (during rest and movement) for evidence of pain .grimacing while being repositioned .The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated .ambulation .repositioning .Confer with the attending practitioner to help identify the extent to which underlying causes of pain can be addressed or reversed .Obtain orders for appropriate tests .x-rays as needed .Obtain orders for appropriate pain medications based upon the resident's current situation .PRN [as needed] doses should be monitored at time of request .Monitoring .PRN pain management response will be recorded post each dose given . 2. Review of the facility's unsigned Charge Nurse JOB DESCRIPTION dated 6/2021, revealed, .Perform administrative duties such as the documenting of: nurses' notes, doctors' orders .reports, evaluations .charts, resident assessments and care plans .Report accidents and incidents when they occur, including all complaints and grievances made by residents and /or their families, and immediately report any time a resident is observed leaving campus . 3. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Dementia, Diabetes, Osteoarthritis, Psychosis, Scoliosis, and Anxiety. Review of Certified Nursing Assistant (CNA) #1 witness statement dated 8/20/2022, revealed that she entered Resident #5's room to change her prior to shift change at approximately 7:00 PM on 8/19/2022, and when she turned Resident #5 back toward her the resident yelled out in pain. CNA #1 asked the resident what was wrong and the resident complained of left (L) arm pain. CNA #1 documented in her statement that she reported the complaint to LPN #1, and they both went to the resident's room. CNA #1 documented that when LPN #1 had Resident #5 lift her arm, she cursed him out. CNA #1 documented that LPN #1 told her he would call for an xray. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment, and required extensive assistance for activities of daily living (ADLs). Review of the Nursing Note dated 8/20/2022 at 8:21 AM [over 13 hours after Resident #5 complained of left arm pain], revealed, This nurse [Licensed Practical Nurse (LPN) #2] was called to resident's room by CNA [Certified Nursing Assistant #1] asking me to assess resident arm d/t [due to] complaints of pain. Upon entering room, this nurse observed resident lying in bed with L arm cradled to side of body. Resident stated her arm was hurting real bad when asked where she was hurting resident stated her shoulder while guarding her L arm. Limited ROM [Range of motion] noted. When this nurse asked resident what happened she stated there was 'a girl that worked with them (referring to the CNAs) that was real rough and yanking' on her. This nurse notified unit manager on duty, DON [Director of Nursing] and telehealth contacted at this time. Orders given to STAT x-ray L shoulder and notify telehealth with results. Review of the Nursing Note dated 8/20/2022 at 2:45 PM [over 19 hours after Resident #5 complained of left arm pain], [Named mobile X-ray company] in facility to complete ordered x-rays. Reported to on-coming nurse . Review of the Nursing Note dated 8/20/2022 at 8:39 PM [over 25 hours after Resident #5 complained of left arm pain], revealed, .PRN Administration .Effective Follow-up Pain Scale was: 0. There was no documentation a pain medication had been administered to Resident #5 on the Medication Administration Record (MAR) for this date and time. Review of the Discharge summary dated [DATE] at 9:20 PM, revealed, .X ray result indicates left shoulder humeral fracture .notified telehealth and got order to transfer resident to hospital for further evaluation .transferred to [named hospital] at 9:20pm [9:20 PM]. Resident #5 was transferred to a hospital for treatment of the left arm fracture over 26 hours after she complained of left arm pain. Review of a Nursing Note created on 8/22/2022 at 8:11 AM, for a late entry note for 8/20/2022 timed at 10:45 AM, revealed, Late Entry .Daily skilled note for [named Resident #5]. See nursing notes, Resident sent to ER [Emergency Room] for follow up to STAT x-ray ordered this shift . This Nurses' Note was created two days later, and Resident #5 did not go to the hospital until 8/20/2022 at 9:20 PM, approximately 26 hours after Resident #5 first complained of bad pain. Review of the Nursing Note dated 8/21/2022 at 4:45 AM, revealed, Return with injury to L humeral, swollen, warm to touch, sling placed . Review of the Nursing Note dated 8/21/2022 at 7:13 PM, revealed PRN [as needed Tylenol for pain medication] Administration was: Effective Follow-up Pain Scale was: 0. The August 2022 MAR did not document this Tylenol was given on 8/21/2022. Review of the Nursing Note created on 8/22/2022 at 7:32 AM, for a late entry note for 8/21/2022 revealed, Resident resting throughout shift PRN [as needed] Tylenol given for pain .Sling in place throughout shift . The August 2022 MAR did not document this Tylenol had been administered on this date and time. Review of the Nursing Note created on 8/22/2022 at 8:14 AM, for a late entry for 8/21/2022 at 10:55 AM, revealed .[Resident #5] resting in bed with no apparent distress noted at this time. vitals stable .Able to make wants and needs known This Nurses' Note was created 27 hours and 29 minutes after Resident #5 had been readmitted back to the facility. Review of the Nursing Note dated 8/22/2022 at 7:18 AM revealed, L humeral [upper arm], swollen, warm to touch, sling placed. Review of the Nursing Note dated 8/22/2022 at 7:24 PM, revealed, Resident left arm, swollen, warm to touch, sling intact. Tylenol given for pain . The August 2022 MAR did not document this Tylenol had been administered on this date and time. Review of the Nursing Note created on 8/22/2022 at 10:55 AM, for a late entry note for 8/22/2022 at 9:34 PM, revealed, .[Resident #5] resting in bed left arm in a sling R/T [related to] fractured arm . Review of the statement by LPN #1 dated 9/8/2022 revealed, I did not witness [Resident #5] falling, she has never fell on my shift. Patient had a fracture from X-ray report, I got a report from out going nurse and I transferred patient to [named Hospital]. She returned to facility next day in the morning. Observations in the resident's room on 11/17/2022 at 10:05 AM, 2:53 PM, and on 11/21/2022 at 5:21 PM revealed Resident #5 was lying in bed, her bed was against the wall on the right side, the call light was in reach, no side rails were present, no odors were noted, and the resident appeared thin and frail. Observation on 11/29/2022 at 9:17 AM revealed Resident #5 was in bed, the head of her bed was raised, she was awake and alert, her call light was in reach. During an interview on 12/2/2022 at 1:40 PM, Licensed Practical Nurse (LPN) #2 was asked about the incident with Resident #5's injured arm. LPN #2 stated, I came into work, Saturday morning, the CNA [named Certified Nursing Assistant #1] came to me and stated Resident #5 reported pain in her shoulder. The CNA #1 said resident had complained the previous night and an X-ray was supposed to have been ordered. I went in to assess her. I could see something was going on with her shoulder. I ordered x-ray through [named mobile xray company]. They came that day I believe and did x-ray of her left upper arm. We got an alert sent to us that it was a fracture. I contacted telehealth again that it was a fracture, and they gave order to send her to ER. We contacted the DON let her know fractured. [Named LPN #6] was asked to assess [named Resident #1] also. She was sent back to facility with a brace on left arm with orders to follow up with ortho [orthopedic doctor]. She did do follow up with Ortho. Surgery was not recommended. We did get statements from CNAs. Social usually interviews the residents around the incident. During an interview conducted on 12/5/2022 at 4:15 PM, CNA #1 was asked about Resident #5's incident. CNA #1 stated, I went in to dry [Resident #5] she didn't say nothing when I flipped her toward the wall then I turned her back toward me she said 'oh' I asked her what's wrong. [Resident #5] said 'I'm hurting, my arm.' I asked her what happened to you she said 'that girl beat the [expletive] of me' I ran out of the room for the nurse. I got [LPN #1] and told him [Resident #5] said her arm hurt that a girl beat the [expletive] out of her. So, we went into her room. He asked her and she told him the same thing. I said [named LPN #1] what you going to do before I leave. He said I'm going to order an x-ray. He said for me to go on home he would handle it. The next morning when I came in .I had the same section. I went in and asked [ Resident #5] how you doing today. She said her arm still hurt. I ran got the other nurse, [named LPN #2]. Told her to check on [Resident #5] her arm still hurts. Told her [LPN #1] was supposed to got an x-ray last night. [LPN #2] pulled the cover back and she said, 'I think her arm is broke'. I told her about telling [LPN #1] the night before and evidently didn't order the x-ray he said he was going to order. The left arm was purple in color at the upper arm. [Named LPN #2] went, got 2 other nurses and they came in the room. They said to get x-ray ordered. This was Friday and they ordered the x-ray. [Named Resident #5] stated the white girl beat her. She is sometimes oriented. She recognizes me and I talk with her regularly. This is the first time I ever heard her say something like this had happened. During an interview conducted on 12/6/2022 at 10:15 AM, LPN #2 was asked about the incident with Resident #5. LPN #2 stated, .I came in to work on 8/20/2022 at about 7:30. [Named CNA #1] came to me and stated she had reported to [named LPN #1] the night before that [named Resident #5] had been complaining of arm pain and she told [named LPN #1]. The resident was still complaining the next morning of arm pain and [named CNA #1] came to get me. I assessed the resident's arm. I got [named LPN #6] to come assess resident's arm. Her arm had bruising at bicep area of her arm and shoulder area didn't look right. We contacted telehealth and got order for x-ray and notified the DON and Administrator. It was a STAT order for x-ray. They came and done x-ray. We got a phone call and fax alert with the result of x-ray. I relayed the results to telehealth doctor, and they gave order to send her to ER [Emergency Room]. I believe it was on my shift I sent her out to ER. She was complaining of pain . LPN #2 was asked if Resident #5 told her what happened to her arm. LPN #2 stated, [Named Resident #5] told me the 'big white, fat, [expletive] shook' her, a CNA. I wasn't here the day before. [CNA #4] does fit that description. The same Nurse [LPN #1] came in the next day on 8/20 [2022], and I believe she was in the hospital when [named LPN #1], he came in, and I told him she was there . During an interview conducted on 12/6/2022 at 10:49 AM, LPN #6 was asked about the incident with Resident #5. LPN #6 stated, [Named LPN #2] came got me and wanted me to look at her [Resident #5's] arm. Her left arm was bruised and didn't look right. I said you need to call [named former DON] and tell her it's an injury of unknown origin, [named Resident #5] said 'that girl hurt my arm, she was stout as a bull and she hurt my arm' I told [named LPN #2] to call telehealth, family and doctor let them know. They came and did x-ray .I know she did go to hospital .Telehealth gave order for the x-ray. Telehealth will give us pain medicine, they have before . During a telephone interview conducted on 12/8/2022 at 9:35 AM, CNA #4 was asked about the incident with Resident #5. CNA #4 stated, The former DON called me and said she had a bruise on her wrist. She said a white woman had hurt her arm. There are only 2 white CNAs, me and .Possibility, I worked, I don't remember working with her that day . During a telephone interview conducted on 12/8/2022 at 12:40 PM, the former Administrator was asked about the incident with Resident #5. The former Administrator stated, I do remember that. An abuse incident should have been done [named CNA #4] she described, but she didn't work with her in the time frame. The doctor had seen her on Wednesday, and she told us on Friday .I spoke with MD [Medical Doctor] and FNP [Family Nurse Practitioner] one had seen her, and she didn't have any problem of pain. The person she described didn't work in that time frame. We looked at schedule to see what staff worked. Had dx [diagnoses] of fractures in past. We did see that she had comorbidities and we noted she had a turtleneck on. She could have been injured putting on that tight turtleneck. We concluded, unsubstantiated abuse, but she had a fracture from manipulating her arm, instead of intentionally hurting her . During a telephone interview conducted on 12/14/2022 at 8:44 AM, LPN #1 was asked about the incident with Resident #5's injured arm. LPN #1 confirmed his statement was true, as the surveyor read the statement dated 9/8/2022. LPN #1 stated, I was told by the nurse when I came on, she had a fracture per x-ray. No complaint of pain on previous day, I work on Friday, Saturday, and Sunday .The CNA did not mention any arm pain. It was next day I came back, and I sent her out. I think I gave her Tylenol, before sending her out . Resident #5 first said she was in pain and alleged abuse by a staff member on 8/19/2022 at about 7:00 PM, to CNA #1. CNA #1 reported the allegation to LPN #1 that night. LPN #1 did not document an assessment of Resident #5, did not do an incident report, and did not report the allegation of abuse. CNA #1 reported the same to LPN #2 on 8/20/2022 about 12 hours later .X-ray was obtained at 2:45 PM on 8/20/2022 (over 19 hours after the first complaint of pain) results showed left humerus fracture (results obtained over 26 hours after first complaints of pain). Therefore, Resident #5 suffered with the fractured area for over 24 hours with only two doses of Tylenol for pain and then was sent out to the hospital. This resulted in an Immediate Jeopardy for neglect of Resident #5. 4. Review of the closed medical record, revealed Resident #14 was admitted to the facility on [DATE], with diagnoses of COVID-19, Cerebral Infarction, Dementia, Alzheimer's Disease, Osteoporosis, Anxiety, and Vitamin D Deficiency. Review of the quarterly MDS assessment dated [DATE], revealed Resident #14 had a BIMS of 4, which indicated severe cognitive impairment. The medical record revealed Resident #14 sustained unwitnessed falls on 9/26/2022, 9/28/2022, 10/4/2022, 10/6/222, and 10/27/2022. There was no documentation that Neuro Check assessments were completed per the facility's fall protocol. Review of the Incident Report dated 9/26/2022 revealed Resident #14 was found on the floor beside his bed, and the Mental Status and Predisposing Factors sections of the Incident Report were not completed. Review of the fall investigation dated 9/26/2022 revealed Neuro Check assessments were not completed per the facility's protocol. Review of the Incident Report dated 9/28/2022 revealed Resident #14 was found on the floor beside his bed and the Mental Status section of the Incident Report was not completed. Review of the fall investigation dated 9/28/2022, revealed the Skin assessment and Neuro Check assessments were not completed per the facility's protocol for unwitnessed falls. Review of the Incident Report dated 10/4/2022 revealed Resident #14 sustained an unwitnessed fall on 10/4/2022, and the Mental Status and Predisposing Factors sections of the Incident Report were not completed. Review of the fall investigation dated 10/4/2022 revealed the Skin assessment and Neuro Check assessments were not completed per the facility's protocol for unwitnessed falls. Review of the Incident Report dated 10/6/2022, revealed Resident #14 was found sitting on the floor with his bedsheet wrapped around his legs. Review of the fall investigation dated 10/6/2022, revealed the Neuro Check assessments were not completed per the facility's protocol for unwitnessed falls. Review of the Nursing Note dated 10/27/2022 at 6:15 AM revealed, .Resident observed sitting on floor by his wheelchair .stated he was attempting to walk .Staff reeducated resident about att [attempting] to ambulate without asst [assistance] .DON [Director of Nursing] notified . Review of the Incident Report dated 10/27/2022, revealed Resident #14 sustained an unwitnessed fall, and the Mental Status and Predisposing Factors section of the Incident Report were not completed. Review of the Neuro Checks assessment dated [DATE], revealed neuro checks should be completed every 15 minutes times (x) 4, every 30 minutes x 4, every 1 hours x 2, then every shift for 72 hours. Review of the fall investigation dated 10/27/2022, revealed Neuro Check assessments were completed on 10/27/2022 at 7:32 AM, 7:47 AM and 8:02 AM. Neuro check assessments were not completed per the facility's protocol for unwitnessed falls. Review of the Nursing Note dated 10/28/2022 at 7:07 AM, revealed .Therapy .went in res [resident's] rm [room] to perform exercise .Res complained of pain when therapy att [attempted] to get him up .Writer came and did a physical asst [assessment] of residents left hip .did not observe hip to be swollen redden [reddened] or discolored of nature .advised oncoming nurse .MD [medical doctor] notified and bilat [bilateral] x-ray . Review of the telehealth Progress Notes dated 10/28/2022 at 1:48 PM, revealed, .resident c/o [complained of] L [left] hip pain .had a fall on 10/27/2022 at 0630 [6:30 AM] .Patient highly confused. Nurse states patient normally gets up to eat and do activities but refusing to get out of bed .decreased ROM [range of motion] to L hip .ASSESSMENT/DIAGNOSIS PLAN NOTES .Pain in left hip .STAT xray left hip 2 views . Review of the Physician's Order dated 10/29/2022 revealed a bilateral hip x-ray was ordered but was not entered into the electronic health record (EHR) as STAT until the day after the order was given. Review of the Nursing Note dated 10/29/2022 at 3:09 PM, revealed Resident #14's x-ray was completed, and the results were pending. Review of the Nursing Note dated 10/31/2022 at 9:30 AM, revealed the x-ray results were received and Resident #14 had a left subcapital hip fracture (fracture in the neck of the thighbone) with moderate displacement, the provider was made aware and gave an order to send the resident to the emergency room. Review of the Nursing Note dated 10/31/2022 at 10:25 AM, revealed Resident #14 was transported to the emergency room for treatment; 4 days after the unwitnessed fall, and 3 days after the resident complained of pain to the Physical Therapist and was unable to stand on his left leg. During an interview conducted on 11/22/2022 at 12:16 PM, LPN #2 confirmed she worked 10/28/2022, the day following Resident #14's fall. LPN #2 stated, .Friday [10/28/2022] morning I come [came] back in to work and was told .he was complaining of pain and refusing to get up .