**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to notify and consult the Physician/Nurse Practitioner (NP) of a change in condition related to falls 1 of 6 (Resident #7) sampled residents reviewed for change in condition. On [DATE], Resident #7 had an unwitnessed fall and was found on the floor with his head under the bed. Resident #7 hit his head while being placed back in bed by staff. The Physician/NP was not notified of Resident #7's unwitnessed fall on [DATE], and on [DATE], Resident #7 experienced a change in mental status. The NP was notified on [DATE] (1 day after the change in mental status and 4 days after the unwitnessed fall) of Resident #7's change in condition and again, was not notified of the unwitnessed fall the resident sustained on [DATE]. The facility's failure to immediately notify the Physician/NP of Resident #7's fall with injury resulted in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death, when Resident #7 had an unwitnessed fall and remained in the facility for 4 days following the fall and after experiencing mental status change the night before being transferred to the hospital where he expired in the emergency room (ER). The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:10 PM, in the Administrator's office. The facility was cited at F-580 at a scope and severity of J. The Immediate Jeopardy was effective [DATE] and is ongoing. A partial extended survey was conducted [DATE] to [DATE]. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility policy titled Notification of Change, revised on [DATE], revealed .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies the resident's representative .when there is a change requiring notification .The facility shall inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification .Circumstances requiring notification include: 1. Accidents .b. potential to require physician intervention .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Unspecified Fracture of Third Lumbar Vertebra, Frontal Lobe and Executive Function Deficit, and Urinary Tract Infection. Resident #7 was discharged on [DATE] to Hospital #1. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 revealed, a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the facility Clinical Note dated [DATE] but entered into the Electronic Health Record (EHR) on [DATE], revealed, .Resident was found on the floor with his head under the bed .While sliding the resident to get his head clear of the bed the resident raised his head and hit it on the underneath of the bed . The Clinical Note documented on [DATE] and dated [DATE] was not documented as a late entry. Review of the facility Clinical Note dated [DATE], revealed, .Res [resident] appears to be more confused, not understanding simple tasks . During an interview on [DATE] at 11:25 AM, the Director of Nursing (DON) verified the unwitnessed fall on [DATE] for Resident #7 was not charted until [DATE]. The DON stated she became aware of Resident #7's unwitnessed fall after he was sent to Hospital #1 emergency room (ER) for a change in mental status when someone reported to her Resident #7 had a knot and a bruise on his head. She stated she followed-up with LPN G, who said Resident #7 had a fall and hit his head pretty hard on [DATE]. After the DON received report on the fall from [DATE], she initiated an investigation and requested LPN G complete an incident report on [DATE]. The DON stated she educated LPN G when he stated he was unaware he needed to document on the fall. Continued interview revealed, the DON was asked what her expectations were when a resident experienced a fall. She replied, .I expect a head-to-toe assessment, neuro checks, notification to the NP, family, DON, Administrator and implement any new orders received . The DON verified no neuro checks were initiated. The DON was then asked what her expectations for a resident for a change in mental status were. She replied, .To reach out to the NP, obtain, and implement any new orders received . The DON looked at the progress note documented by LPN F and stated .[LPN F] should have contacted the NP herself .The NP should have been notified as soon as the change in mental status was noticed .with any change in condition, there should be follow-up charting for 72 hours . During a telephone interview on [DATE] at 3:57 PM, Licensed Practical Nurse (LPN) G stated .I did not report the fall because I was unfamiliar with the computer system .the Unit Manager was there and saw him on the floor . During a telephone interview on [DATE] at 5:00 PM, the NP stated she was not notified about Resident #7's unwitnessed fall on [DATE]. During an interview on [DATE] at 12:45 PM, LPN K, who was the Unit Manager, confirmed she observed Resident #7 on the floor and did not notify the NP, Director of Nursing (DON), Assistant Director of Nursing (ADON), or resident representative about Resident #7's unwitnessed fall on [DATE]. When asked if she followed-up on Resident #7's fall the next day, LPN K stated No, the ADON deals with the falls in the facility. Continued interview revealed LPN K admitted she did not notify the NP, DON, ADON, or family about Resident #7's fall and should have followed-up the next day on the fall from [DATE]. During an interview on [DATE] at 11:17 PM, Family Member (FM) KK, the conservator for Resident #7, stated she had not been notified of a fall on [DATE] nor of a change in mental status on [DATE]. During a telephone interview on [DATE] at 9:06 AM, FM LL, who could also make decisions for Resident #7, confirmed she had not been notified about a fall on [DATE] nor a change in mental status on [DATE]. During a telephone interview on [DATE] at 10:25 AM, the NP stated she was not notified of Resident #7's change in mental status on [DATE] but would expect the facility to notify her of any change in condition for any resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, hospital record review, and interview, the facility failed to provide an environment that is free from accident hazards for 1 of 6 (Resident #7) sampled residents reviewed for falls. On [DATE] at 5:30 PM, Resident #7, known to have a history of falls with injury, was found on the floor following an unwitnessed fall from bed. LPN G documented staff (CNA AA and CNA CC) assisted Resident #7 off the floor and Resident #7 hit his head on the bed. CNA AA and CNA CC then placed Resident #7 back in bed. There was no documentation to show a post-fall assessment was completed prior to moving Resident #7 from the floor to the bed. There was no documentation to show neuro checks were conducted. There was no incident report or investigation documented following the unwitnessed fall to determine the root cause. There were no immediate interventions documented following the fall and no notification to the Physician/Nurse Practitioner (NP) on [DATE]. On [DATE] (4 days after the unwitnessed fall) Resident #7 was transferred to the hospital on [DATE] for a change in mental status. There was no documentation that facility staff reported Resident #7's unwitnessed fall on [DATE] to the Emergency Department (ED). The facility's failure to provide an environment that was free from accident hazards resulted in an Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:10 PM in the Administrator's office. The facility was cited at F-689 with a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective [DATE] and is ongoing. A partial extended survey was conducted [DATE] to [DATE]. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility policy titled, Accidents and Supervision, revised [DATE] revealed, .The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents .1. Identification of Hazards and Risks .a. Communicating the interventions to all relevant staff .Providing training as needed .d. Documenting interventions .e. Ensuring that the interventions are put into action . Review of the facility policy titled, Fall Risk-Fall Prevention, revised [DATE] revealed, .1. The fall risk assessment shall be completed by a licensed nurse .b. After a fall .c. Upon a significant change in medical status . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Unspecified Fracture of Third Lumbar Vertebra, Frontal Lobe and Executive Function Deficit, and Urinary Tract Infection. Resident #7 was discharged on [DATE] to Hospital #1. Review of the care plan for Resident #7 revealed, .[[DATE]] At Risk For Falls R/T [related to] impaired mobility .Interventions .Keep area free of obstructions to reduce the risk of falls or injury .Place call bell/light within easy reach .Provide reminders to use ambulation and transfer assist devices .Remind [Resident #7] to call for assistance before moving from bed-to-chair and from chair-to-bed .[[DATE]] Footwear will fit properly and have non-skid soles . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of the facility document (Incident Report) dated [DATE], revealed LPN G documented, Observed resident on the floor between both beds and his head under his bed. Resident did not have non-skid footwear on. While assisting resident up from the floor, raised his head and bumped it on the bottom of the bed. Resident mental status was at his normal. Resident was resting comfortably in bed when writer [LPN G] exited room. Continued review revealed a bruise to Resident #7's forehead. Review of the facility Clinical Note dated [DATE] but not entered into the Electronic Health Record (EHR) until [DATE], revealed LPN G documented Resident #7 was found on the floor with his head under the bed. Continued review revealed that while staff were assisting him out from under the bed, he raised his head and hit it on the bottom of the bed. LPN G documented there were no injuries. The Clinical Note was not documented as a late entry. Review of the facility Clinical Note dated [DATE] revealed LPN F documented Resident #7 experienced a change in condition. The provider was not notified of Resident #7's change in condition until [DATE], the following day. Review of the facility Fall Risk assessment dated [DATE] revealed Resident #7 had a history of multiple falls in the last 90 days, had an unsteady gait and was at moderate risk for falls. Review of the facility Hospital Transfer Form dated [DATE] but completed on [DATE] revealed .Mental Disorders/Neurological/Psychiatric Issues .Change in Mental Status . There was no documentation by LPN G of the unwitnessed fall on [DATE]. Review of the hospital record dated [DATE] at 10:05 AM revealed, .PT [patient] was found unresponsive in bed .[nursing home] staff reports patient is normally talking and oriented, BG [blood glucose] was 517 .Bruising on forehead purple and yellow in color . Resident #7 expired at the hospital on [DATE]. Septic shock was documented as the cause of death. During an interview on [DATE] at 11:25 AM, the DON verified the unwitnessed fall on [DATE] for Resident #7 was not charted until [DATE]. The DON stated she became aware of Resident #7's unwitnessed fall after he was sent to Hospital #1 emergency room (ER) for a change in mental status when someone reported to her Resident #7 had a knot and a bruise on his head. She stated she followed-up with LPN G, who said Resident #7 had a fall and hit his head pretty hard on [DATE]. After the DON received report on the fall from [DATE], she initiated an investigation and requested LPN G complete an incident report on [DATE]. The DON stated she educated LPN G when he stated he was unaware he needed to document on the fall. Continued interview revealed, the DON was asked what her expectations were when a resident experienced a fall. She replied, .I expect a head-to-toe assessment, neuro checks, notification to the NP, family, DON, Administrator and implement any new orders received . The DON verified no neuro checks were initiated. The DON was then asked what her expectations for a resident for a change in mental status were. She replied, .To reach out to the NP, obtain, and implement any new orders received . The DON looked at the progress note documented by LPN F and stated .[LPN F] should have contacted the NP herself .The NP should have been notified as soon as the change in mental status was noticed .with any change in condition, there should be follow-up charting for 72 hours . During a telephone interview on [DATE] at 3:57 PM, LPN G stated Resident #7 experienced an unwitnessed fall on Thursday, [DATE] .[LPN K] found him [Resident #7] .we went in and assessed him [LPN G, CNA AA, CNA CC] .everything seemed fine .he was being belligerent when we got him up off the floor .[LPN G] did not do an incident report .I was off Friday [[DATE]], Saturday [[DATE]], Sunday [[DATE]] .Monday [[DATE]], the night nurse [LPN F] informed me [Resident #7] needed a urine .when I got to his room between 9 AM and 10 AM to give meds .he was totally different .I went to call the NP .got order to send Resident #7 out .found out later Resident #7 had passed .a few days later, CNA AA and CNA CC said Resident #7 had multiple falls over the weekend [after the fall on [DATE]] .Resident #7 was between his and his roommate's bed .lying on his back .Resident #7 said he slid out of bed and landed on his bottom .Resident #7 bumped his head on the frame of the bed when we got him up .Resident #7 had scooted under the bed .head was under the bed .No visible injuries noted at that time .I did neuro checks but did not chart it .I was not trained well on that system .on that Monday, he had a bruise to the forehead or temporal area . Continued interview revealed LPN G stated .I did not report the fall because I was unfamiliar with the computer system and the Unit Manager was there and saw him on the floor . LPN G was asked if he reported the fall when Resident #7 was transferred out to the hospital. LPN G replied, No. I just told them about the change in mental status . During a telephone interview on [DATE] at 5:00 PM, the facility NP was asked what her expectations were to report a change in mental status. She replied, .I would expect to be notified immediately after the patients immediate needs were met, no matter the time .On call is available for the night shift .If emergent or unstable, I would expect staff to call 911 and then notify me immediately after . Continued interview revealed, the NP was not notified about Resident #7's fall on [DATE] and was contacted on [DATE] about a change in mental status for Resident #7. During an interview on [DATE] at 12:45 PM, LPN K, the Unit Manager, recalled she was about to leave for the day and went to tell the nurse something when she observed LPN #4 with 2-3 unnamed CNAs in Resident #7's room. Resident #7 was positioned on the floor, toward the foot of the bed, sitting up with his back against the bed. LPN K stated Resident #7 was not cooperating, so she backed out of the room and let staff finish with Resident #7. When asked her expectations for staff when a fall occurred, LPN K stated she would expect the nurse on duty to complete an event note, progress note, and 72-hour charting. When asked if LPN K followed-up on Resident #7's fall the next day, LPN K stated No, the ADON [Assistant Director of Nursing] dealt with the falls in the facility. Continued interview revealed LPN K admitted she did not notify the NP, DON, ADON, or family about Resident #7's fall and should have followed-up the next day on the fall from [DATE]. During a telephone interview on [DATE] at 5:57 PM, CNA DD was asked if Resident #7 had experienced any fall, CNA DD responded, Which one, because he had several. CNA DD could not recall any dates of the falls. During an interview on [DATE] at 11:17 PM, Family Member (FM) KK stated she had not been notified of a fall on [DATE] nor of a change in mental status on [DATE]. During an interview on [DATE] at 9:06 AM, Family Member (FM) LL stated she had not been notified of a fall on [DATE] nor of a change in mental status on [DATE]. During an interview on [DATE] at 3:07 PM, CNA GG stated Resident #7 did fall and was found on the floor face down, beside the bed and the bedside table. CNA GG stated he did not observe the fall but did notify the unnamed nurse and helped get Resident #7 up off the floor into the bed. When asked if Resident #7 had experienced any change in mental status, CNA GG stated Resident #7 would typically curse and yell, but he actually became calm and quiet after the unwitnessed fall. Continued interview revealed, CNA GG felt there was something different with Resident #7 and asked the unnamed nurse if she felt Resident #7 looked okay, the unnamed nurse replied, Yes. Refer to F-580, F-600, and F-726.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, www.hopkinsmedicine.org/health, Police Incident Report dated [DATE] review, facility investigation review, medical record review and interviews, the facility failed to ensure residents were free from abuse/sexual for 6 of 9 (Residents #3, #7, #9, #11, #14, and #15) sampled residents reviewed for abuse/neglect. On [DATE] during group activities Resident #11, who had a BIMS of 12, approached Resident #15, who had a BIMS of 4, began to rub across her shoulders and back, and then tried to kiss her. Resident #15 told Resident #11 to stop and pushed him away. Resident #11 then put some money on the table in front of Resident #15 and pushed it towards her while saying, If this isn't enough, let me know. On [DATE] Resident #11 approached Resident #15 during activities and pulled up his shirt and began rubbing his nipples. Resident #15 pushed him away from her. Resident #11 returned to his table and within a few minutes, stood up, pulled his pants down, and pointed to his penis saying, If any of you ladies want this come to room [ROOM NUMBER]. On [DATE], 5 days after Resident #11 began having inappropriate sexual behaviors, Resident #3, who had a BIMS score of 15, reported to staff that during the night before Resident #11 approached his bed and placed his genitals in his (Resident #3)'s hand. Resident #11 was transferred to a psychiatric facility on [DATE], 8 days after inappropriate sexual behaviors with Resident #15 were documented. On [DATE] during activities The facility failed to prevent Neglect when on [DATE] Resident #7 was found on the