[named LPN #3] said he had called [named telephonic physician's group], notified the RP [responsible party] .was just needing help getting the x-ray ordered through the mobile x-ray company .he said he needed help calling, and we don't call, we do it all online .left the nurses' station to go to the other one to get our password to be able to do that .the password wasn't valid and I couldn't log on to [named the mobile x-ray site] .when [named LPN #6] come in I asked her for the password so we could get it ordered .[named LPN #6] took over the whole situation . During an interview conducted on 11/23/2022 at 9:39 AM, the Physical Therapist stated, .[On 10/28/2022] went in to do his [Resident #14] treatment, he had been able to sit, stand and transfer .he couldn't stand .because of pain .went and found [named LPN #3] .walked down with me and did assess him .moaned and verbally complained about his left hip which was uncharacteristic of him .he would move his right side and say see no pain here, it's [pain] just right here .indicated his left upper leg . The Physical Therapist confirmed LPN #3 said he was going to notify the physician and obtain an order for an x-ray. During an interview on 12/1/2022 at 12:00 PM, the Medical Director confirmed that facility staff should fully follow physician's orders and should have followed up on Resident 14's STAT x-ray, and not have waited until almost 2 days after the x-ray was obtained. During an interview conducted on 12/2/2022 at 1:28 PM, LPN #2 confirmed that she contacted the telephonic physician's group through a facetime visit and obtained an order for a bilateral hip x-ray. LPN #2 stated, .I let [named LPN #6] know .she facilitated that and ordered it through [named mobile x-ray company] . LPN #2 confirmed she was not sure if she told LPN #6 the bilateral hip x-ray order was supposed to be entered STAT. LPN #2 was asked when came in on 10/29/2022, did she receive in report that the x-rays had not yet been obtained. LPN #2 stated, Yes, [named LPN #10] said .they weren't going to be able to come out .but would be out first thing in the morning [10/29/2022] . LPN #2 was asked what she did next. LPN #2 stated, I administered prn [as needed] pain medication that I didn't document . LPN #2 confirmed that she did not attempt to contact the mobile radiology company, the nurse practitioner, or the doctor when the x-ray was not obtained STAT as ordered. During an interview on 12/5/2022 at 4:09 PM, LPN #4 confirmed the facility's protocol when a resident fell included a fall risk assessment, pain assessment, skin assessment, and if the fall was unwitnessed, neurochecks were required. LPN #4 confirmed every section of the Incident Report should be completed following a resident's fall. During an interview conducted on 12/6/2022 at 9:51 AM, LPN #2 was asked the facility's protocol for resident falls. LPN #2 stated, .That seems like it has changed some over the years, when I first started working it seems like we would complete a pain and skin assessment .seems like it is no longer required .when you ask upper management .I've done my incident report, I've contacted telehealth and ask what else I need to do .they say oh well that's fine . LPN #2 was asked who she meant by upper management and she stated, [Named former Director of Nursing (DON)]. LPN #2 was asked if there was a policy or protocol on falls that instructed staff which assessments should be completed. LPN #2 stated, I don't know. I would like to assume that there is somewhere, where I couldn't tell you. LPN #2 was asked was she was uncertain what protocol to follow when a resident falls. LPN #2 stated, Yes .because it may or may not change depending on our DON or Administrator at the time .we can never keep an Administrator or DON .typically the nurse it happens on should complete all of that .your neurochecks if it's unwitnessed .the nurse here when it happens is responsible for ensuring all of that is complete . LPN #2 was asked the protocol for an unwitnessed fall and stated, Incident report, neurochecks .you start under the assessment tab in the chart .will set up its own schedule you have to follow for 72 hours .the time frames are triggered but you have to trigger it [Neuro Check assessments] initially .a lot of times I try to do the pain assessment even though it may not be required right now. I know that it has been in the past . LPN #2 confirmed that the former DON told her the pain assessment was no longer required when a resident had fallen. LPN #2 confirmed that a pain assessment and skin assessment were required to be completed for each fall prior to the former DON's administration. LPN #2 confirmed that the facility's protocol for Neuro Check assessments should have been followed for Resident #14's unwitnessed falls that occurred on 9/26/2022, 9/28/2022, 10/4/2022, 10/6/2022, and 10/27/2022. Resident #14 fell multiple times, and the post fall protocol was not followed by staff. Then he had a fall on 10/27/2022, complained of pain on 10/28/2022, the xray was not completed STAT as ordered, and xrays results were not obtained until 10/31/2022, revealing a left hip fracture. Therefore, Resident #14 suffered with the untreated fractured hip for 4 days, when the facility failed to follow the fall protocol and plan of care. This resulted in an Immediate Jeopardy for Resident #14. The surveyors verified the Removal Plan through review of root-cause analysis, in-services, audits and staff interview conducted: Governing Body re-educated the DON of notification to Primary Care Physician (PCP) with changes of condition, review of 24/72 Hour Shift Report in Clinical Startup. Surveyors verified by review of in-services and interviews. Governing Body educated community Leadership and Interdisciplinary Team (IDT) on Clinical Start up to be conducted Monday thru Friday DON/Assistant Director of Nursing (ADON)/Staff Development Coordinator (SDC)/Unit Managers (UM). Incidents and changes of condition are to be identified and followed through until stabilized to include PCP and Responsible Party (RP) notification. Surveyors verified staff interviews and in-services. Governing Body/Administrator (Admin)/DON/SDC initiated education and on-going to licensed nurses on Shift Report, Notification of Change in Condition, to include new onset or worsening of pain, on Admission, Quarterly, and Significant Change. Training included licensed staff were educated that residents are to receive treatment and care within professional standards of practice, person-centered care to honor resident's choice. Example: A. An accident involving the resident which results in injury and has the potential for requiring physician intervention; B. A significant change in the resident's physical, mental, or psychosocial status, including a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications ; C. A need to alter the resident's medical treatment significantly; D. A need to transfer the resident to a hospital/treatment center; E. A discharge without proper medical authority; and/or F. Instructions to notify the physician of changes in the resident's condition. STAT orders should be followed within the 4 hour time frame, if provider cannot (lab, xray) perform, licensed nurse to notify provider of delay for further treatment orders. Surveyors verified by review of in-services and interviews. Governing body to educate community leadership and department heads/IDT to include Medical Director re: QAPI and Ad Hoc QAPI related to Quality of Care issues. Surveyors verified by review of QAPI minutes. Surveyors varied by review of QAPI minutes and staff interviews. DON/ADON/SDC/UM and licensed staff re-educated to utilize the PointClickCare Clinical Communication Portal to identify residents requiring follow up documentation, labs, xrays, appointments. Surveyors verified by review of in-services. DON/SDC/ICP/UM/HR will educate new licensed staff regarding Quality of Care concerns F684. Surveyors verified by review of new hire in services. QAPI will be held again 12/8/22 with Governing Body to discuss deficiency, education, systemic changes, and monitoring moving forward. Surveyors verified by review of QAPI minutes and forms for monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, facility investigation review, review of time detail reports, review of daily assignment sheets, review of Safety Check logs, medical record review, observation, and interview, the facility failed to ensure a safe environment for 5 of 11 sampled residents (Resident #1, #2, #3, #4, and #14) reviewed for resident-to-resident altercations and accident hazards. The facility's failure to ensure a safe environment resulted in Immediate Jeopardy (IJ) when the facility failed to provide 1 on 1 supervision for Resident #1, a severely cognitively impaired resident with known combative and aggressive behaviors, which resulted in resident-to-resident altercations between resident #1 and Residents #2, #3, and #4 on 3 different occasions; and when the facility failed to follow their policy for post-fall assessments when Resident #14 sustained 4 falls with no completion of the post-fall assessments, and then sustained a 5th fall on 10/27/2022, which resulted in a left hip fracture. 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 Interim Administrator and Interim Director of Nursing (IDON) were notified of the Immediate Jeopardy (IJ) on 11/21/2022 at 5:43 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy (IJ) for a second Immediate Jeopardy (IJ) for F-689 on 12/7/2022 at 5:32 PM, in the Conference Room. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. A partial extended survey was conducted from 12/12/2022 through 12/13/2022. The IJ was effective from 8/19/2022 through 12/13/2022. An acceptable Removal Plan, which removes the immediacy of the jeopardy, was received on 12/13/2022 at 10:42 PM, and was validated onsite by the surveyors on 12/14/2022, through policy review, review of education records, and staff interviews. The findings include: 1. Review of the facility's policy titled, Unmanageable Residents ., dated 8/2021, revealed .Each resident will be provided with a safe place of residence .Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately .Provide for the safety of all concerned .Complete documentation of the incident must be recorded in the resident's medical record and an incident report must be filed with the Administrator . Review of the facility's policy titled, Accidents, dated 8/2022, revealed .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes .and a facility-wide commitment to safety at all levels of the organization, including staff, residents, and families .Data will be utilized to the extent available to identify potential hazards, risks, and solutions related to safety issues within the community .staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary .Resident supervision is a core component of the systems approach to safety .type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment .Resident to Resident Altercations .Review as potential abusive situation, including the identification of .willful .Assess for need for additional or adequate supervision based upon a history of aggressive behaviors which may disrupt or annoy others .repetitive behaviors .address potential underlying issues which may lead to such behavior .address community process for appropriate supervision including .adequate staffing levels for services to those with dementia or history of trauma .Providing safe supervision when required . Review of the facility's policy titled, .Assessing Falls and Their Causes ., dated 5/2022, revealed .If a resident has just fallen, or is found on the floor without witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities .If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid .Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details .Attending Physician and family in an appropriate time frame .a fall results in a significant injury or condition change .Nursing staff will observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and will document findings in the medical record .Documentation will include any observed signs or symptoms of pain .deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function .An incident report must be completed for resident falls . Review of the facility's policy titled, .Behavior Assessment and Monitoring, dated 11/2022, revealed .Problematic behavior will be identified and managed appropriately .The staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition, including .changes in behavior .Management .The staff will identify and discuss with the practitioner situations where non-pharmacologic approaches are indicated, and will institute such measures to the extent possible . 2. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Schizophrenia, Dementia with Mood Disturbance/Behavioral Disturbance/Psychotic Disturbance, Chronic Kidney Disease, Conversion Disorder with Seizures, Hypertension, and Chronic Hepatitis C. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment, exhibited wandering behaviors daily, and required extensive to total assistance of staff for all activities of daily living (ADLs) except eating, for which he required supervision with setup help only. A. Review of the Incident Report dated 8/21/2022, revealed .resident [Resident #1] foot accidentally ran over by another resident [Resident #2] who is blind .resident [Resident #1] .