floor with his head under the bed. Staff failed to complete a post-fall assessment, an incident report, and notify the Physician/NP on [DATE], and there was no monitoring for adverse outcomes related to the fall. On [DATE] (3 days after the fall), Resident #7 experienced a change in mental status, and the physician/NP was not notified. On [DATE] (4 days after the fall) and 1 day after the change in mental status, the NP was notified and again not made aware of the fall with head injury. Nursing staff transferred Resident #7 to the emergency room (ER) without report of the recent fall with head injury. Resident #7 expired after arrival in the ER. The facility's failure to prevent sexual abuse for Resident #3, #11, and #15 and neglect for Resident #7 resulted in Immediate Jeopardy. The facility failed to ensure Resident #9 was free from physical abuse that resulted in actual HARM when Resident #14 was observed hitting and punching Resident #9's hand and bending her fingers back that resulted in pain, bruising and swelling of Resident #9's hand. The facility's failure to protect residents from abuse and neglect resulted in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:10 PM in the Administrator's office. The facility was cited at F-600 with a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective [DATE] and is ongoing. A partial extended survey was conducted on [DATE] to [DATE]. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility policy titled, Abuse Prohibition Plan, effective date [DATE], revealed, .The facility has a zero-tolerance policy for abuse .The facility shall attempt to identify and shall investigate any reported violation or allegation of abuse .'Sexual Abuse .' is non-consensual sexual contact of any type with a resident. It includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault ' Physical Abuse' includes, but not limited to hitting, slapping, pinching, and kicking .'Neglect' means 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 investigation shall begin immediately .It is the policy of this facility that Residents shall be protected from the alleged offender(s) .If the alleged offender is a facility Resident, the staff member shall immediately remove the perpetrator from the situation and another staff member shall stay with the alleged offender and wait for further instruction from the Administrator .Employees must always report any allegation of abuse or suspicion of abuse immediately to the supervisor . Review of an undated article titled, Frontotemporal Dementia [FTD], from www.hopkinsmedicine.org/health revealed, .Symptoms of FTD .common symptoms .Behavior and /or dramatic personality changes, such as swearing, increased interest in sex .Socially inappropriate, impulsive, or repetitive behaviors . Review of a Police Incident Report dated [DATE], revealed, .The caller, [Named Administrator], was notified today when she arrived back from vacation .I [Police Officer] was told [Named Resident #3] has a speech problem, and is very delayed when trying to speak .I was not able to speak with him [Resident #3] .[Named Resident #11] has been placed in the psychiatric ward .[Named Administrator] said [Named Resident #11] has these types of episodes when he does not take his medication as prescribed, which he is currently not doing . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Schizophrenia, Dysphagia, Dysarthria and Anarthria. Dysarthria is a less severe form of Anarthria and causes slurred or slowed speech. Anarthria is the loss of the ability to speak. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed, a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of the undated current care plan for Resident #3 revealed there were no focus/problems or interventions on the care plan for risk related to actual abuse allegations. Review of the provider/Nurse Practitioner (NP) progress note dated [DATE] for Resident #3, revealed, .Patient being seen for follow-up on events this past weekend involving roommate .patient reports he does not want to discuss in detail w [with]/me what occurred over the weekend .does affirm allegation against roommate and that he [Resident #3] may be open to discussing w/local PD [Police Department] .Reports emotional and mental distress from prior roommate's actions . Review of the facility Clinical Notes for Resident #3 dated [DATE]- [DATE] frequently referenced Resident #3's desire to sit on the front porch, even referenced it as something he loves to do on a daily basis. The Clinical Notes referred to Resident #3 feeling safe and calm, in a good mood and smiling. During an interview on [DATE] at 3:08 PM, MDS Coordinator #1 and #2 confirmed there were no interventions related to actual risk associated with the allegation of nonconsensual sexual contact/sexual abuse Resident #3 reported on [DATE]. MDS Coordinator #1 and #2 agreed residents that experience alleged abuse should be monitored for risk of immediate and late onset of affects such as psychosocial harm. During an interview on [DATE] at 4:11 PM, Resident #3 agreed to interview in the presence of his roommate. Resident #3 was asked to recall the incident with his previous roommate, Resident #11, during the night of [DATE] - [DATE]. The surveyor provided support and patience during the interview as Resident #3 was very slow to answer and had difficulty expressing himself. Resident #3 stated, .[Named Resident #11] came to my bed and tried to push me on my side, 3 or 4 times .almost fell off the bed .he [Resident #11] stopped and looked right at me, took out his d k and put it in my hand .I yelled .he walked away laughing . Resident #3 was asked if he felt safe in the facility, Resident #3 replied, .I am safe with this roommate [pointing towards current roommate] but when he goes home, who will keep me safe .He [Resident #11] is still here, I see him out in the hall . Resident #3 became tearful and paused for several minutes. When asked if he reported the incident to staff after Resident #11 walked away, Resident #3 replied, .I tried but they wouldn't stand still long enough for me to talk, they think I can't talk . Resident #3 thanked the surveyor for standing still and listening to him. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder, Schizoaffective Disorder, and Frontotemporal Neurocognitive Disorder. Common symptoms of Frontotemporal Neurocognitive Disorder include but are not limited to behavior such as socially inappropriate, impulsive, or repetitive behaviors, and increased interest in sex. Review of a Psychiatric Evaluation dated [DATE], for Resident #11 revealed, .recently admitted to the facility after being hospitalized at [Named psychiatric medical facility from Named Long term care facility] for verbal aggression, cussing, and threatening his staff .history of medication refusal/spitting medication .BIMS 7/15 . Review of the admission MDS assessment dated [DATE] for Resident #11 revealed, a BIMS score of 12, which indicated moderately cognitively impaired. Continued review revealed Resident #11 required supervision to walk in corridor. Review of care plan for Resident #11 revealed, . [DATE] .Remind [Resident #11] that BEHAVIOR is not appropriate .Resident prefers to walk around facility constantly and enjoys sitting on front porch . [DATE] .displayed inappropriate sexual behaviors towards others .Redirect [Named Resident #11] and remind him of what is appropriate/not appropriate in social settings XXX[DATE] .rejects or resists care (history of refusing medications) . Resident #3, the victim of the alleged sexual assault enjoys sitting on the front porch. There were no care plan interventions for either resident to address psychosocial risk associated with repeated exposure in the facility. Review of the facility Clinical Notes for Resident #11 dated [DATE], revealed .Resident was down in the dining room rubbing up against a female resident the [then] gave her money and said if it isn't enough to let him know . Review of the facility Clinical Notes for Resident #11 dated [DATE], revealed .Resident was down in the dining room pulling his pants down and pointing to his penis telling the ladies to come to room [ROOM NUMBER] he had the room # written on a piece of paper. He also went over to another resident and tried to kiss her. Activities went and got the nurse . Review of the facility Clinical Notes for Resident #11 dated [DATE] at 8:45 AM, revealed .Resident was down in the dining room on [DATE] [2023] two different times this resident was making sexual comment's [comments] to the lady residents pulling his shirt up and rubbing his nipples and rubbing himself up on two female residents. Also [Also,] resident was rubbing his penis asking a female resident if she wanted some of that. Resident also had his room # written on a piece of paper telling the lady resident to come to his room. Activities reported this to the nurse . Review of the facility Clinical Notes for Resident #11 dated [DATE] at 1:53 PM, revealed .This resident was in the hallway raising up his shirt and playing with his nipples . Review of the facility Clinical Notes for Resident #11 dated [DATE] at 6:31 PM, revealed .Another resident family member notified Nurse Management this shift of sexual inappropriate behavior towards roommate/resident on last night. Roommate immediately moved out of room, placed in another room. Family [Resident #3's family] at bedside agreeable and aware. Review of the facility Clinical Notes for Resident #11 dated [DATE] at 1:29 PM, revealed, .Resident was down in the dining room cussing and giving the finger to other residents . Review of the NP progress note for Resident #11 dated [DATE] at 1:34 PM, revealed, .Received call from facility administrator yesterday evening regarding recent patient events/behaviors .exhibited sexually inappropriate behaviors on several occasions over the last week .unwanted sexual advances towards other residents and undressing, fondling himself, and exposing genitals in the presence of other residents in the dining/activities room, a common shared area for residents . event occurred over the weekend and prompted nurse to notify facility admin of behavior who in turn notified me .allegedly physically assaulted roommate . Review of the facility Clinical Notes for Resident #11 dated [DATE] at 9:23 AM, revealed, .Admin [Administrator] spoke to NP regarding Resident's behaviors and NP stated she would review his medications and a referral to psych was to be started by the building on Monday 9/25 [2023] .Nursing made aware . Review of the facility Clinical Notes for Resident #11 dated [DATE] at 9:35 AM, revealed .resident was observed being inappropriate in the dinning [dining] room. resident sent back to his room. spoke with [Named psychiatric facility] psych in [Named city] and sent a referral packet earlier today. waiting for a call back. resident is being observed for any other behaviors . Review of a signed written statement dated [DATE] revealed Registered Nurse (RN) JJJ stated, .was informed by the activities director that [Named Resident #15] was in the dining room and that she was visibly upset .[Named Resident #15] had made allegations that [Named Resident #11] had been trying to hug on her .given her money .After the activities director had informed me of the situation, we brought it to the DON's attention . Review of a signed written undated statement revealed LPN O stated, .This nurse was informed of Resident [Resident #11] playing with his genital area and Rubbing his nipples and this nurse informed staff that he should be sent to his Room for that behavior . Review of the facility Clinical Notes for Resident #11 dated [DATE] - [DATE] revealed multiple behaviors for Resident #11 which included spitting out medications, refusing medications, walking in the hallway with his shirt pulled up over his abdomen, and outburst of yelling and cursing staff. Interviews conducted during the survey revealed Administration and nursing staff denied abnormal behaviors for Resident #11 since his return from the psychiatric unit after the sexual allegations. Review of the (Named Psychiatric facility) Discharge Summary for Resident #11 dated [DATE], revealed, .Reason for admission and Examination .Patient is admitted for sexually inappropriate behaviors where he put his genitalia in his roommate's hand, pulling his pants down showing his genitalia, pulling his shirt up rubbing his nipples . Review of the Psychiatric Evaluation (Amended) for Resident #11 dated [DATE], revealed, .currently readmitted to the facility after being hospitalized .for hypersexuality .While hospitalized , the resident was started on Provera [hormone] 5 mg [milligram] by mouth twice daily for hypersexuality .The residents ' medication, Provera, was being ordered this day from the pharmacy . Review of the NP Progress Note for Resident #11 dated [DATE] at 2:05 PM, revealed, .Assessment .Nymphomania [hypersexuality] (finding) .Oth [other] sexual dysfnct [dysfunction] .modified 13 Oct. [October] 2023 . During an interview on [DATE] at 2:10 PM, the Administrator stated Resident #11 had no sexual behavior prior to this incident on [DATE]. The Administrator stated Resident #11 had refused medications for a few days before and then had the inappropriate behaviors. When asked what were the effects of Resident #11 not taking his medications, the Administrator replied, .Resident #11 was in activities and pulled his shirt up .rubbed his nipples . [Named Resident #3] reported to his sister that [Named Resident #11] had tried to put his genitals in [Named Resident #3]'s hand . [Named Family member (FM) HH] reported the incident to the nurse, who reported to the Administrator . During an interview on [DATE] at 4:42 PM, the Activities Director stated Resident #11 was in activities when he pulled up his shirt and rubbed his nipples. She stated she removed Resident #11 from the activity room, escorted him to the nurse and reported what had happened in the dining room. During an interview on [DATE] at 9:32 AM, the DON stated, .I did a small investigation that involved [Named Resident #11] and his behavior in the dining room with other residents present .[Named Resident #11] was redirected and escorted from the dining room to his room .[Named Resident #11] was placed on 1 to 1 with the MDS [Minimum Data Set] Coordinator in his room .He [Resident #11] had been refusing his medications and this is why he was having behaviors . When asked what intervention had been initiated for Resident #11's inappropriate sexual behavior with Resident #15, the DON replied, .I spoke with [Named Resident #11] and told him he was not to hug anyone else without their permission . During an interview on [DATE] at 11:10 AM, Licensed Practical Nurse (LPN) O confirmed Resident #11 was sent to a psychiatric facility due to exposing himself to other residents. LPN O stated, .The day [[DATE]] [Named Resident #11] left going to [Named psychiatric facility] he was alone in his room. I walked him out to the car and he became agitated and hit the window of the car .He [Resident #11] had behaviors of spitting out his medications and cussing staff . During an interview on [DATE] at 11:47 AM, the Activity Director confirmed she had reported and documented Resident #11's inappropriate sexual behaviors multiple times beginning [DATE], and continuing on [DATE], and [DATE]. The Activity Director stated, .on the 18th [[DATE]] [Named Resident #11] was in activities and walked up to [Resident #15], put his hands on her shoulders and began to massage her .He [Resident #11] tried to kiss her while he was rubbing her and she pushed him away .He [Resident #11] put some money on the table in front of her [Resident #15] and pushed it towards her and said, ' .If that isn't enough, just let me know .' then he laughed and walked back to his table . I asked him to leave activities and reported it to the nurse, not sure which one, I think she was agency .On the 21st [[DATE]] he [Resident #11] was sitting at his table, stood up, and pulled his pants down then pointed to his penis and yelled, ' .if any of you ladies wants this come to room [ROOM NUMBER] .' he [Resident #11] had a piece of paper with the number 311 written on it He then walked over and tried to kiss [Named Resident #15] .I went and got the nurse [Named LPN H] .she [LPN H] came in and told him to go to his room .On the 22nd [[DATE]] he [Resident #11] he walked up to [Named Resident #15] rubbed up against her, and started rubbing his nipples and making sexual comments like ' .Do you want some of that .' then handing a piece of paper with his room number on it .I told him to leave activities and went to get a nurse .he [Resident #11] was walking down the hall outside of activities and pulled up his shirt and started rubbing his nipples . I went and told the nurse .may have been a different agency nurse .I told them he could not come back to activities . When asked if she had reported the inappropriate behaviors to anyone else, the Activity Director replied, .We talked about it in the morning meetings that week and [Named DON] said the psych nurse would see him . The Activity Director stated, .The Administrator and the DON have been upset about my documentation and said we would be in trouble if the State came in and seen it .I will not change my statements and say I heard that he [Resident #11] had done those things, I saw it happen . During an interview on [DATE] at 12:11 PM, the Social Services Director (SSD) confirmed there had been discussions about the inappropriate sexual behaviors reported by the Activity Director in the morning meetings. The SSD stated, .Either the Administrator or the DON keeps a record of the morning meetings .He [Resident #11] was to be seen by the NP .I think the Administrator spoke to the NP on the 26th [[DATE]] .He [Resident #11] would write letters to his girlfriend and bring them to me .the letters contained very explicit sexual content . During an interview on [DATE] at 12:50 PM, the DON reviewed a binder that contained the minutes for the morning meetings and confirmed there were no meeting minutes in the binder for [DATE] - [DATE]. The DON stated, .There were no interventions related to [Named Resident #11]'s sexual behaviors in activities because we did not know about them .I think the documentation by Activity was actually just hearsay .he [Resident #11] was sent out to psych .He [Resident #11] has had no continued behavior since returning to the facility . During an interview on [DATE] at 1:13 PM, LPN H confirmed the Activity Director notified her about Resident #11's inappropriate behavior. LPN H stated, .