[hit] resident [Resident #2] in wheelchair on the back of the head with an open hand . Review of a Nursing Note dated 8/21/2022, revealed .resident [Resident #1] had hit another resident [Resident #2] softly on the head due to being run over by wheelchair. Resident [Resident #2] in wheelchair is blind and didn't see resident [Resident #1] . B. Review of an Incident Report dated 8/28/2022 at 6:56 PM, revealed .nurse was called to dayroom by CNA [Certified Nursing Assistant] stating there was blood on the floor. [Named Resident #1] was observed Lying on floor with hands under head in sleeping position. [Named Resident #2] was observed sitting in WC [wheelchair] with small amount of blood noted from lower lip. [Named Resident #1] had small scratch noted to face L [left] of nose. [Named Resident #1] was assisted to chair by nurse and [named Resident #2] was supervised in dayroom. Residents asked what happened and neither resident was able to say what happened .first aide administered .Abrasion .face . Review of the Staff Interview/Statement Sheet dated 8/28/2022, revealed .Upon come'n [coming] on shift I was looking for CNA to get report. When looking in the dayroom [named Resident #1] was on the floor, [named Resident #2] was in his wheelchair he had [named Resident #1] by the arm, I notify [notified] the nurse that [named Resident #1] was on the floor, and there was blood on the floor. The statement was signed by CNA #4. Review of the Weekly Skin Evaluation for Resident #1 dated 8/28/2022, revealed .small scratch observed to face to L [left] of nose . The facility was unable to provide any additional statements obtained from staff working that shift. The facility was unable to provide evidence that Resident #2 received testing after his possible exposure to a communicable disease following the incident with Resident #1, who has Chronic Hepatitis C. C. Review of the Incident Report dated 9/7/2022, revealed the report was incomplete and did not give any details regarding an incident that occurred between Resident #1 and Resident #3 on 9/7/2022. Review of a Staff Interview/Statement Sheet dated 9/7/2022, revealed .On September 7, 2022 at approximately 6:55 pm [PM] I [CNA #5] was giving end of shift report to [named CNA #6] when the resident [named Resident #3] walked in the direction of resident [named Resident #1]. [Named Resident #1] was sitting in the chair and immediately reach [reached] up with a closed fist and struck [named Resident #3] in the jaw .left side .[named CNA #6] stepped in between [named Resident #1] and [named Resident #3]. I took [named Resident #3] to a safe area. After making sure [named Resident #3] was in a safe area, we both reported the incident to the nurse [named LPN #3] . D. Review of an Incident Audit Report dated 9/7/2022, revealed .Incident Description .09/07/2022 .20:45 [8:45 PM] .Writer [LPN #3] standing at med [medication] cart passing medication when writer observed res [Resident #1] walking up behind res [Resident #4] .Res [Resident #1] struck res [Resident #4] .in the rear right side of his neck with a closed fist. Writer immediately jumped in between the residents and redirected res .[Resident #1] .away from res [Resident #4] .Writer walked down to his [Resident #1] room and put cna [CNA] as one on one with res. Writer went back and assessed resident [Resident #4], Res [Resident #4] had no obvious signs of injury and made no faces of pain or any complaints . Review of the quarterly MDS dated [DATE], revealed Resident #1 had a BIMS of 99, which indicated resident inability to complete the interview, physical behavioral symptoms toward others on 4-6 days, verbal behavioral symptoms toward others on 1-3 days, and behavioral symptoms toward himself on 1-3 days of the 7-day lookback period. Review of the Nursing Note dated 9/8/2022 at 9:00 AM, revealed .Resident [Resident #1] was transported to [named hospital] for a psychiatric evaluation r/t [related/to] physical altercation with another resident . Review of Resident #1's Care Plan revised 9/9/2022, revealed .Potential for injury to self or others r/t [related to] impaired mental and physical status and aggressiveness, combative and resistive behaviors .9/9/22 [2022] .One on one supervision and care . Review of the Nursing Note dated 9/9/2022 at 1:10 AM, revealed .Resident arrived back to facility. Review of the Safety Check Logs for Resident #1 beginning 9/7/2022 through 11/17/2022, revealed 1 on 1 monitoring documentation for following days were missing: a. 9/17/2022-all day b. 9/21/2022-all day c. 9/23/2022-all day d. 9/24/2022-all day e. 9/25/2022-all day f. 9/26/2022-all day g. 10/22/2022-from 7:00 AM through 7:00 PM h. 10/24/2022-from 7:00 AM through 7:00 PM i. 11/1/2022-from 3:00 AM through 7:00 AM j. 11/5/2022-from 7:00 AM through 11:59 PM k. 11/6/2022-all day l. 11/10/2022-all day Review of the outcome of the facility's investigation into the resident-to-resident altercations that occurred between Resident #1 and Resident #3, and Resident #1 and Resident #4, dated 9/15/2022, revealed .Our investigations outcome has revealed that [named Resident #1] needs indefinite 1:1 [1 on 1] monitoring . Review of the Nursing Note dated 9/20/2022 at 5:17 AM, revealed .Res [Resident #1] sleep [asleep] most of shift .Res did get up and wonder [wander] periodically and push on exit door handles. No one on one personnel avail [available] for res and staff safety. DON notified . Review of the Nursing Note dated 9/21/2022 at 12:20 AM, revealed Res [Resident #1] sleep most of shift, no behaviors noted .No one on one personnel avail for res and staff safety. DON notified . Review of the Care Plan revised 11/1/2022, revealed .Potential for injury to self or others r/t [related to] impaired mental and physical status and aggressiveness, combative and resistive behaviors . E. Review of the time punch detail dated 11/10/2022, revealed CNA #2 clocked in at 1:52 PM. Review of the Incident Report dated 11/10/2022 at 2:15 PM, revealed .Resident [Resident #1] observed laying [lying] in hallway floor on back with resident [Resident #2] .laying [lying] on top of him [Resident #1] .while on floor resident [Resident #2] was observed with hands around [named Resident #1] neck .Memory Impaired [checked] .Confused/Disoriented [checked] .Non compliance [checked] .Impulsive [checked] .Hallucinations [checked] .Decreased safety awareness [checked] .Delusions [checked] . Review of the Nurse Practitioner Progress Note dated 11/10/2022 at 3:02 PM, revealed .This writer heard what sounded like something that fell outside office door and upon inspection, resident [named Resident #2] .had his hands around another resident's neck [Resident #1] .[Resident #1] was lying on the floor and [named Resident #2] was .over him .[named Resident #2] stated shortly after that [named Resident #1] hit him on the back of his head .[named Resident #1] has been in supervision due to combative behaviors towards other residents and staff. He was not being monitored at the time of the incident and was in the hallway alone .Nurse .to initiate the process of transferring residents to Psychiatric facility for further evaluations due to behaviors above . Review of the Staff Interview/Statement Sheet dated 11/10/2022, revealed .I [CNA #3] was sitting in front of the dayroom charting when I heard the wheelchair hit the ground. I immediately went over there. I seen [saw] [named Resident #1] on the ground and [named Resident #2] hands were around his [Resident #1] neck hollering he pushed my chair, hit me in my head . The statement was signed by CNA #3. Review of the Staff Interview/Statement Sheet dated 11/10/2022, revealed .I [CNA #2] was just getting to work .putting my belongings up and used the restroom when I heard some fussing .came out the bathroom in the hall and there was [named Resident #2] on top of [named Resident #1] saying he [Resident #1] hit me [Resident #2] . The statement was signed by CNA #2. Review of the Staff Interview/Statement Sheet dated 11/10/2022, revealed .I [CNA #8] was in the breakroom having lunch when I heard a noise in the hallway. I went to see what was going on that is when I noticed [named Resident #2] on [named Resident #1]. [Named Resident #2] was saying that [named Resident #1] had hit him on the back of his head. [Named Resident #2] wheelchair had turned over . The statement was signed by CNA #8. Review of the daily assignment sheet for the secure unit dated 11/10/2022, revealed the staff assigned for 7:00 AM through 7:00 PM on the unit were LPN #6, CNA #2, CNA #3, and CNA #8. At the time the resident-to-resident altercation occurred only LPN #6 was at the Nurses' Station, and CNA #3 was on the unit. CNA #2 and CNA #8 were in the breakroom. No staff member was 1 on 1 with Resident #1. Review of the Physician's Order dated 11/22/2022, revealed .Ensure resident [Resident #1] is receiving 1:1 supervision .Review safety check log to ensure documentation completed as ordered . Review of the laboratory results dated [DATE], revealed Resident #1 was positive for Hepatitis C. Observation in the Resident #1's room on 11/17/2022 at 10:25 AM, revealed Resident #1 lay on top of the bed, was fully clothed, wore nonskid socks, and a staff member provided 1 on 1 monitoring. Observation in the secure unit on 11/21/2022 at 11:09 AM, revealed Resident #1 walked with 1 on 1 staff member, dressed in a gown, pants, and nonskid socks. Observation in the secure unit Day Room on 11/29/20221 at 9:16 AM, revealed Resident #1 sat in a chair, was fully clothed, his left foot was bare and he had a nonskid sock on his right foot. Staff was present for 1 on 1 monitoring. 3. Review of the closed medical record, revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Diabetes, Dementia with Psychotic Disturbance, Schizoaffective Disorder-Bipolar Type, Hypertension, Epilepsy, Chronic Kidney Disease, Depression, and Mixed Receptive-Expressive Language Disorder. Review of the annual MDS dated [DATE], revealed Resident #2 had a BIMS of 11, which indicated moderate cognitive impairment, with delusions and wandering behaviors on 3 days of the 7-day lookback period, highly impaired vision, and required extensive to total staff assistance for ADLS. Review of the Nursing Note dated 8/21/2022, revealed .resident was hit on the back of the head by other resident [Resident #1] due to accidentally running over his feet in wheelchair. Resident had no pain and just asked who did it. Resident [Residents] was [were] separated and both are calm . Review of the Nursing Note dated 8/28/2022, revealed .This nurse alerted by CNA there was blood in dayroom floor. Upon entering room this nurse observed resident [Resident #2] sitting in WC [wheelchair] with small amount of blood observed on bottom lip. [Named Resident #1] was observed lying on the floor with hands under head in sleeping position witheyes [with eyes] closed, small scratch noted on face to L [left] of nose. Residents separated and supervised at this time . Review of the Weekly Skin Evaluation dated 8/28/2022, revealed .small laceration noted to bottom lip with small amount of blood observed . Review of the quarterly MDS dated [DATE], revealed Resident #2 had a BIMS score of 10, which indicated moderate cognitive impairment, with no behaviors, highly impaired vision, and required extensive staff assistance for ADLs. Review of the Nursing Note dated 11/10/2022, revealed .Resident [Resident #2] observed laying [lying] in hallway on top of resident .[Resident #1] with hands around [Resident #1] neck. Resident noted yelling .he [Resident #1] .hit me in my head . Review of the Nursing Note dated 11/11/2022 at 5:42 PM, revealed Resident #2 was transferred to a psychiatric facility for evaluation. 4. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease, Hypertension, Depression, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident had a BIMS of 3, which indicated severe cognitive impairment with no behaviors. Review of the Nursing Note dated 9/7/2022 at 8:33 PM, revealed .Reported by staff this resident [Resident #3] .was observed walking in dayroom towards resident [Resident #1] .as he was sitting in chair. Resident [Resident #1] .was observed hitting resident [Resident #3] in face with closed fist in left jaw .immediately separated. Resident [Resident #3] noted with redness to left side of face .new order given to send to [named hospital] for CT (computed tomography) scan . Review of the Head CT and the Maxillofacial CT dated 9/8/2022, revealed Resident #3 had no acute abnormalities. Review of Nursing Note dated 9/8/2022 at 8:17 AM, revealed .[Resident #3] returned to facility . Observation in the Day Room on 11/17/2022 at 10:21 AM, 11/21/2022 at 11:07 AM, 11/28/2022 at 4:17 PM, and 11/30/2022 at 9:39 AM, revealed Resident #3 sat in her wheelchair, was fully clothed, wore nonskid socks, and watched television (TV) with other residents present. Observation in the resident's room on 11/28/2022 at 10:27 AM, 12/2/2022 at 3:46 PM, and 12/5/2022 at 10:46 AM, revealed Resident #3 was in bed, her eyes were closed, and she appeared to be sleeping. 5. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease, Dementia with Behavioral Disturbance, Hypertension, and Protein-Calorie Malnutrition. Review of the quarterly MDS dated [DATE], revealed Resident #4 had a BIMS of 99, which indicated resident inability to complete the interview, with physical behavioral symptoms toward others on 1-3 days and rejection of care behaviors on 4-6 days of the 7-day lookback period, and daily wandering behaviors. Review of the Nursing Note dated 9/7/2022 at 8:42 PM, revealed .Writer standing at med cart passing medication when writer observed res [Resident #1] walking up behind res [Resident #4] .Res [Resident #1] struck res [Resident #4] .in the rear right side of his neck with a closed fist. Writer immediately jumped in between the residents and redirected res [Resident #1] .away from res [Resident #4] .Writer walked down to his room and put cna [CNA] as one on one with res [Resident #1]. Writer went back and assessed resident [Resident #4] .no obvious signs of injury and made no faces of pain or any complaints . Observation in the Day Room on 11/17/2022 at 10:25 AM, revealed Resident #4 sat in a chair, was fully clothed, and played with his pants drawstring. Other residents were present. Observation in the Dining Room on 11/21/2022 at 11:03 AM, revealed Resident #4 sat in a chair, was fully clothed, wore a hat, and nonskid socks. Other residents were present. Observation in the Secure Unit Hallway on 11/29/2022 at 9:14 AM, revealed Resident #4 sat in a chair, he was fully clothed, wore nonskid socks, his eyes were closed, and he appeared to be asleep. During an interview conducted on 11/17/2022 at 1:47 PM, CNA #2 confirmed she was scheduled to supervise Resident #1 on 11/10/2022. CNA #2 stated, When I called my supervisor to let her know I was running late .she said I would be in the Gardens [secure unit] with him . CNA #2 confirmed she arrived to work at about 2:00 PM. CNA #2 stated, .clocked in, put my belongings up in the breakroom .used the restroom in the breakroom, and we literally heard the commotion .run [ran] straight out the door .[named Resident #2] was on top of [named Resident #1] saying he [Resident #1] hit me in the back of the head .he [Resident #2] was just protecting himself .[named Nurse Practitioner] was already at the scene .we proceeded to separate them .let our charge nurse know . CNA #2 stated, He will get angry toward me to the point where I'm literally scared, and I have seen him get mean and holler at other residents or staff .I did see him hit one of our other staff members before .like a light switch he will be sweet one second and then just flip, you never know when he will get in that mood . During an interview conducted on 11/17/2022 at 2:12 PM, CNA #8 confirmed she worked the secure unit on 11/10/2022, and no one was assigned to provide 1 on 1 monitoring to Resident #1 until CNA #2 came in around 2:00 PM. During an interview conducted on 11/17/2022 at 2:20 PM, LPN #6 stated, .never know when he's [Resident #1] going to strike out .he hit me .out of the blue . LPN #6 was asked about the resident-to-resident altercation between Resident #1 and Resident #3. LPN #6 stated, .she would walk and cry, she was walking towards him crying, and he hit her. We put a CNA with him, and as they were walking him to go to his room .[named Resident #4] was in his doorway and out of nowhere he punched him in the back for no reason .he will be laughing or singing us a song, then the next minute he does it [hits someone], and it's not a light tap. It's hard for his weight . LPN #6 confirmed she was the Charge Nurse on 11/10/2022, she was at the Nurses' Station when the altercation occurred, and no one was providing 1 on 1 continuous monitoring of Resident #1. LPN #6 stated, .[named CNA #2] had talked to [named the Scheduler], and she said [named CNA #2] was going to be late .we just had to watch out for him as best we could . LPN #6 was asked if she asked for help when she found out CNA #2 would be late. LPN #6 stated, I did, I was like who is coming in .she [Scheduler] said she was going to talk to CNA #1 .to come sit with him until CNA #2 came in . LPN #6 confirmed CNA #1 never came to sit with Resident #1. LPN #6 was asked if Resident #1 was left alone at times. LPN #6 stated, Yes .we would just check [on him] . LPN #6 confirmed no one saw the resident-to-resident altercation between Resident #1 and Resident #2. LPN #6 was asked if Resident #2 was aggressive. LPN #6 stated, No, he's never .I mean he hallucinates and talks to voices, but for him to hit somebody, no .he's blind so he doesn't know who [named Resident #1] is, he can't see him .he's never hit anybody .this is like the 2nd incident between those two . During an interview conducted on 11/17/2022 at 2:37 PM, the Nurse Practitioner confirmed she was the first one on the scene when Resident #1 and Resident #3 had the resident-to-resident altercation on 11/10/2022. The Nurse Practitioner stated, .sitting here at my desk heard some commotion outside the door, sounded like something fell .