[Named Activity Director] told me he [Resident #11] was exposing himself to people in the dining room .I went down there and he [Resident #11] was sitting in his chair drinking coffee and smiling at me . When asked if she investigated or asked any of the residents present in the room about the behavior, LPN H replied, .There was nothing to investigate, he was sitting there drinking coffee . When asked if she had been trained on Abuse since being employed by the facility, LPN H replied, .Yes, many times . LPN H was asked if she had to actually see abuse in order to act on an allegation. LPN H replied, .Tell me if it was my responsibility to report the allegation, since the Activity Director was in management . During an interview on [DATE] at 3:08 PM, MDS Coordinator HHH and MDS Coordinator III confirmed neither one had performed 1 on 1 monitoring for Resident #11 prior to the resident being transferred to a psychiatric facility. MDS Coordinator HHH and III both confirmed Resident #11's inappropriate sexual behaviors on 9/18 - [DATE] had been presented by the Activity Director and discussed in the morning meetings. During an interview on [DATE] at 3:18 PM, the Administrator stated, .We were unable to substantiate the allegations of sexual abuse between [Named Resident #3] and [Named Resident #11] because it was not witnessed and both residents have an extensive history of psych behaviors, but no sexual behaviors .[Named Resident #3] has not been happy with living in the facility and does not want to be here .I think he [Resident #3] has been sexually inappropriate with staff .[Named Resident #11] had been refusing medication and spitting it out so his behavior increased and he was sent out .before that he was seen by the NP and had a medication change . When asked about the documentation of Resident #11's sexually inappropriate behaviors during activities reported by the Activity Director, the Administrator stated, .Well, after we got those notes cleaned up, we had to talk to [Named Activity Director] and explain why she could not document what someone tells her rather than what she actually sees. I think the behaviors was just what someone told her happened . When asked what she meant by getting the notes cleaned up, the Administrator replied, .We reviewed the notes and then asked staff if anything had been reported to them because [Named Activity Director] said she had reported to the nurse .We didn't find anyone she had reported the information to . The facility investigation contained signed written statements from 2 nurses confirming notification of Resident #11's sexual behaviors. During a telephone interview on [DATE] at 3:30 PM, former Assistant Director of Nursing (ADON) stated, .I conducted the morning meetings when the DON was unavailable .The minutes would be recorded and placed in the big binder in the DON ' s office .Yes, I was aware of the behaviors reported by [Named Activity Director] not sure what all the interventions were, I am sure a staff member had to be present in the dining room when he [Resident #11] was in there . When asked if having a staff member present would stop Resident #11's inappropriate behavior, the ADON replied, Of course. When asked about the behavior that occurred with Activity staff present in the dining room, the ADON replied, .There was staff in there and it happened anyway, well ain't that something . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease with Early Onset, and Chronic Kidney Disease, Stage 3. Review of the admission MDS assessment dated [DATE] for Resident #15 revealed, a BIMS score of 4 which indicated severe cognitive impairment. Resident #15 was independent with mobility/walking. Review of the Psychotherapy progress notes for Resident #15 dated [DATE] - [DATE], revealed no notes or evaluations related to nonconsensual sexual contact and inappropriate sexual behaviors toward Resident #15 from Resident #11. No Psychotherapy progress notes for [DATE] - [DATE] were provided by the facility. Review of undated care plan for Resident #15 revealed, .exhibits wandering behavior . Continued review revealed there was no problems/focus and interventions for risk related to victim of inappropriate sexual behavior and nonconsensual sexual contact by Resident #11 on [DATE] - [DATE]. Review of the facility Clinical Notes for Resident #15 dated [DATE]-[DATE], revealed there were no documentation of inappropriate sexual behaviors and nonconsensual sexual contact experienced by Resident #15 from Resident #11. During an interview on [DATE] at 3:08 PM, MDS Coordinator HHH and III confirmed there were no interventions related to actual risk associated with the nonconsensual sexual contact Resident #15 experienced from [DATE]-[DATE]. MDS Coordinator HHH and III agreed residents that experience alleged abuse should be monitored for risk of immediate and late onset of affects such as psychosocial harm. During an interview on [DATE] at 4:00 PM, Resident #15 was smiling, giggling, and very childlike in behavior (bouncing in chair during interview). Resident #15 was asked if she had a fun time in activity and if anyone ever bothered her or upset her during activity. Resident #15 replied, .I like to color and make pretty things . When asked if anyone had ever made her mad or touched her in a bad way. Resident #15 replied, .[Named (first name) Resident #11] kisses me here [pointed to her neck] and tells me how much he loves me .he just loves me all the time .but I tell him to get back .I don't want nobody kissing me . Resident #15 then got up from the table and walked away. During an interview on [DATE] at 4:27 PM, the Administrator was asked what the facility had done to protect Resident #15 from targeted nonconsensual sexual behavior from other residents. The Administrator stated, .[Named Resident #15] is young and pretty and puts herself in very social situations .She socializes, laughing and talking with everyone . The Administrator was asked if she thought Resident #15 caused the nonconsensual contact that occurred in [DATE]. The Administrator stated, No, I feel like she is so friendly and people take it wrong .[Named Resident #1) had been sent out to a psychiatric unit and I really don't know of any other interventions the facility could put in place . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Unspecified Fracture of Third Lumbar Vertebra, Frontal Lobe and Executive Function Deficit, and Urinary Tract Infection. Resident #7 was discharged on [DATE] to Hospital #1. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 revealed, a BIMS score of 15 which indicated no cognitive impairment. Continued review revealed Resident #7 had an indwelling catheter. Review of the care plan for Resident #7 revealed, .Problem .[[DATE]] at risk for UTI (Urinary Tract Infection) .Interventions .Provide cues/assist [Named Resident #7] to drink fluids with medications and between meals .Monitor [Named Resident #7] for burning/painful urination .Obtain urine samples as ordered .Periwipes available to resident .Record I & O .Catheter care .Change catheter as needed for blockage or malfunction .Check catheter tubing for proper drainage and position .Keep drainage bag covered to promote dignity .Observe for discomfort, urine color, clarity, amount, odor, presence of blood; Notify MD of abnormal findings and follow up as indicated .Offer extra fluids throughout the day .Problem .At Risk For Falls R/T [related to] impaired mobility .Interventions .Keep area free of obstructions to reduce the risk of falls or injury .Place call bell/light within easy reach .Provide reminders to use ambulation and transfer assist devices .Remind [Resident #7] to call for assistance before moving from bed-to-chair and from chair-to-bed .