[named Resident #2] had [named Resident #1] on the floor with his hands around his neck, the wheelchair he [Resident #2] gets around in had been turned over .he was mumbling something .has a speech impediment .but when he finally calmed down and got him back to his chair, he said 'he [Resident #1] hit me on my head .I'm tired of him hitting me' .got [named Resident #1] up and back to his room. Apparently, he had been unsupervised .he was in the hallway by himself .there was no one assigned to him that day . During a telephone interview conducted on 11/18/2022 at 10:59 AM, the Interim Administrator confirmed that Resident #1 had been left unsupervised the morning of 11/10/2022. The Administrator stated, .They did not have a specified person, the CNAs were tag teaming .he technically did not have a quote unquote person for that shift .just wasn't as efficient in making sure he was covered as it should have been . During an interview conducted on 11/21/2022 at 9:37 AM, the Interim Administrator confirmed she started shadowing the former Administrator on 11/7/2022 for half a day, then returned to the facility on [DATE] for the rest of the week. The Interim Administrator stated, I wasn't in the system .let them handle it [the resident-to-resident altercation between Resident #1 and Resident #2] .I was aware of it the day of .both of us [the Former Administrator and the Interim Administrator] were in the office together . During an interview conducted on 11/21/2022 at 9:44 AM, the Interim DON (IDON) presented the 1 on 1 monitoring documentation and stated, .incomplete documentation is here .these are all we have . The IDON was asked if the facility investigation included the incomplete 1 on 1 monitoring documentation. The IDON stated, Not that I'm aware of, I had to go pull them. The IDON was asked if they were all dated. The IDON stated, They are very random .they are not complete .I just collected what we had .obviously saw that was not being done correctly . The IDON confirmed each page should have been dated and signed by the staff completing the documentation. During an interview conducted on 11/21/2022 at 10:10 AM, the Scheduler confirmed that on the day shift there were 3 CNAs scheduled for the secure unit and that included a CNA for 1 on 1 with Resident #1. The Scheduler confirmed that the nurse on the secure unit would make the assignments for the CNAs and designate 1 CNA for 1 on 1 monitoring. The Scheduler confirmed that CNA #2 texted her and told her she would be late on 11/10/2022. The Scheduler confirmed that she told LPN #6 that CNA #2 said she was going to be late. The Scheduler stated, .I was on a cart working . The Scheduler was asked what her plan was for 1 on 1 monitoring on 11/10/2022, when she learned CNA #2 was going to be late. The Scheduler stated, .There's a Unit Manager back there, and there's a nurse, and we can all help out .that's the way it's supposed to be . The Scheduler stated, .Truthfully, I would say the 1 on 1 is not working .he is walking then hits a resident out of the blue .he could end up hurting one of them really bad not meaning to . During a telephone interview conducted on 11/21/2022 at 2:43 PM, LPN #3 confirmed that he was working on 9/7/2022, when the resident-to-resident altercations occurred between Resident #1 and Resident #3, and Resident #1 and Resident #4. LPN #3 stated, .It was right at shift change .one right after the other . LPN #3 confirmed Resident #1 was not in 1 on 1 at the time of the altercations, but was placed in 1 on 1 monitoring following the two altercations that occurred that day [9/7/2022]. LPN #3 stated, It wasn't decided to put him in 1 on 1 until we had to wait so long on him to be transported .I said look this guy can't just keep walking around here hitting people .they said they didn't have the staff . LPN #3 was asked about his documentation stating there was not staff to provide 1 on 1 monitoring of Resident #1. LPN #3 stated, That's correct .that was like my last resort of asking them over and over again and nobody was doing nothing [anything] . LPN #3 was asked if the former DON was aware. LPN #3 stated, She told me she would get somebody, or she would call the staffing person .but nothing ever happened . LPN #3 confirmed that when only 2 CNA's were scheduled, they assigned 1 CNA to the men and 1 CNA to the women, and the CNA assigned to the men was the one who would also provide 1 on 1 monitoring for Resident #1. LPN #3 stated, The rationale was he [Resident #1] was asleep through the night . LPN #3 was asked if there were times Resident #1 was left unsupervised. LPN #3 stated, Oh yeah, absolutely when she was making rounds .it's impossible, because that means she wouldn't have cared for anybody else .I knew that still wasn't adequate, so that's why I started documenting . LPN #3 was asked if it was safe for the other residents for Resident #1 to be left unsupervised. LPN #1 stated, Oh, absolutely not. During an interview conducted on 11/22/2022 at 11:15 AM, LPN #4 was asked how she as the Unit Manager insured the 1 on 1 monitoring documentation was completed. LPN #4 stated, I just went down there and kept checking to be sure they were doing the sheets .made sure [named former DON] was getting the sheets and they were aware . LPN #4 confirmed there were 6 Safety Check Logs that weren't dated, and she could not tell for which days they were documented. LPN #4 confirmed that she was unaware there was not a CNA available to provide 1 on 1 monitoring of Resident #1 on 11/10/2022 until after the altercation occurred between Resident #1 and Resident #2. LPN #4 stated, .I didn't even know the aide had come to work as late as she had .it happened during PAR [Patient At Risk meeting], and the nurse called me down there and told me what had took [taken] place .trying to figure out why it occurred .notified [named LPN #6] that anytime anyone needs to go to the bathroom .they need to find someone to relieve t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, staff personnel file review, Safety Check Logs, medical record review, observation, and interview, the facility failed to ensure nursing staff were competent and proficient in practice to assure resident safety, to maintain residents' highest practicable well-being, to timely assess and report injuries of unknown origin, to supervise an aggressive and combative resident, to follow STAT (urgent, immediate or rush) physician orders, to follow up on radiology results, to administer pain medication, and to timely transfer residents to the hospital. The failure of the facility to ensure competent nursing staff resulted in Immediate Jeopardy for 4 of 18 sampled residents (Resident #1, Resident #2, Resident #5, and Resident #14) reviewed for abuse and accident hazards. Resident #1, a vulnerable resident with severe cognitive impairment, who displayed combative and aggressive behaviors and was care planned for 1 on 1 monitoring, was left unsupervised and had an altercation with Resident #2, who had moderately impaired cognition. Resident #5, who had moderate cognitive impairment, alleged abuse and complained of left upper arm and shoulder pain, the allegation of abuse was not reported until the following day, the injury of unknown origin was not assessed timely, and pain medication was not administered timely. Resident #5 had an oblique left proximal humerus fracture. Resident #14, who had severe cognitive impairment, complained of left leg and hip pain approximately 24 hours following a fall, STAT physician orders for radiology were not followed, the radiology results were not followed up on timely, pain medication was not administered, and the resident was not transferred to the hospital until 72 hours later. Resident #14 had a left Subcapital hip fracture. 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 Interim Administrator and Regional Vice-President were notified of the Immediate Jeopardy (IJ) on 12/7/2022 at 5:33 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-726. The facility was cited F-726 at a scope and severity of J. A partial extended survey was conducted from 12/12/2022 through 12/13/2022. The Immediate Jeopardy was effective from 8/19/2022 through 12/13/2022. An acceptable Removal Plan, which removes the immediacy of the jeopardy, was received on 12/13/2022 at 10:43 PM, and was validated onsite by the surveyors on 12/14/2022, through policy review, review of education records, review of audit tools, and staff interviews. The findings include: 1. Review of the facility's policy titled, Administering Pain Medications, dated 4/2021 revealed, .The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medications .Be familiar with the physiologic and behavioral (non-verbal) signs of pain .Verbal expressions such as groaning, crying, screaming .Facial expressions such as grimacing, frowning, clenching of the jaw .Limitations in his or her level of activity due to the presence of pain .Guarding, rubbing or favoring a particular part of the body .Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after analgesic relief is obtained .The pain assessment consists of gathering both subjective and objective data .Conduct a pain assessment as indicated. The initial assessment is comprehensive and should follow the facility pain assessment procedure .Conduct an abbreviated pain assessment if there has been no change of condition since the previous assessment .Whether pain has improved or worsened since the last assessment .The general condition of the resident .Verbal and non-verbal signs of pain .Evaluate and document the effectiveness of non-pharmacological interventions .Administer pain medications as ordered .Document the following in the resident's medical record .results of the pain assessment .medication .dose .route of administration .and .results of the medication . Review of the facility's policy titled Staff Competency ., dated 5/2022 revealed, .Nursing staff will demonstrate competency in skills and techniques necessary to care for the resident's needs, as identified through resident assessments and resulting plans of care .In-service training classes are conducted to provide employees with information concerning their position, methods and procedures to follow when implementing assigned duties, and to provide up-to-date information that will assist the employee, as well as the facility, in providing quality health care .At a minimum there should be competency demonstrated, at the appropriate staff level on the following topics .Abuse, neglect and exploitation policies and procedures .Dementia management .infection control .Person Centered Care .Effective Communication .Basic nursing skills .Pain Management .Identification of changes in condition .Staff competency in change of condition will be provided for RN [Registered Nurse], LPN [Licensed Practical Nurse], and Nurse Aides (CNA), which includes an understanding of how to identify, report and intervene based upon licensure category . Review of the facility's policy titled .Abuse Investigations . dated 5/2022 revealed, .Reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse .neglect or injury of unknown source be reported, the Administrator .will appoint a member of management to investigate the alleged incident .The individual conducting the investigation will, at a minimum .Review the resident's medical record to determine events leading up to the incident .Interview the person(s) reporting incident; Interview any witnesses to the incident .Interview the resident .as medically appropriate .Interview staff members .on all shifts .who have had contact with the resident during the period of the alleged incident .Review all events leading up to the alleged incident .Post validated allegations of abuse, the QA [Quality Assurance] team should evaluate the following .Immediate and ongoing training needs and staff competency as needed . Review of the facility's policy titled .Abuse Prevention Program, Investigation . dated 8/2022 revealed, .Reports of resident abuse, neglect and injuries of unknown sources shall be promptly and thoroughly investigated by facility management .Post validated allegations of abuse, the QA [Quality Assurance] team should evaluate the following .Changes that may need to be made to prevent further occurrences .Defining how care will be changed or improved to protect residents .Immediate and ongoing training needs and staff competency as needed . Review of the facility's policy titled .Pain Clinical Protocols and Guidelines dated 10/2022 revealed, .Pain management will be provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences .Through established assessments, the nursing staff will identify individuals who have pain or who are at risk for having pain .This includes a review of each person's known diagnoses and conditions that commonly cause or predispose to pain .It also includes a review for any treatments that the resident currently is receiving for pain .The nursing staff will assess each individual for pain .whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain .Through the assessment process, the nursing staff will attempt to identify the nature .characteristics such as location, intensity, frequency, pattern .and severity of pain .Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level .The staff will observe the resident .during rest and movement .for evidence of pain .grimacing while being repositioned .The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated .ambulation .repositioning .Confer with the attending practitioner to help identify the extent to which underlying causes of pain can be addressed or reversed .Obtain orders for appropriate tests .x-rays as needed .Obtain orders for appropriate pain medications based upon the resident's current situation .PRN [as needed] doses should be monitored at time of request .Monitoring .PRN pain management response will be recorded post each dose given . 2. Review of the facility's Job Description, dated 8/2018 revealed, .Director of Nursing .Coordinates all departments relating to nursing. Accountable for all .training, and education of all nursing employees .Evaluates resident records to assure accuracy .residents are receiving optimal nursing care .Monitors lab, x-ray .services .Coordinates and delegates nursing orientations and on-going education for all nursing staff .Participates in in-service education .Responsible for supervising direction of resident care .Responsible for 24-hour supervisory nursing coverage of the care center by preparing schedules for nursing supervisors .Coordinates and delegates nursing coverage to appropriate personnel as necessary .Report accidents and incidents when they occur, including all complaints and grievances made by residents and/or families .Attend and participate in orientation programs, ongoing training and educational classes .Perform assigned tasks in accordance with facility policies and procedures .Must be able to communicate with all employees and give supervision and management direction .Thorough knowledge of state and federal regulations regarding long term care .Can demonstrate sound judgement, dependability, and good teamwork and communication skills . Review of the facility's Charge Nurse .JOB DESCRIPTION, dated 6/2021 revealed .Perform administrative duties such as the documenting of .nurses' notes, doctors' orders .reports, evaluations .charts, resident assessments and care plans .Report accidents and incidents when they occur, including all complaints and grievances made by residents and /or their families . 3. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Dementia, Diabetes, Osteoarthritis, Psychosis, Scoliosis, and Anxiety. Review of the significant change Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) of 8, which indicated moderate cognitive impairment, and required extensive assistance for activities of daily living (ADLs). Review of the Nursing Note dated 8/20/2022 at 8:00 AM revealed Resident #5 was administered Tylenol 1000 milligrams (mg) for her complaint of pain in her arm and shoulder by Licensed Practical Nurse (LPN) #2. There was no documentation LPN #2 conducted a follow-up pain assessment within 30 or 60 minutes following the PRN pain medication per the facility's policy. Review of the Nursing Note dated 8/20/2022 at 8:21 AM revealed CNA #1 asked LPN #2 to come to Resident #5's room to assess the resident's arm after she complained of pain to CNA #1. Resident #5 cradled her left arm to her side, stated that her arm and shoulder hurt real bad, and had limited range of motion (ROM). LPN #2 notified the Unit Manager, former DON, and telehealth, who ordered a STAT x-ray of Resident #5's left shoulder. Review of the CNA #1's witness statement dated 8/20/2022, CNA #1 documented, .I went in to dry [named Resident #5] turn her to the wall first, she didn't say anything turn [turned] her back toward myself, she hollow [hollered] out. I said what's wrong, she said Baby, my arm hurts. [I] Immediately went and found [named LPN #1], [LPN #1] was in the back Dining Room eating. I told him [Resident #5] said somebody jump on her then I told him she said her arm was hurting, so he got up and me and him went to her room. He check [checked] her arm, told her to lift her arm, she started cussing him out. I said what you gonna [going to] do, he said I'm gonna call for xray, so I left . Review of the Staff Interview/Statement Sheet dated 8/20/2022, revealed .This writer [LPN #1] did head to toe assessment on patient [Resident #5] .on 8/19/2022 resident denies pain and was able to raise extremities. No visible injuries noted . The statement was signed by LPN #1. Review of the Physician's Order dated 8/20/2022 at 8:29 AM revealed a STAT order for xrays of Resident #5's left shoulder, humerus, and elbow. Review of the Nursing Note dated 8/20/2022 at 2:45 PM revealed the mobile x-ray company completed the ordered x-rays on Resident #5 six (6) hours and 40 minutes following the time of the STAT physician's order. Review of the Radiology Report dated 8/20/2022 at 4:28 PM revealed Resident #5 had an oblique proximal humerus fracture. Resident #5 was not sent to the hospital for the oblique left proximal humerus fracture until 8/20/2022 at approximately 9:30 PM, over 26 hours after she first complained of severe pain in her arm and shoulder. The facility's hospital Transfer Form was dated 7/30/2022 at 9:30 PM. Review of the Nursing Note dated 8/21/2022 at 4:45 AM revealed Resident #5 returned to the facility with a sling in place to her left arm. Her left upper arm was swollen and warm to the touch. Review of the Nursing Note dated 8/21/2022 at 2:26 PM revealed .[Resident #5] resting throughout shift PRN Tylenol given for pain .Sling in place throughout shift . Review of the Nursing Note dated 8/21/2022 at 7:13 PM revealed .PRN Administration was: Effective Follow-up Pain Scale was: 0 . Review of the Nursing Note dated 8/22/2022 at 7:24 AM revealed .Resident left arm, swollen, warm to touch, sling intact. Tylenol given for pain . Review of the Medication Administration Record (MAR) dated 8/1/2022 through 8/31/2022 revealed Tylenol was only documented as administered to Resident #5 on 8/20/2022 at 8:00 AM and 8/21/2022 at 5:25 AM for the month of August. Tylenol was not documented on the MAR as administered on 8/21/2022 at 2:26 PM or on 8/22/2022 at 7:24 AM. Observations in the Resident #5's room on 11/17/2022 at 10:05 AM, at 2:53 PM, and on 11/21/2022 at 5:21 PM revealed Resident #5 was lying in bed, her bed was against the wall on the right side, the call light was in reach, no side rails were present, no odors were noted, and the resident appeared thin and frail. Observation on 11/29/2022 at 9:17 AM revealed Resident #5 was in bed, the head of her bed was raised, she was awake and alert, her call light was in reach. During an interview conducted on 12/5/2022 at 4:15 PM, CNA #1 confirmed that she worked the 7:00 AM to 7:00 PM shift on 8/19/2022, and when she went in to change Resident #5 shortly before shift change at 7:00 PM, the resident complained of left upper arm and shoulder pain. CNA #1 stated, .I asked her what happened to you, she said, 'that girl beat the shit out of me,' I ran out of the room for the nurse. CNA #1 confirmed that she got LPN #1 and told him what Resident #5 said and they both went into the resident's room. CNA #1 stated, .[Resident #5] told him the same thing .[LPN #1] said 'I'm going to order an x-ray' . CNA #1 confirmed that when she came in on the following morning 8/20/2022 she had the same section of rooms and when she checked on Resident #5 the resident told her that her arm still hurt. CNA #1 stated, .I ran, got the other nurse [named LPN #2] .told her to check on [named Resident #5's] arm .Told her LPN #1 was supposed to got [have gotten] an xray last night . CNA #1 confirmed that she and LPN #2 went to the resident's room and when LPN #2 pulled back the cover she [LPN #2] said she thought the resident's arm was broken. CNA #1 stated, .told her about telling [named LPN #1] the night before and evidently [he] didn't order the x-ray he said he was going to order . CNA #1 confirmed Resident #5's upper arm was purple in color. During an interview on 12/6/2022 at 10:15 AM, LPN #2 was asked about Resident #5's injury of unknown origin. LPN #2 confirmed that on 8/20/2022 at about 7:30 AM, CNA #1 told her that she had reported to LPN #1 the night before that Resident #5 had complained of left arm pain and still complained of pain that morning. LPN #2 stated, .I assessed the resident's arm .got [named LPN #6] to come assess the resident's arm. LPN #2 confirmed that Resident #5 had bruising at the bicep area of her arm and the shoulder area didn't look right. LPN #2 stated, We contacted telehealth and got order for x-ray and notified the DON and Administrator. It was a stat order . During an interview on 12/6/2022 at 1:44 PM, the Administrator was asked about the Transfer Form for Resident #5 which was dated 7/31/2022 at 9:30 PM. The Administrator stated, It [the Transfer Form] self-populates the same date on the next Transfer Form you do. He [LPN #1] did not insert the correct date. It [date of transfer] was 8/20/2022 . During a telephone interview on 12/14/2022 at 8:44 AM, LPN #1 confirmed his written statement from 8/20/2022. LPN #1 stated, .[Resident #5] No complaint of pain on [the] previous day [8/19/2022]. LPN #1 denied that CNA #1 reported to him that Resident #5 had arm pain. LPN #1 stated, .I sent her out [to the hospital]. I think I gave her Tylenol, before sending her out . Resident #5 sustained an injury of unknown origin on 8/19/2022 and complained of pain at approximately 7:00 PM. The nurse was notified of the resident's complaint and did not notify the physician or nurse practitioner of the resident's change in status or obtain an order for an xray, and did not notify the Administrator of the allegation of abuse. The injury of unknown origin was not followed up on by staff until 8/20/2022, the STAT order was not obtained until 6 hours and 40 minutes after it was given, and the resident was not transferred to the hospital until 25 hours after she first complained of pain. Resident #5 sustained an oblique left proximal humerus fracture and received only 1 dose of Tylenol for pain management within the 25 hours following her complaint. The facility's failure to ensure staff were competent to assure resident safety and to maintain residents' highest practicable well-being resulted in Immediate Jeopardy for Resident #5 when staff did not timely assess an injury of unknown origin, did not follow STAT physician's order for radiology, did not transfer Resident #5 to the hospital in a timely manner, and did not provide adequate pain control to a resident who suffered a fractured humerus. 4. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Dementia with Behavioral Disturbance/Psychotic Disturbance, Chronic Kidney Disease, Hypertension, and Chronic Hepatitis C. Review of the Staff Interview/Statement Sheet dated 9/7/2022 revealed CNA #5 was giving shift report to CNA #6 when Resident #3 walked toward Resident #1 who was sitting in a chair. Resident #1 reached up and struck Resident #3 in the left jaw with his closed fist. CNA #6 stepped between the residents, CNA #5 took Resident #3 to a safe area, and the CNAs reported the incident to LPN #3. Review of the Nursing Note dated 9/7/2022 at 8:17 PM revealed LPN #3 was at the medication cart when he observed Resident #1 walk up behind Resident #4 and strike him in the rear right side of his neck with a closed fist. LPN #3 immediately redirected Resident #1 away from Resident #4, put a CNA 1 on 1 with Resident #1, then assessed Resident #4. Resident #4 had no obvious signs of injury and made no faces of pain or had any complaints. Review of the Incident Report dated 9/7/2022 revealed the Incident Report was incomplete and did not provide any details regarding the incident that occurred between Resident #1 and Resident #3 on 9/7/2022. Review of the Nursing Note dated 9/7/2022 at 8:17 PM revealed LPN #3 was at the medication cart when he observed Resident #1 walk up behind Resident #4 and strike him in the rear right side of his neck with a closed fist. LPN #3 immediately redirected Resident #1 away from Resident #4, put a CNA 1 on 1 with Resident #1, then assessed Resident #4. Resident #4 had no obvious signs of injury and made no faces of pain or had any complaints. Review of the Care Plan with a revision date of 9/8/2022 revealed Resident #1 had violent outbursts, altercations with 2 other residents, and was transferred to the hospital for a psychiatric evaluation. Review of the quarterly MDS dated [DATE] revealed Resident #1 had severe cognitive impairment, physical behavioral symptoms toward others on 4-6 days, verbal behavioral symptoms toward others on 1-3 days, and behavioral symptoms not directed toward others on 1-3 days of the 7-day look back period. Review of the Care Plan revised 9/9/2022 revealed Resident #1 had been placed in 1 on 1 supervision as an intervention for hitting other residents. Review of the outcome of the facility's investigation of the altercations that occurred on 9/7/2022 between Resident #1 and #3, and Resident #1 and #4 dated 9/15/2022, revealed facility staff determined Resident #1 should be placed in indefinite 1 on 1 monitoring until more appropriate placement could be found for him. Review of the Safety Check Log for the 1 on 1 monitoring documentation for Resident #1 revealed missing documentation for 8 full days which included 9/17/2022, 9/21/2022, 9/23/2022-9/26/2022, 11/6/2022, and 11/10/2022, and 4 partial days which included 10/22/2022 and 10/24/2022 from 7:00 AM through 7:00 PM, 11/1/2022 from 3:00 AM through 7:00 AM, and 11/5/2022 from 7:00 AM through 11:59 PM. Review of the Nursing Notes dated 9/20/2022 at 5:17 AM and 9/21/2022 at 12:20 AM revealed there was no staff available for 1 on 1 monitoring of Resident #1, and the former DON was notified. Review of the daily staffing assignment sheet dated 11/10/2022, revealed CNA #2 was scheduled from 7:00 AM to 7:00 PM. Review of the time punch detail report dated 11/10/2022, revealed CNA #2 clocked in at 1:52 PM. Review of the Incident Report dated 11/10/2022 at 2:15 PM revealed Resident #1 was found lying on the hallway floor and Resident #2 was on top of him with his hands around Resident #1's throat. Review of CNA #2's Staff Interview/Statement Sheet dated 11/10/2022 revealed she had just arrived at work, put her belongings away, and used the restroom when she heard a commotion in the hallway. CNA #2 confirmed that she observed Resident #1 on the floor in the hallway and Resident #2 was on top of Resident #1, stating that Resident #1 hit him. Review of the Progress Note dated 11/10/2022 at 3:02 PM revealed the Nurse Practitioner heard a noise outside of her office door, went out to inspect, and found Resident #1 lying on his back in the hallway with Resident #2 on top of him. Resident #2's hands were around Resident #1's throat. Resident #2 stated that Resident #1 hit him in the back of the head. The Nurse Practitioner documented that Resident #1, who was supposed to be in 1 on 1 staff supervision, was not being supervised at the time and was in the hallway alone when the incident occurred. Review of the daily assignment sheet for the secure unit dated 11/10/2022, revealed there were 4 staff members scheduled for the 7:00 AM through 7:00 PM shift, LPN #6, CNA #2, CNA #3, and CNA #8. At the time the resident-to-resident altercation occurred LPN #6 was at the Nurses' Station and only CNA #3 was on the hall. CNA #2 and CNA #8 were in the Breakroom. There was no staff member present to provide 1 on 1 monitoring of Resident #1. 5. Review of the closed medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Diabetes, Dementia with Psychotic Disturbance, Schizoaffective Disorder-Bipolar Type, Hypertension, Chronic Kidney Disease, Depression, and Mixed Receptive-Expressive Language Disorder. Review of the annual MDS dated [DATE] revealed Resident #2 had a BIMS of 11, which indicated moderate cognitive impairment, with delusions and wandering behaviors on 3 days of the 7-day look back period, highly impaired vision, and required extensive to total staff assistance for ADLs. Review of the Nursing Note dated 8/21/2022 revealed, .resident was hit on the back of the head by other resident [Resident #1] due to accidentally running over his feet in wheelchair. Resident had no pain and just asked who did it. Resident was separated and both are calm . Review of the quarterly MDS dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status of 10, which indicated moderate cognitive impairment, with no behaviors, highly impaired vision, and required extensive staff assistance for ADLs. Review of the Nursing Note dated 11/10/2022 revealed, .[Resident #2] observed laying in hallway on top of [Resident #1] .with hands around [Resident #1] neck. [Resident #2] noted yelling .[Resident #1] hit me in my head . Review of the Nursing Note dated 11/11/2022 at 5:42 PM revealed Resident #2 was transferred to a psych facility for evaluation. During an interview conducted on 11/17/2022 at 9:15 AM, the Interim Administrator confirmed that Resident #1 was supposed to be in 1 on 1 monitoring on 11/10/2022, was left unsupervised, and that's when the altercation between Resident #1 and Resident #2 occurred. During an interview conducted on 11/17/2022 at 1:31 PM, CNA #8 confirmed she was working on 11/10/2022, but was on her lunch break when the altercation between Resident #1 and Resident #2 occurred. CNA #8 was asked who was on the hall with the residents. CNA #8 stated, A nurse was in the break room with me, he came out with me, I think it was another CNA [named CNA #4], I can't think who else was out there . CNA #8 stated, I noticed [named Resident #2] was on top of [named Resident #1], he [Resident #2] was hollering [named Resident #1] had hit him on the back of the head . CNA #8 confirmed she was very familiar with Resident #2. CNA #8 was asked to describe Resident #2's temperament. CNA #8 stated, He will not bother you unless you provoke him. During an interview conducted on 11/17/2022 at 1:47 PM, CNA #2 confirmed that she was running late on 11/10/2022, and did not arrive at the facility until approximately 2:00 PM. CNA #2 was asked what education or training the facility provided for monitoring a combative or aggressive resident. CNA #2 stated, .just to make sure we watched him and prevent any other incidents between him and any other resident . CNA #2 confirmed they had abuse inservices but no specific training or education regarding de-escalation or handling a combative resident. CNA #2 confirmed that when she arrived on the secure unit and went to the break room there was not a staff member sitting outside of Resident #1's room. CNA #2 was asked were there 1:1 monitoring documentation papers on the over bed table. CNA #2 stated, No, it wasn't there I had to ask for it . CNA #2 confirmed the facility staff had told her Resident #1 was never to be left alone, at any time. CNA #2 was asked was anyone in the hall when she entered the break room. CNA #2 stated, .[Named Resident #2] was in his wheelchair at the opposite end . CNA #2 was asked how long she thought she was in the break room. CNA #2 stated, I would say about 5 minutes .went in and put my stuff up, used the bathroom and washed my hands, heard the commotion and run straight out the door .[named LPN #5] .and [named CNA #8] .was on break. We all heard the commotion . CNA #2 confirmed Resident #2 was on top of Resident #1 and Resident #2 was saying he hit me in the back of the head when she arrived in the hallway. During an interview conducted on 11/17/2022 at 2:20 PM, LPN #6 confirmed she was the Charge Nurse and worked the secure unit on 11/10/2022. LPN #6 was asked where she was when the incident between Resident #1 and Resident #2 occurred. LPN #6 stated, I was at the Nurses' desk charting . LPN #6 confirmed that CNA #2 had only been on the hall for 10-15 minutes when the incident occurred and that no one was sitting with Resident #1. LPN #6 stated, .We had to just watch out for him to do the best we could . During an interview conducted on 11/21/2022 at 10:10 AM, the Scheduler confirmed that she had to sit 1 on 1 with Resident #1 at times, when they needed help. The Scheduler was asked did the facility provide any training or inservices on how to handle a resident in 1 on 1 monitoring. The Scheduler stated, No, not that I remember . During a telephone interview conducted on 11/21/2022 at 11:59 AM, LPN #3 confirmed that he worked the secure unit on the 7:00 PM through 7:00 AM shift, and there were several times the facility did not provide him with enough staff to provide 1 on 1 supervision of Resident #1. LPN #3 stated, .They said they didn't have the staff . LPN #3 confirmed the Unit Manager told him they did not have enough staff. LPN #3 was asked did the facility provide staff any special education for 1 on 1 monitoring. LPN #3 stated, No .it was just like grab somebody and sit with him .with [named Resident #1] you need somebody who understands his disability, his dementia, and triggers, and be proactive in stopping triggers .to keep him from becoming violent .if they had taken the time to do it [1 on 1 monitoring] right .they could've .