[[DATE]] At risk for complications related to [Resident #7] has diagnosis of diabetes Interventions .Administer medications as ordered and monitor for adverse side effects .Diet as ordered .Labs as ordered, report abnormal findings to MD [Medical Doctor] with follow-up as indicated .Monitor blood sugar levels per MD order and notify MD of abnormal findings as indicated .Observe for excessive thirst, excessive eating, frequent voiding, change in level of consciousness, perspiration, fatigue, nausea/vomiting, tremors, provide interventions as per MD order; monitor for effectiveness and report to MD if ineffective .Monitor for change in level of consciousness .Problem .At risk for complications of renal failure .Observe for edema, warmth and color of extremities, shortness of breath, and vital signs daily. Report abnormalities to MD with follow-up as indicated .Problem .At risk for infection R/T indwelling catheter. [Resident #7] needs catheter related to bladder-neck obstruction .Interventions .Clean around catheter with soap and water .Keep tubing below level of bladder and free of kinks or twists .Report any sign of infection (temperature, pain, urine that looks cloudy, dark, or with blood) . [[DATE]] Footwear will fit properly and have non-skid soles . Review of the facility document (Incident Report) dated [DATE], LPN G documented, Observed resident on the floor between both beds and his head under his bed. Resident did not have non-skid footwear on. While assisting resident up from the floor, raised his head and bumped it on the bottom of the bed. Resident mental status was at his normal. Resident was resting comfortably in bed when writer [LPN G] exited room. Continued review revealed a bruise to Resident #7's forehead. Review of the facility Clinical Note dated [DATE] but entered on [DATE], revealed LPN G documented, Resident was found on the floor with his head under the bed. Staff was assisting to get resident off the floor. While sliding the resident to get his head clear of t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, (Named Glucometer- a device used to check blood sugar levels with the use of a blood sample) User's Guide review, Guidelines for General Use of (Named germicidal cloth) wipes used by the facility review, DME (Durable Medical Equipment) supplier recommendation letter review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not cleaned and disinfected with facility required cleansing wipes to prevent cross-contamination of bloodborne pathogens for 2 of 11 (Residents #17 and Resident #18) sampled residents reviewed for blood glucose monitoring. Observations on 4/2/2024 revealed Licensed Practical Nurse (LPN) P failed to clean and disinfect the multi-use blood glucose meter before and after use on each resident in accordance with recommendations and facility policy, failed to perform hand hygiene, and failed to don gloves when performing point of care testing for Resident #18. Observations on 4/3/2024 revealed LPN E, LPN O, and Registered Nurse (RN) A failed to clean and disinfect the blood glucose meters that are used for multiple residents, in accordance with manufacturer recommendations and facility policy. The facility's failure to ensure staff properly disinfected the blood glucose meter that was used for multiple residents, in accordance with recommendations and the facility ' s policy, placed the residents at risk for potential contamination with bloodborne pathogens and the likelihood to cause serious injury, harm, impairment, and/or death resulted in Immediate Jeopardy. The facility had 7 residents receiving blood glucose monitoring with a multi-use blood glucose meter and the facility's failure had the potential to affect the 11 residents receiving blood glucose monitoring with a multi-use blood glucose meter. 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 appropriately clean and disinfect a multi-use blood glucose meter during medication administration. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy for F-880 on 4/4/2024 at 4:45 PM, in the Director of Nursing (DON)'s office. The facility was cited Immediate Jeopardy at F-880 at a scope/severity of K. The Immediate Jeopardy began on 4/2/2024 and is ongoing. A partial extended survey was conducted 4/4/2024 to 4/11/2024. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility's policy titled, Cleaning and Disinfecting Glucometer, revised 10/9/2023, revealed, .Policy: To minimize the risk of transmitting blood-borne diseases .device shall be cleaned and disinfected after each use .Protocol: The facility shall ensure blood glucometers are cleaned and disinfected after each use and according to manufacturer's instructions for multiple-resident use . Review of the (Named Glucometer) User's Guide dated 2/10/2020 revealed, .Healthcare Professional Information .Healthcare professionals performing blood glucose (BG) test with this system on multiple patients must always wear gloves .Important Safety Instructions .Adhere to standard precautions when handling or using this device. All parts of the glucose monitoring system should be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professionals .The meter should be disinfected after use on each patient .This blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed .Cleaning Instructions: Cleaning is the removal of visible dirt and debris .The cleaning process does not reduce the risk for transmission of infectious diseases .wash hands with soap and water .put on single-use [disposable] medical protective gloves .Wipe the glucometer thoroughly including the front, back and sides .Remove gloves .Disinfection Instruction: The meter must be disinfected between patient uses .Before disinfecting clean the meter .Wash hands with soap and water and put on single-use medical protective gloves .Wipe the glucose meter thoroughly including the front, back and sides .allow to remain wet for two minutes .take off gloves and wash hands .before proceeding to the next patient . Review of the General Guidelines For Use, dated 2021, revealed, .[Named germicidal wipes] .If present, use a wipe to remove visible soil prior to disinfecting .Unfold a clean wipe and thoroughly wet surface .Allow treated surface to remain wet for two (2) minutes. Let air dry . Review of a letter of recommendation from DME supplier dated 4/4/2022, revealed, .As referenced in the manual for the [Named glucometer], the meter may be cleaned and disinfected using [Named disinfecting wipes] or any other EPA [Environmental Protection Agency]-registered disinfecting wipe .important note to consider when using an alternative EPA-registered disinfecting wipe is that the [Named glucometer] has been shown safe in disinfecting via [by way of] testing validation with [Named disinfecting wipes], but additional testing has not been conducted on other EPA-registered wipes .For this reason, customers are encouraged to follow the disinfectant's instructions for use carefully to ensure disinfection . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was admitted to the facility on [DATE]. Resident #17 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Resident #17's active diagnoses included Diabetes Mellitus. Resident #17 received insulin 6 of 7 days of the look-back period. Review of the medical record revealed Resident #17 received Lispro [short acting] insulin before meals per sliding scale [based on pre-defined BG ranges requiring a finger stick blood test]. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Acute and Chronic Respiratory Failure, Acute on Chronic Diastolic (Congestive) Heart Failure, and Type 1 Diabetes Mellitus. Continued review revealed Resident #18 had a diagnosis of Methicillin Resistant Staphylococcus Aureus infection (MRSA). Review of the Quarterly MDS assessment dated [DATE] revealed Resident #18 had a BIMS score of 15, which indicated no cognitive impairment. Active Diagnoses included Diabetes Mellitus with hyperglycemia. Review of the Physician Order Sheet dated March 2024 revealed Resident #18 had orders which included .11/21/2023 .lispro [short acting insulin] .administer SQ [subcutaneous-under the skin] ACHS [before meals and at bedtime] per sliding scale. Review of the Medication Administration Record (MAR) dated 4/2/2024 revealed Resident #18 received insulin ACHS per sliding scale. Documentation on Resident #18's MAR revealed BG levels were checked at 8:00 AM and 12:00 PM, on the day of the surveyor's onsite observation. Review of the undated Care Plan Report for Resident #18 revealed, .At Risk for Infection .assessed for signs and symptoms of infection .STATUS: Active .GOAL DATE: 5/29/2024 .Metabolic-Diabetes Status .Administer a finger stick blood test per order .STATUS: Active . Observation and interview on the 200 Hall on 4/2/2024 at 11:24 AM, revealed Licensed Practical Nurse (LPN) P walked out of the dining room holding a used blood glucose test strip wrapped in a blood soiled alcohol pad and used lancet (device used to prick the finger to obtain a blood sample) in her right hand. LPN P carried a glucometer in her left hand. LPN P did not have gloves on either hand. LPN P placed the used glucometer on top of the medication cart and threw away the BG test strip and alcohol pad in the trash and the lancet in the biohazard container. LPN P documented Resident #18's BG on the Electronic Health Record (EHR) and picked up the dirty glucometer and placed it back in the medication cart. When asked if LPN P completed a BG fingerstick for Resident #18 in the dining room without donning gloves, LPN P replied, Yes. When asked if not following infection control protocol during a BG fingerstick was safe, LPN P replied, No. LPN P confirmed the glucometer was used for multiple residents' point of care finger sticks. Observation and interview on 200 Hall on 4/2/2024 at 11:34 AM, revealed, LPN P took a BG test strip, an alcohol pad, a lancet, and the dirty glucometer out of the cart and placed the test strip, alcohol pad, and the lancet in a plastic cup. LPN P took a