[I] sat down with the DON and talked to her about it .I guess I just [expletive] her off .to me that was paramount . During a telephone interview on 11/23/2022 at 9:56 AM, CNA #3 confirmed that she worked the secure unit on 11/10/2022, when the incident occurred between Resident #1 and #2, that she was not scheduled to provide 1 on 1 monitoring of Resident #1 that day, that she was the only CNA on the hall at the time the incident occurred, and that she did not witness the incident. CNA #3 was asked did the facility provide education to staff on how to provide 1 on 1 monitoring. CNA #3 stated, I don't think so, I use my own judgement . During an interview conducted on 11/23/2022 at 11:38 AM, the Interim DON (IDON) stated, .No .there was no education provided [1 on 1 monitoring education] . The IDON was asked should education for 1 on 1 monitoring and how to complete the Safety Check Log have been provided. The IDON stated, Yes .there was obviously no protocol . During a telephone interview on 11/29/2022 at 4:30 PM, the former DON was asked how she ensured staff was competent to provide 1 on 1 monitoring of a combative and aggressive resident. The former DON stated, We have a [named computer] course on de-escalating patients and our log that they're checking on him to make sure and documenting . The former DON confirmed the de-escalation training would be found in the computer system. The former DON was asked what training was provided to staff regarding how to complete the Safety Check Log. The former DON stated, I think it's pretty self-explanatory . The former DON denied knowledge of missing dates, gaps in time, and missing signatures on the Safety Check Logs for Resident #1's 1 on 1 monitoring. During an interview conducted on 12/5/2022 at 9:55 AM, the Inter[TRUNCATED]

Based on policy review, job description review, and interview, Administration failed to provide oversight to ensure systems and processes were developed and consistently followed, failed to provide oversight of nursing staff, failed to identify the root cause of concerns identified in the facility, and failed to ensure systems and processes were developed and consistently followed by facility staff. Administration failed to provide oversight that established and implemented policies and procedures to ensure residents were free from verbal, physical, and sexual abuse. Administration failed to provide oversight that established and implemented policies and procedures to ensure residents' Care Plans were followed to ensure safety measures were in place for a resident with a history of aggressive and combative behaviors. Administration failed to provide oversight that established and implemented policies and procedures to ensure facility staff investigated abuse allegations thoroughly. Administration failed to provide oversight that established and implemented policies and procedures to ensure abuse allegations were reported timely to all respective entities. Administration failed to provide oversight that established and implemented policies and procedures to ensure the facility had sufficient numbers of competent staff to provide care and services to residents and to follow doctor's orders. Administration failed to provide oversight that established and implemented policies and procedures to ensure care was provided for Resident #5 who had arm fracture pain and Resident #14 who had hip fracture pain. These failures resulted in Immediate Jeopardy for Resident #1, #2, #3, #4, #5, and #14. 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 Interim Administrator and the Interim Director of Nursing (IDON) were notified of the Immediate Jeopardy (IJ) for F-600 and F-689 on 11/21/2022 at 5:43 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy for F-684 and a second F-600 on 12/7/2022 at 5:31 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy for a second F-689 on 12/7/2022 at 5:32 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy for F-726 and F880 on 12/7/2022 at 5:33 PM, in the Conference Room. The Interim Administrator was notified of the Immediate Jeopardy for F-656 on 12/8/2022 at 10:07 AM, in the Conference Room. The Interim Administrator was notified of the Immediate Jeopardy for F-835 and F-867 on 12/13/2022 at 3:44 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600, F-656, F-684, F-689, F-726, F-835, F-837, and F-880. The facility was cited at F-600, F-684, F-689 at a scope and severity of J which is Substandard Quality of Care. An partial extended survey was conducted from 12/12/2022 through 12/13/2022. A Removal Plan which removed the immediacy of the jeopardy was accepted on 12/13/2022 at 10:45 PM, and was validated onsite by the surveyors on 12/14/2022 through review of inservice education, root cause analysis review, review of audit tools, review of QAPI minutes, Interdisciplinary Team (IDT) meeting minutes, and staff interviews on all shifts. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction for each deficiency. The findings include: Review of the facility's .Job Description, dated 8/2018, revealed .Director of Nursing .Coordinates all departments relating to nursing. Accountable for all functions, activities, training, and education of all nursing employees .Evaluates resident records to assure accuracy, care plans are current and complete and residents are receiving optimal nursing care .Monitors lab, x-ray .services .Works with administration in interpreting, maintaining, updating, and executing personnel policies, facility manuals and job descriptions .Coordinates and delegates nursing orientations and on-going education for all nursing staff .Participates in in-service education .Responsible for supervising direction of resident care .Responsible for 24-hour supervisory nursing coverage of the care center be preparing schedules for nursing supervisors .Coordinates and delegates nursing coverage to appropriate personnel as necessary .Report accidents and incidents when they occur, including all complaints and grievances made by residents and/or families, and immediately report any time a resident is observed leaving campus .Attend and participate in orientation programs, ongoing training and educational classes .Perform assigned tasks in accordance with facility policies and procedures .Must be able to communicate with all employees and give supervision and management direction .Thorough knowledge of state and federal regulations regarding long term care .Can demonstrate sound judgement, dependability, and good teamwork and communication skills . Review of the facility's Administrator Job Description dated 5/2021, revealed .Supervises, plans, develops, monitors and maintains appropriate standards of care throughout all departments in the nursing home. Manages staff at the facility .Supervise and promote guidance and support to department heads .Meet standard staffing goals and ensure state licensure and certification standards are met .Recruit, employ, and ensure adequate training of personnel in the facility .implement procedures and controls necessary to provide quality resident care .Recognize and respond to changes in residents conditions and report observations to nursing/medical staff .Determine staffing needs of the facility .Develop and improve staff competency through training .Direct various committees of the facility, such as care plan, infection control .quality assessment and assurance .Monitor procedures to assure compliance with the guidelines of state and federal regulations and facility policy .Review, resolve and report complaints and grievances made by residents, families .Develop and authorize the development of established universal precautions and isolation procedures, and review and monitor compliance by staff .Monitor the workplace for possible health and safety hazards .Audit documentation for errors to inconsistencies and make necessary corrections or document reasons for corrections not made . Review of the facility's policy titled, Facility Policies and Procedures dated 5/2022, revealed .To ensure that our facility's operational policies and procedures are maintained on a current basis, the Quality Assurance and Assessment Committee will review our operational policies and procedures and resident care policies .Affected staff will be informed of changes in our policies and procedures. Appropriate in-service training will be conducted when changes in resident care and/or other policies and procedures are introduced . During an interview conducted on 11/21/2022 at 9:44 AM, the IDON confirmed that she became the IDON on 11/14/2022. THE IDON stated, .[My] background is cleaning up nursing homes .not to leave until everything is back in compliance . The IDON provided the Safety Check Logs [1:1 monitoring forms] for Resident #1 and stated, .Incomplete documentation is here, these are all we have. The IDON confirmed that the 1:1 documentation was not included in the facility's investigation of the resident-to-resident altercation between Resident #1 and #2. The IDON confirmed there were dates missing from several of the forms. The IDON stated, They are very random, they are not complete .I just collected what we had .put them in order .obviously saw that [1:1 monitoring documentation] was not being done correctly . During an interview conducted on 11/22/2022 at 10:10 AM, the Interim Administrator stated, .We knew as a whole there was a problem .recognized when we had a morning meeting on Friday [11/11/2022] that 1 on 1 didn't happen in the morning .that was the day the former Administrator and the former DON was leaving .I came in on Monday [11/14/2022] .went back to Alabama on Tuesday [11/15/2022] and wasn't able to get back in the building until 1:30 on Wednesday [11/16/2022] .Thursday [11/17/2022 when the survey team entered the facility] was going to be my first day in the building to tie it all up and bring it all together . During an interview conducted on 11/22/2022 at 11:15 AM, LPN #4 confirmed she was the Unit Manager of the secure unit and that she was aware of LPN #3's documentation on 9/20/2022 and 9/21/2022 that staff were not available for 1 on 1 monitoring. LPN #4 stated, I was aware .and they [Administration] knew that. LPN #4 stated, .Several times I reached out over the weekend [to the former DON] with no response .things weren't getting taken care of .they [former Administrator and former DON] knew they was [were] leaving .at that point nothing mattered I would go in with my concerns . LPN #4 was asked were they aware of the times there was not staff for 1 on 1 monitoring. LPN #4 stated, Yes .they were absolutely aware, and they did nothing to try to get the Staffing Coordinator [Scheduler] to bring in extra people, none of that . During an interview conducted on 11/23/2022 at 11:38 AM, the IDON confirmed no documentation was found that de-escalation education, education on providing 1 on 1 monitoring of a combative and aggressive resident, or education on how to accurately complete the 1 on 1 monitoring form was completed. During a telephone interview conducted on 11/29/2022 at 4:30 PM, the former DON confirmed she became DON in July of 2022. The DON was asked if the Medical Director was made aware that there were times there was not enough staff to provide 1 on 1 monitoring of Resident #1. The DON stated, I don't think so. During an interview conducted on 12/1/2022 at 12:00 PM, the Medical Director confirmed he was never made aware that sometimes the facility did not have enough staff to provide 1 on 1 monitoring of Resident #1. The Medical Director confirmed that he was not made aware of the altercation that occurred on 8/28/2022 between Resident #1 and #2, and Resident #2's possible exposure to a communicable disease. During a telephone interview conducted on 12/1/2022 at 3:13 PM, the Regional Nurse Consultant (RNC) stated, .the 1 on 1 documentation, it should have been in POC [Point of Care, the place where the Certified Nursing Assistants (CNAs) document in the electronic health record (EHR)] .I wasn't aware until sometime in October that he [Resident #1] had been in 1 on 1 for this extended period of time . The RNC confirmed she was not aware that there were gaps, missed days, and missing times in the Safety Check Log (1:1 monitoring form). The RNC was asked if anyone followed up on the Safety Check Logs. The RNC stated, I know on one of my rounds I noticed there were several sheets on a clipboard, addressed with [named former DON] that those needed to be pulled and scanned into PCC [facility's electronic health record] . The RNC confirmed the former DON was supposed to follow up with the mobile radiology company to address the delay in treatment for Resident #14's hip fracture but did not know if the former DON actually did so. The RNC stated, .The communication between me and [named the former DON] was not good .always felt like she thought she knew more than I did . During an interview conducted on 12/1/2022 at 9:53 AM, the Interim Administrator stated, I talked to [named RNC] .They did an Ad Hoc [impromptu Quality Assurance and Performance Improvement (QAPI)] meeting following Resident #14's delay in treatment] .the [former] DON that was here .sitting at her laptop typing notes, there's no notes in Abaqis [Quality Management System] .she's [RNC] going to recreate what they talked about to see what that looks like because they [former Administrator and former DON] screwed up .that STAT order didn't get communicated across the board . During an interview conducted on 12/2/2022 at 1:28 PM, LPN #2 confirmed there was an issue with obtaining STAT radiology services on the weekends. LPN #2 was asked did she make the former Administrator and former DON aware of the problems with radiology. LPN #2 stated, Yes .