pair of gloves, the dirty glucometer, and plastic cup into Resident #17's room. LPN P informed Resident #17 she was going to perform a fingerstick for a BG level before lunch. LPN P placed the dirty glucometer on the bedside table and inserted the BG test strip into it, then proceeded to wipe Resident #17's finger off with the alcohol pad and started to place the lancet in position to prick the resident's finger. The surveyor requested LPN P stop and step into the hallway for a private conversation. The surveyor advised LPN to not continue with the BG fingerstick without properly disinfecting the dirty glucometer. LPN P agreed and walked to the medication cart and placed the glucometer on top of the cart. LPN P used an alcohol pad and wiped the glucometer off then placed it back on top of the medication cart. LPN P was asked if the alcohol pad was approved to disinfect the glucometer with and she replied, I think so. LPN P was asked how long the surface of the glucometer had to remain wet for disinfection, she replied, 30 seconds. The surveyor asked LPN P to read the information for properly disinfecting the glucometer before using the glucometer on any other residents. LPN P locked the medication cart and walked away. During an interview in the DON's office on 4/2/2024 at 11:41 AM, the DON stated she expected the multi-use glucometers to be cleaned and disinfected after every finger stick BG test. The DON stated the nurse should use the (Named germicidal cleaning cloth). The DON was made aware of LPN P's deficient practice during observation. The DON stated she would go and correct LPN P right away. The DON stated LPN P was an agency nurse and asked the surveyor if she wanted to follow a facility nurse for a glucometer BG finger stick observation. Observation and interview on 4/3/2024 at 12:05 PM, revealed LPN E stated she had completed the afternoon BG finger sticks. LPN E was asked to demonstrate cleaning and disinfection of the multi-use glucometer on the 300 Hall medication cart. LPN E provided a verbal step by step tutorial which included using one alcohol pad to clean and disinfect the glucometer. When asked what the required length of time the glucometer had to stay wet, LPN E replied, 30 seconds to 1 minute. When asked if the alcohol wipe was an approved wipe for disinfecting the glucometer, LPN E replied, Yes, I think so. LPN E asked the surveyor if the alcohol wipe was okay to use on the glucometer. The surveyor replied, The appropriate method and supplies would depend on the manufacturer's recommendations and the facility policy. Observation and interview on 4/3/2024 at 12:14 PM, revealed LPN O performed a BG finger stick in the dining room, placed the used test strip, alcohol pad, and lancet in a plastic cup and walked back down the hall to the 200 Hall medication cart wearing the gloves she wore during the fingerstick procedure. Without changing gloves, LPN O took a germicidal cloth out of the medication cart, wiped the glucometer off, then placed the glucometer in a plastic cup to dry. The surveyor asked LPN O how long the glucometer was required to stay wet for disinfection, LPN O replied, 5 minutes. LPN O was asked if the glucometer should be cleaned off with a germicidal cloth, then disinfected with a second cloth, she replied, No. Observation and interview on 4/3/2024 1:16 PM, revealed Registered Nurse (RN) A was asked to demonstrate how to clean and disinfect the multi-use glucometer on the 400 Hall medication cart. RN A took the glucometer out of the cart along with a barrier paper and a germicidal cloth wipe. RN A gave a verbal tutorial which did not include the use of 1 germicidal wipe to clean the glucometer and then 1 germicidal wipe to disinfect the glucometer. RN A was asked how long the surface of the glucometer was required to remain wet for disinfection, she replied. Maybe 1 minute until it is dry. It doesn't take long. Observation of the nurse station and interview with the Administrator in Training (AIT) on 4/3/2024 at 1:19 PM, revealed a laminated copy of the General Guidelines For Use noted above was posted at the nurse station with the following handwritten notes printed on the document.*FOR MULTI-RESIDENT/SHARED EQUIPMENT* .Wet for 2 minutes! .Use between Residents . The surveyor requested a copy of the posted guidelines and stated the 3 nurses that were observed and interviewed had not correctly demonstrated the use of the germicidal cloth to clean and disinfect the multi-use glucometers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation review, and interview the facility failed to ensure 1 of 38 residents (Resident #33) was free from abuse placing the resident in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) when Resident #33 sustained a left humerus (long bone that extends from the shoulder to the elbow) fracture during an attempted transfer, without a mechanical lift, on 10/22/2019. The facility failed to ensure Resident #33 was free from Psychosocial harm as evidenced by Resident #33 had increased anxiousness, cried when she talked about the incident that occurred on 10/22/2019, was fearful of Certified Nursing Assistant (CNA) #1, and received psychosocial therapy and medication changes. The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate Jeopardy (IJ) on 3/3/2020 at 7:31 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. The facility's noncompliance at F-600 continues a 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: Review of the facility policy, Abuse Prohibition Plan, revised 5/2019, revealed, .The facility has a zero-tolerance policy for abuse. Verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion is prohibited. The resident will not be subjected to mistreatment, neglect, exploitation or misappropriation of property. The facility will attempt to identify and will investigate any reported violation or allegation of abuse .Willful means the individual deliberately, not that the individual must have intended to, inflict injury or harm . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis, Acute and Chronic Respiratory Failure, Polyneuropathy, and Fibromyalgia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #33 was cognitively intact. Further review revealed the resident required 2 person total assist with transfers. Review of the Comprehensive Care Plan dated 9/25/2019, showed, .Transfers-[Mechanical] Lift Assist . Review of Resident #33's Physician Visit note dated 10/23/2019 showed Resident #33 was having left shoulder pain and an X-ray was ordered. Review of Resident #33's Mobile Radiology report dated 10/23/2019, showed, .Impacted nondisplaced left humeral fracture .NP [Nurse Practitioner] made aware . Review of Resident #33's Physician Order Sheet dated September 13, 2019 showed, .Fentanyl 25mcg [micrograms]/hr [hour] transdermal patch 1 patch transdermal every 72 hrs for pain .9/18/2019 Oxycodone 10 mg [milligram] every 6 hrs for pain . Review of Resident #33's physician order dated 10/23/2020 showed, .Biofreeze [topical pain medication]4% topical gel to left shoulder prn [as needed] for pain . Review of Resident #33's Physician Visit note dated 10/25/2019, showed Resident #33 had a contusion to her left arm and the X-ray showed fracture. Further review showed, .Send to Ortho [Orthopedic] Urgent Care for further evaluation of L [Left] Shoulder pain to eval [evaluation] and fx[fracture]/treatment . Review of Resident #33's Orthopedic Consult Note [from the Orthopedic Urgent Care Center] dated 10/25/2020 showed, .10/22/2019 someone was attempting to transfer her and squeezed her too tightly. An xray performed at the facility reported a fracture. She has pain from her left shoulder radiating down into the left forearm. The pain has been worsening and is exacerbated by lifting, moving and exertion. There is associated bruising as well. Plan: Sling, Send to ER [Emergency Room], discussed that the xrays to reveal evidence of a fracture at the humerus . Review of Resident #33's ER Note dated 10/25/2019 showed, .a tech was transferring her from her wheelchair to a bed 2 days ago. He tried to lift her under her arms. When this occurred she felt a pop in her left shoulder. She has had pain ever since then. It is sharp and throbbing, 10 out of 10 in severity, it is worse with movement. She has noticed some increased bruising, she denies any other injuries . Review of Resident #33's ER Radiology report of the left humerus dated 10/25/2019, showed, .Comminuted fractures proximal humerus . Review of Resident #33's Clinical Notes Report dated 10/25/2019, showed, .Resident returned from ER by ambulance/stretcher. Awake alert and oriented. Diagnosis: Unspecified fracture of upper end of left humerus, initial encounter for closed fracture. Sling to left arm in place . Review of Resident #33's Psychotherapy notes dated 10/28/2019, 11/4/2019, 11/18/2019, and 12/2/2019, showed she was receiving psychotherapy related to her increased anxieties, frustration, and concern over the incident that occurred 10/22/2019. Review of Resident #33's Physician Orders dated 11/11/2019, showed a new medication order