[they did] absolutely nothing . During an interview conducted on 12/12/2022 at 2:38 PM, the Interim Administrator confirmed that she was finishing the investigation on Resident #12 because the former Administrator and former DON did not conduct a thorough investigation into Resident #12's allegation of abuse. The Administration failed to maintain oversight, establish, and implement policies and procedures to ensure allegations of abuse are thoroughly investigated, and reported. Refer to F-600. The Administration failed to maintain oversight, establish, and implement policies and procedures to ensure adequate staffing. Refer to F-726. The Administration failed to maintain oversight, establish and implement policies and procedures to ensure behavior monitoring for residents. Refer to F-656, F-684, F-689, and F-867. The Administration failed to maintain oversight, establish, and implement policies and procedures to ensure an effective QAPI program was in established in the facility. Refer to F-867. The surveyors verified the Removal Plan through review of inservice education, root cause analysis review, review of audit tools, review of QAPI minutes, Interdisciplinary Team (IDT) meeting minutes, and staff interviews on all shifts: RVP (Regional [NAME] President) reviewed job description with current Admin (Administrator). Governing Body to provide education to new leadership (Admin/DON) for Clinical Startup. Educate and encourage community to utilize PCC (Electronic Health Record) to highest ability to include Clinical Communications portal to communicate resident needs/follow-up. Educate Admin/DON re: safe environment, following physician orders to include STAT (urgent) orders, addressing communicable disease, residents requiring 1:1 monitoring, and following resident's plans of care. The surveyors verified by staff interviews and review of in-services. Educate new clinical leaders for Clinical Startup on hire and as needed. The surveyors verified by review of the in-services, orientation training, and interviews. Educate leadership, Admin/DON, to follow up with Relias (Computer training system) training and new hire Onboarding to ensure training in complete prior to providing direct care. The surveyors verified by review of orientation training program and interviews. QAPI plan and Facility Assessment to be completed annually in December and updated as needed (reviewed quarterly) to assess educational needs. Surveyors verified by review of QAPI minutes and interviews. DON/Staff Development Coordinator (SDC) /Unit Manager (UM) to review 24/72 hour report and follow up with individual licensed staff for documentation improvement to include: safe environment, following physician orders to include STAT, addressing communicable disease, residents requiring 1:1 monitoring. Surveyors verified by review of audits and staff interviews on all shifts. Admin/DON will submit self-reports to Governing Body for review, recommendation, and guidance within 5 days post incident. The surveyors verified by interviews and review of facility self-reports. Admin/DON work will Mission Education Department for assistance in training. The surveyors verified by review of in-services and interviews. Community to work with Home Office for assistance in recruitment of staff. Surveyors verified by interviews. Admin/DON to be on weekly call with Governing Body to discuss issues/concerns and status of regulatory compliance with recent IJs. Surveyors verified by review of call logs and interviews. The facility's noncompliance of F-835 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on job description review, policy review, document review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that identified opportunities for improvement related to resident safety, infection control and competent staffing, and failed to implement performance improvement activities in order to provide a safe environment for residents, prevent the spread of infections and communicable disease, and ensure systems and processes were in place and were consistently followed by staff and administration, and ensure competent staff that practiced in accordance with standards of practice and facility guidelines and followed resident care plan interventions for safety. The QAPI committee failed to provide oversight that established and implemented policies and procedures to assure the facility was administered in a manner to use its resources effectively and efficiently. The QAPI committee program failed to identify the root cause of injuries of unknown origin. The facility failed to ensure cognitively impaired residents (Resident #5 and #14) were properly assessed and treatment was provided following accidents and injuries of unknown origin resulting in a fracture to Resident #14 's hip and a fracture to Resident #5's arm. The QAPI committee failed to provide oversight that established and implemented policies and procedures to ensure that a resident (Resident #2) was properly assessed and monitored following an incident of exposure to a communicable disease and the incident was reported to the Health Department. The QAPI committee failed to provide oversight that established and implemented policies and procedures to ensure that a resident (Resident #1), a cognitively impaired resident with a history of aggressive and combative behaviors, received 1 on 1 monitoring for safety as indicated on his Care Plan. 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 Interim Administrator and Interim Director of Nursing (IDON) were notified of the Immediate Jeopardy (IJ) for F-600 and F-689 on 11/21/2022 at 5:43 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy for F-684 and a second F-600 on 12/7/2022 at 5:31 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy for a second F-689 on 12/7/2022 at 5:32 PM, in the Conference Room. The Interim Administrator and Regional [NAME] President were notified of the Immediate Jeopardy for F-726 and F880 on 12/7/2022 at 5:33 PM, in the Conference Room. The Interim Administrator was notified of the Immediate Jeopardy for F-656 on 12/8/2022 at 10:07 AM, in the Conference Room. The Interim Administrator was notified of the Immediate Jeopardy for F-835 and F-867 on 12/13/2022 at 3:44 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600, F-656, F-684, F-689, F726, F-835, F-837, F-867 and F-880 at a severity of J. The facility was cited at F-600 at scope and severity of J, which is Substandard Quality of Care. The facility was cited at F-684 at scope and severity of J, which is Substandard Quality of Care. The facility was cited at F-689 at scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 8/19/2022 through 12/13/2022. A Removal Plan which removed the immediacy of the jeopardy was accepted on 12/13/2022 at 10:45 PM, and was validated onsite by the surveyors on 12/14/2022 through review of inservice education, root cause analysis review, review of audit tools, review of QAPI minutes, Interdisciplinary Team (IDT) meeting minutes, and staff interviews on all shifts. The findings include: The facility's policy titled, QAPI Committee, Program Feedback, Data Systems and Monitoring . revised 10/2022, revealed .This facility shall establish and maintain a Quality Assessment and Assurance Committee (QAPI) that oversees the identification and handling of quality issues. The facility shall establish a system for program feedback, data collection systems, and monitoring, including adverse events .The primary goals of the Quality Assessment and Assurance Committee are .To oversee facility systems and processes related to improving quality of care and services .To promote consistent facility systems and processes and appropriate practices in resident care .To help identify negative outcomes relative to resident care and resolve them appropriately .To coordinate the development, implementation, monitoring, and evaluation of action plans to achieve specified quality goals .To coordinate and facilitate communication regarding the delivery of quality resident care .The committee will meet monthly at an appointed time .The Infection Preventionist shall report on the Infection Prevention and Control Program, include all Health-care associated Infections (HAI's) on a regular basis .The committee will oversee the development and implementation of actions to correct quality concerns and promote overall quality of care and services in the facility .Examples of actions that may be implemented to help address quality issues may include .Adverse Event review including, systematic identification, analysis which lead to corrective action .Educational training programs .Staffing changes .Sources may include .EHR [Electronic Health Records] .Incident Reports .Complaints .If a medical error or adverse event has occurred, initiate feedback and learning throughout the facility by .Education of the staff .The committee shall advise the administration of the need for policy and procedural changes and, as appropriate, monitor to ensure that such changes as implemented . Review of the facility's policy titled, Facility Policies and Procedures dated 5/2022, revealed .To ensure that our facility's operational policies and procedures are maintained on a current basis, the Quality Assurance and Assessment Committee will review our operational policies and procedures and resident care policies .Affected staff will be informed of changes in our policies and procedures. Appropriate in-service training will be conducted when changes in resident care and/or other policies and procedures are introduced . Review of the facility's Administrator Job Description dated 5/2021, revealed .Supervises, plans, develops, monitors and maintains appropriate standards of care throughout all departments in the nursing home. Manages staff at the facility .Supervise and promote guidance and support to department heads .Meet standard staffing goals and ensure state licensure and certification standards are met .Recruit, employ, and ensure adequate training of personnel in the facility .implement procedures and controls necessary to provide quality resident care .Recognize and respond to changes in residents conditions and report observations to nursing/medical staff .Determine staffing needs of the facility .Develop and improve staff competency through training .Direct various committees of the facility, such as care plan, infection control .quality assessment and assurance .Monitor procedures to assure compliance with the guidelines of state and federal regulations and facility policy .Review, resolve and report complaints and grievances made by residents, families .Develop and authorize the development of established universal precautions and isolation procedures, and review and monitor compliance by staff .Monitor the workplace for possible health and safety hazards .Audit documentation for errors to inconsistencies and make necessary corrections or document reasons for corrections not made . Review of the facility's .Job Description, dated 8/2018, revealed .Director of Nursing .Coordinates all departments relating to nursing. Accountable for all functions, activities, training, and education of all nursing employees .Evaluates resident records to assure accuracy, care plans are current and complete and residents are receiving optimal nursing care .Monitors lab, x-ray .services .Works with administration in interpreting, maintaining, updating, and executing personnel policies, facility manuals and job descriptions .Coordinates and delegates nursing orientations and on-going education for all nursing staff .Participates in in-service education .Responsible for supervising direction of resident care .Responsible for 24-hour supervisory nursing coverage of the care center by preparing schedules for nursing supervisors .Coordinates and delegates nursing coverage to appropriate personnel as necessary .Report accidents and incidents when they occur, including all complaints and grievances made by residents and/or families .Attend and participate in orientation programs, ongoing training and educational classes .Perform assigned tasks in accordance with facility policies and procedures .Must be able to communicate with all employees and give supervision and management direction .Thorough knowledge of state and federal regulations regarding long term care .Can demonstrate sound judgement, dependability, and good teamwork and communication skills . Review of the QAPI Immediate Action Plan dated 12/11/2022, revealed, QA Committee not completing AdHO [AdHoc (Impromptu)] [symbol for and] RCA [Root Cause Analysis] as indicated .What are the implications of not taking action .High Risk - Actual harm has occurred .Educate Dept [Department] Heads Re [Related to] QA, RCA, Adhoc .Educate staff about QAPI [symbol for and] how to get data to QAPI .Governing body to support/educate leadership . During a telephone interview conducted on 11/29/2022 at 4:30 PM, the former DON confirmed an Ad Hoc QAPI meeting was not conducted following the resident to resident altercation that occurred between Resident #1 and #2 on 11/10/2022, and the facility's inability to provide staff for 1 on 1 monitoring of Resident #1. During an interview conducted on 12/1/2022 at 12:00 PM, the Medical Director confirmed that a QAPI meeting was not conducted following the resident to resident altercation between Resident #1 and #2 that occurred on 11/10/2022. During a telephone interview conducted on 12/7/2022 at 4:14 PM, the former DON confirmed the incident where Resident #2 had possible exposure to a communicable disease was not taken to the monthly QAPI and an Ad Hoc QAPI meeting was not conducted following the incident. The former DON stated, I didn't know we were supposed to [take the incident to QAPI] . During an interview completed on 12/13/2022 at 12:42 PM, the Interim Administrator was asked how often do you have QA. The Interim Administrator stated, Monthly .in looking at the notes, one month was missed but I prefer monthly . The Interim Administrator was asked who attends the QA meetings. The Interim Administrator stated, Department heads .and the Medical Director and/or the Nurse Practitioner. The Interim Administrator was asked what topics were discussed in QA. The Interim Administrator stated, Each department has their things they bring, the DON looks at wounds, med errors .Infection Control nurse looks at that .nursing talks about weight loss, skin, nursing related, Dietary talks about diets, food preferences, Social .any discharges and reports to the Ombudsman, Activities covers volunteers, and resident council .MDS brings reports and we look at the Quality Measures .we are setting up to do our own inhouse surveys of staff, residents, families .any PIPS [Performance Improvement Plans], and follow up on those . The Interim Administrator was asked do you discuss falls, incidents, and accidents. The Interim Administrator stated, Yes ma'am .that would fall under the DON. The Interim Administrator was asked what would prompt an Ad Hoc meeting. The Interim Administrator stated, The IJs prompted an Ad Hoc meeting .It depends on the extent of the concerns .if a concern is brought up and it's something we feel like the whole team needs to be aware of, we would do it .if a concern that just addresses 1 department, I would probably just make that department aware . The Interim Administrator was asked would you do an Ad Hoc for incidents of abuse. The Interim Administrator stated, I typically haven't in the past, but now I'm second guessing myself .If I feel like if I could investigate it and get a good handle on it, I probably wouldn't .certainly if something substantiated, it would probably be more relevant .what we did with these .behavior related, I've asked my care plan team .talked to CNAs, asked them to go back and do another care plan meeting and reevaluate our interventions, expect our interventions to be more patient related .have put them in there in a way so the CNAs can pull them up and know the interventions . The Interim Administrator was asked if incidents, injuries of unknown origin, and allegations of Abuse were discussed in QA. The Interim Administrator stated, All reportables will be discussed in there .anything from the meeting before .the way QAPI works like December, you're really addressing all of November's stuff. The Interim Administrator was asked when a problem was brought before QA and a plan was put in place, who monitored to make sure the plan was effective, how often was it monitored, and if it was not effective, what do you do next. The Interim Administrator stated, Whoever would monitor would be based on the department the plan is addressed by .that dept head that particular concerns is related to .how often is often determined how that PIP is written .then as an Interim Administrator I would look at each person's PIP and discussing is this working or not working, and do we need to implement something different. The Interim Administrator was asked if the facility had an effective QA program. The Interim Administrator stated, I think the program is effective, so yes .I think it could be utilized more effectively, and that's what I'm hoping to be able to do . The Interim Administrator was asked do you think that QAPI program was being utilized adequately. The Interim Administrator stated, No ma'am . The Interim Administrator was asked who was ultimately responsible for the QAPI program. The Interim Administrator stated, .Me . The Interim Administrator was asked who was ultimately responsible for the safety of the residents. The Interim Administrator stated, Me. The QAPI committee failed to maintain oversight, establish and implement policies and procedures to provide adequate supervision of residents and to properly assess and provide treatment for injuries and reports of pain. Refer to F-600 The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure staff maintained residents' safety by following their plan of care for safety interventions related to aggressive behaviors. Refer to F-656 The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure the facility provided care to residents in accordance with professional standards of practice. Refer to F-684 The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure incidents of resident to resident abuse and accidents were prevented, residents were monitored, and care and treatment was provided timely. Refer to F-689. The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure nursing staff were competent and proficient in practice to assure resident safety, to maintain residents' highest practicable well-being. Refer to F-726. The QAPI Committee failed to maintain oversight, failed to establish and implement policies and procedures, failed to ensure the Administration consistently followed policies and procedures, failed to provide oversight of nursing staff, failed to identify the root cause of concerns identified in the facility, and failed to ensure systems and processes were developed and consistently followed by facility staff. Refer to F-835. The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure residents were properly tested after exposure to Hepatitis C, a communicable disease, and failed to ensure the exposure was reported to the Health Department. Refer to F-880.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Center for Disease Control (CDC)'s Hepatitis C Questions and Answers for the Public, policy review, medical record review, review of facility emails, and interview, the facility failed to prevent the potential spread of infection and communicable disease for 1 of 1 sampled resident (Resident #2) reviewed. This failure resulted in Immediate Jeopardy when a Hepatitis C-positive resident (Resident #1) was involved in an altercation with another resident (Resident #2), and both residents were bleeding, which exposed staff and Resident #2 to potential contact with Hepatitis C-contaminated blood, when the facility failed to test Resident #2 for Hepatitis C following the exposure, and when the facility failed to report the exposure to the Health Department. Immediate Jeopardy (IJ) is a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, severe injury, harm, impairment, or death to a resident. The Administrator and the Regional [NAME] President were notified of the Immediate Jeopardy on 12/7/2022 at 5:33 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-880. The facility was cited at F-880 at a scope and severity of J. The IJ was effective on 8/19/2022 through 12/13/2022. A partial extended survey was conducted 12/12/2022 through 12/13/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/13/2021 at 10:43 PM, and was validated onsite by the surveyors on 12/14/2022 through review of root cause analysis, in-services, audits, and staff interviews conducted. The findings include: 1. Review of the CDC's Hepatitis C Questions and Answers for the Public, dated 7/ 28/2020, revealed .The hepatitis C virus is usually spread when someone comes into contact with blood from an infected person .You should get tested for hepatitis C if you .Have been exposed to blood from a person who has hepatitis C . 2. Review of the facility's policy titled, Exposure Reporting and Investigating, dated 5/2022, revealed Employee exposure incidents to blood .or other potentially infectious materials must be reported to the community management as soon as practical after such incident occurs . Review of the facility's policy titled, Exposure Reports ., dated 5/2022, revealed An occupational exposure report shall be completed for all known employee exposures to blood and/or body fluids .Release of such information will only be on a need-to-know basis .For example, to the Administrator, Director of Nursing Services .and government officials, as required by law . Review of the facility's policy titled, Infection Prevention and Control Program . dated 10/2022, revealed The community Infection Prevention and Control Program is designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The program covers all residents, staff .and others who provide care and services to residents on behalf of the facility .The Infection Control Committee is established to provide the oversight of the program .The Infection Control Committee shall oversee the internal community system for the preventing, identifying, reporting, investigating and controlling of infections and communicable diseases for all staff .and other individuals providing services .The program establishes facility-wide systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors .The community program will follow accepted national standards, e.g. [for example] CDC .Components of the program will include .Surveillance system .Reporting requirements .Environmental cleaning .Recording system .The Infection Control Committee may include .Administrator .Director of Nursing .Infection Control Coordinator .The Infection Preventionist will report monthly to the QAPI [Quality Assurance Performance Improvement] Committee . 3. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Dementia with Mood Disturbance/Behavioral Disturbance/Psychotic Disturbance, Seizures, Hypertension and Chronic Hepatitis C. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had severely impaired cognition, physical behaviors directed towards others on 4-6 of 7 days and verbal behaviors directed towards others on 1-3 of 7 days. Review of the Care Plan dated 4/8/2022, revealed .has mood and behavioral problems .displayed as combative behavior towards other resident and staff, agitation, anxiety or restlessness r/t [related to] impaired mental status .has potential for complications r/t hepatitis C . Review of the Nurses Note dated 8/28/2022 at 9:24 PM, revealed .This nurse was notified by CNA [Certified Nursing Assistant] that there was blood on dayroom floor. Upon entering dayroom this nurse observed [named Resident #1] lying on the floor with hands under head in sleeping position with eyes closed. small scratch noted on face to L [Left] side of nose. [Named Resident #2] was sitting in WC [wheelchair] with small amount of blood coming from bottom lip. [Named Resident #1] was assisted into chair in hallway by nurse and [named Resident #2] was supervised in dayroom . 4. Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Diabetes, Dementia with Psychotic Disturbance, Schizoaffective Disorder-Bipolar Type, Depression, and Speech Disturbances. Review of the quarterly MDS dated [DATE] revealed Resident #2 had moderately impaired cognition, was rarely or never understood by and rarely or never understood others, and had highly impaired vision. Review of the Nurses Note dated 8/28/2022 at 10:01 AM, revealed .This nurse alerted by CNA there was blood in dayroom floor. Upon entering room this nurse observed resident sitting in WC with small amount of blood observed on bottom lip. [Named Resident #1] was observed lying on the floor with hands under head in sleeping position with eyes closed, small scratch noted on face to L of nose. Residents separated and supervised at this time . The facility was unable to provide documentation Resident #2 was tested for Hepatitis C following the incident with Resident #1 on 8/28/2022. Review of an email provided by the facility dated 9/4/2022 at 12:02 PM, from the Infection Preventionist to the DON, revealed .Just wanted to follow up with you regarding the incident on the Gardens, notifications and order status for infection control purposes. The DON replied to the email that she had notified the Nurse Practitioner (NP), and the nurses on the floor should have ordered labs on both residents. Review of an email provided by the facility revealed the Infection Preventionist emailed the DON again on 9/5/2022 to report she had not seen any labs related to the incident or a progress note from the NP. The DON replied, I'll look into it. The facility was unable to provide documentation the possible communicable disease transmission was reported to the local health department. During an interview conducted on 11/28/2022 at 2:48 PM, the Infection Preventionist was asked what precautions should be taken for a Resident with Chronic Hepatitis C. The Infection Preventionist stated, Standard Precautions .make sure any blood, if blood is ever drawn, whether it be from lab or an incident, that all precaution and testing is completed, even of staff. The Infection Preventionist was asked if she recalled the incident on August 28th. The Infection Preventionist stated, .I can't recall that one specifically . The Infection Preventionist was asked if she knew if any precautions were completed. The Infection Preventionist stated, .it was not a witnessed incident, there was no explanation as to the source of the injuries, neither party could say what happened .I remember we did discuss assessing hands for breaks in the skin to see if that contact and transferal which there was none .I did not have access to the lab company that we used at that time, but labs were ordered. What all was included I could not tell you off the top of my head .They were supposed to have the same matching lab sets .I want to say [named the former Director of Nursing (DON)] was going to talk to .our Nurse Practitioner, but I can't say for sure .the Nurse Practitioner was supposed to do a follow-up assessment on both residents, post incident assessment and get the orders for the labs . During an interview conducted on 11/28/2022 at 3:45 PM, the Infection Preventionist confirmed no labs to assess for Hepatitis C were collected from Resident #2 following the 8/28/2022 incident. The Infection Preventionist was asked if the DON responded to the email. The Infection Preventionist stated, I didn't see anything, and I should have continued to press her. That's on me. The Infection Preventionist was asked if this incident should have been followed. The Infection Preventionist stated, Absolutely, and the risk of blood being involved. The Infection Preventionist was asked what process should be followed following an exposure to Hepatitis C. The Infection Preventionist stated, We notify our Nurse Practitioner, get the standard lab orders .with his [Resident #1] diagnosis, a hepatitis panel on both residents just to make sure, and just on this incident, I would have asked if she wanted to include RPR [Rapid Plasma [NAME]] .labs as well, anything that could be transmitted via blood especially with the situation being highly suspect, with not having a witness, and having 2 residents that can't tell you what happened . During an interview conducted on 11/29/2022 at 10:01 AM, the Nurse Practitioner (NP) was asked if she recalled the incident on 8/28/2022 involving Resident #1 and #2. The NP stated, I do not remember that .[the nurse] notified Telehealth but didn't notify me . The NP was asked what protocol should be followed when an incident such as this occurred when the resident was Hepatitis C-positive. The NP stated, They should have done a panel for the other resident, should have been taken like as risk management, the whole shebang with blood on the floor, protocol that goes with that .we don't know if there was any contact .protocol as with HIV [Human Immunodeficiency Virus] any blood really .telehealth should have given them those orders as well .even if it's a day I'm off, they're supposed to notify me .if I'm not physically here, they're supposed to notify me .they [the facility] should know that . During a telephone interview conducted on 11/29/2022 at 2:32 PM, CNA #4 was asked to describe the incident between Resident #1 and Resident #2 on 8/28/2022. CNA #4 stated, Coming on shift, they tell us we have to do a walk through .I see [Resident #1] on the floor and the blood on the floor .Right as you come in the room, maybe an inch inside the door .I wasn't sure who's blood but said .He's on the floor .and went and got the nurse and she came and did her assessment. CNA #4 was asked did you see blood on his [Resident #1] face or a scratch or anything. CNA #4 stated, No ma'am, I didn't really know where the blood was coming from. I just knew there was blood on the floor .then [Resident #2] was like in his chair talking about he had to do what he had to do to protect himself .[Resident #2's] wheelchair was facing [Resident #1]. [Resident #2] was knelt forward and he had his hand holding him [Resident #1] down . During a telephone interview conducted on 11/29/2022 at 1:39 PM, the former DON was asked if she recalled the incident on 8/28/2022 involving Resident #1 and #2. The former DON stated, Vaguely, yes . The former DON was asked if labs were collected after that incident. The former DON stated, I don't know. I do know that typically we will call telehealth or the Nurse Practitioner to let them know of an incident .I don't know if telehealth or the NP ordered any labs. The former DON was asked if she was aware Resident #1 was Hepatitis C-positive. The former DON stated, No [adamantly stated] . The former DON was asked what protocol should have been followed considering there was blood on the floor and on both residents, and Resident #1 was Hepatitis C-positive. The former DON stated, Honestly had I known he was Hep [hepatitis] C-positive, even if the physician didn't ask for labs, I would have gotten labs on [named Resident #2]. I would have wanted serial labs .No, I had no idea. The former DON was unable to recall the emails sent by the Infection Preventionist. The former DON was asked if she spoke with the NP regarding this incident. The former DON stated, I'm pretty sure I told her what happened .I typically did, and if we needed anything, I would call [named the NP] or inform her in the morning meeting .if she would have ordered labs, I would have checked with the nurses to see if they were drawn or resulted . During an interview conducted on 11/30/2022 at 9:40 AM, Licensed Practical Nurse (LPN) #6 was asked what protocol should have been followed after the incident on 8/28/2022 involving Resident #1 and Resident #2. LPN #6 stated, Should notify the doctor of the incident and let him know of his [Resident #1] diagnosis, and both of them should have been tested . During an interview conducted on 12/1/2022 at 12:00 PM, the Medical Director was asked if he was notified of the incident that occurred between Resident #1 and #2 on 8/28/2022. The Medical Director stated, No. The Medical Director was asked if a resident had Chronic Hepatitis C, should there be a particular protocol followed by facility staff after possible blood exposure. The Medical Director stated, If it's open wound, yes .check the other resident, labs and screening for other and STD [sexually transmitted diseases]. During an interview conducted on 12/5/2022 at 1:52 PM, the Infection Preventionist was asked what things were reportable to the Health Department. The Infection Preventionist confirmed the potential exposure to Hepatitis C should have been reported to the Health Department. 5. The surveyors verified the Removal Plan through review of root cause analysis, in-services, audits, and conducting staff interviews. Governing Body will educate community leaders, Administrator (Admin) and Director of Nursing, regarding Unmanageable Residents F742 and F743, Lab and Diagnostic Test Results - Clinical Guidelines, and admission of Residents with Communicable Disease F880. Surveyors verified by review of in-services and interviews. Governing Body/Admin/DON/Staff Development Coordinator (SDC) will educate licensed nurses to Unmanageable Residents F742 and F743, Lab and Diagnostic Test Results - Clinical Guidelines, and admission of Residents with Communicable Disease F880. Surveyors verified by review of in-services and interviews. DON/SDC/Infection Preventionist (ICP)/Unit Manager (UM) will educate new licensed staff regarding Unmanageable Residents F742 and F743, Lab and Diagnostic Test Results - Clinical Guidelines, and admission of Residents with Communicable Disease F880. Surveyors verified by interviews. The Interdisciplinary Team will review the 24 Hour Report and resident altercations through the Clinical Startup Process Monday through Friday to assess need for laboratory related to communicable disease and infections. Surveyors verified by interviews. Residents are screened on admission and during change of condition for potential communicable diseases as we follow our policy of admission of Residents with Communicable Disease F 880, if resident is noted to have flu or COVID, etc. with change of condition, resident is isolated based on necessary precautions and if there is a roommate, roommate is quarantined and tested as indicated until known infection status. Surveyors verified by interviews. Residents with communicable diseases are tracked by The Infection Control Nurse or designee will maintain a log of residents with current evidence of infection or colonization due to multidrug-resistant organisms, including Methicillin-resistant Staphylococcus aureus (MRSA)/Vancomycin-Resistant Enterococci (VRE)/Clostridioides difficile (C. Diff). When considering room assignments the log will be checked to prevent placing a resident with MRSA/VRE/C. Diff infection or colonization with a resident at risk of infection. Surveyors verified by interviews. Residents that have been or could be exposed to a communicable disease will be quarantined and have appropriate testing as indicated. Surveyors verified by interviews. DON/IDON/SDC/UM will assess residents with communicable diseases and infections for potential exposures and appropriate follow up 3 x week for 4 weeks, then 1 x week for 8 weeks. Results of the audits will be submitted to the Quality Assurance Committee for review and recommendations. Surveyors verified by interviews. The facility's noncompliance of F-880 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.