as follows: .Lorazepam [medication for anxiety] 1 milligram [mg] 1 PO [by mouth] BID [twice daily] PRN [as needed] in adjunction to [in addition to] scheduled dose . Continued review indicated she received 16 doses of the PRN Lorazepam from 11/11/2019 through 12/4/2019 following the incident. Review of the facility's documentation titled, Activity Calendar, dated October 2019, showed, Bingo scheduled on 10/22/2019 at 3:00 PM. During an interview on 3/2/2020 at 9:05 AM, Resident #33 stated about 4 months ago I was lying in bed when [named CNA #1] came in and was going to get me up for bingo. He didn't have a lift and I told him 'No!' I'm not going without the lift. I asked him to please get the lift, but he wouldn't go get it. During further interview revealed CNA #1 proceeded to lift the resident by her arms to transfer her to a chair from the bed. Resident #33 stated, When he pulled me up, I heard a loud pop and I started having pain in my left arm. I told him it hurt, but he just said, 'You didn't break your arm!' Then he picked up my arm and moved it around and said, 'see' It really hurt when he did that. During further interview revealed Resident #33 informed the Director of Nursing (DON) the next day that CNA #1 did not use the lift when he attempted to transfer her and she insisted for him to use the lift, but he didn't and when he pulled her up by her arms she heard a pop and began to have pain in her left arm. Review of the medical record showed Resident #13 was admitted to the facility on [DATE] with diagnoses which included Atrial Fibrillation, Chronic Pain Syndrome, and Difficulty in Walking. Review of Significant Change MDS dated [DATE], showed, Resident #13 was cognitively intact. During an interview on 3/2/2020 at 3:30 PM with Resident #13, Resident #33's roommate, she stated she had been Resident #33's roommate since 9/2019. Further interview she stated she was lying in her bed when CNA #1 attempted to transfer Resident #33. She stated, I heard [named Resident #33] tell [named CNA #1] 'No, No' but [named CNA #1] continued to get [named Resident #33] up. During further interview she stated they usually use a mechanical lift to get Resident #33 out of bed, but CNA #1 did not have one and additional staff assistance. During a telephone Interview on 3/3/2020 at 1:13 PM, Resident #33's family member stated Resident #33 told her CNA #1 attempted to get her up for Bingo without assistance. Further interview she stated he didn't use the lift and she thought her arm was broke during the attempted transfer. During further interview revealed Resident #33 told her CNA #1 took her arm and moved it up and down after she told him she heard a pop and she stated she had pain in her left arm. Further interview she stated, [named Resident #33] cries every time she talks about the situation with her arm. During an interview on 3/4/2020 at 2:00 PM with the Activities Director confirmed Resident #33 would attend Bingo 2 days a week, on Tuesday and Thursday, but did not attend on Tuesday, 10/22/2019. During an interview on 3/4/2020 at 4:19 PM with Nurse Practitioner #1 she stated the facility told her this injury was chronic. However on her 10/25/2019's assessment she found fresh bruising and contusions on her left arm. During further interview she stated when she talked to Resident #33's family member, she said Resident #33 had a fracture to her neck a couple of years ago, not her arm. That's when I ordered for [named Resident #33] to be sent to Orthopedic Urgent care for further evaluation of left shoulder pain and fracture. During an interview on 3/4/2020 at 4:30 PM with Licensed Practical Nurse #2 stated Resident #33 reported to her that her arm was hurting after CNA #1 had lifted her. During further interview revealed Resident #33 reported CNA #1 bear hugged her and she felt pain in her arm and the pain did not go away. During further interview she stated, I re-educated [named CNA #1] to use 2 person assist and mechanical lift with [named Resident #33]. During further interview she stated she reported the incident to her supervisor and was informed they already knew about it. During an interview on 3/3/2020 at 4:51 PM with the Director of Nursing (DON) confirmed Resident #33 was a 2 person assist transfer with a mechanical lift, since admission. Further interview she stated Resident #33 felt CNA #1 was a little rough during the transfer when her arm was broken. During further interview she stated, If a resident reported a CNA was rough, I would report it to the administrator, go to the CNA, consider the resident's ability as a historian, would take all factors into consideration and investigate it to rule it out as abuse. During further interview the DON confirmed she was notified by Resident #33 on 10/25/2019 that CNA #1 was rough with her during the attempted transfer on 10/22/2019. During an interview on 3/6/2020 at 5:16 PM with the Administrator confirmed the incident involving Resident #33 was reported to her by the DON in October 2019 but was not considered abuse at that time. During an interview on 3/3/2020 at 12:25 PM Resident #33 became tearful and began to cry, when she recalled the incident involving CNA #1 in October [2019], and she continued to cry through the remainder of the interview. During an interview on 3/3/2020 at 4:45 PM with Resident #33 in her room she stated, Every time I see [named CNA #1], I cry because there were a lot of things I could do before this happened and now I can't do them, now I have to ask for help to even pull myself up in bed. Resident #33 began to cry again and stated, I am afraid of [named CNA #1]. During a telephone interview on 3/4/2020 at 4:00 PM with the Psychologist, he confirmed, I see [named Resident #33] once a week for anxiety and the injury had caused her pain and discomfort. Further interview he stated Resident #33 was frustrated and anxious about her arm and focused on the incident with her arm every week for 4 weeks right after the incident happened. An Immediate Action Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/6/2020 at 2:55 PM and corrective actions were validated on site by the surveyors on 3/6/2020. The Immediate Action Removal Plan was verified by the surveyors on 3/6/2020 by: 1. The surveyors verified through review of CNA #1's employee file, CNA #1 was placed on suspension pending completion of investigation on 3/6/2020 and the facility substantiated the allegation of abuse. 2. The surveyors verified the facility's policy to report and investigate any events through review of staff education. Staff interviews on abuse allegation reporting and interview with the Administrator of events that occurred. Review of events reported on 3/4/2020. 3. The surveyors verified the facility's Incident Reporting System intake information regarding Resident #33 and CNA #1 was reported to the state agency on 3/4/2020. 4. The surveyors verified Resident #33 was seen on 3/4/2020 by the Psychiatric Nurse Practitioner through review of the Psychiatric Nurse Practitioner consult notes dated 3/4/2020 and by interview on 3/4/2020. 5. The surveyors verified the facility interviewed Resident #33 and her family member obtaining statements. 6. The surveyors verified an abuse investigation was conducted on 3/4/2020. The surveyors verified interviews with interviewable residents and skin assessments were conducted on non interviewable residents. 7. The surveyors reviewed the facility's abuse policy and verified there were no changes made to the policy. 8. The surveyors verified staff education of abuse to include the definition and examples of willful abuse. The facility's noncompliance at F-600 continues at a scope and severity of D for the monitoring of 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 facility policy review, medical record review, and interview the facility failed to report an abuse allegation to the State Survey Agency for 1 of 38 residents (Resident #33) reviewed or abuse. The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate Jeopardy (IJ) on 3/3/2020 at 7:31 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. The facility's noncompliance at F-609 continues a 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: Review of the facility policy titled, Abuse Prohibition Plan, revised 5/2019, showed, .It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Regulations and Law .All alleged violations are reported immediately but not later than 2 hours after the allegation is made, if the events that caused the allegations involve or result in serious bodily injury . Review of the medical record showed Resident #33 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis, Acute and Chronic Respiratory Failure, Polyneuropathy, and Fibromyalgia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact. Further review revealed the resident required 2 person total assist transfers. Review of the Comprehensive Care plan dated 9/25/2019, showed, .Transfers-[mechanical] lift assist . Review of the Radiology report dated 10/23/2019, showed, .Impacted nondisplaced left humeral fracture . During an interview on 3/2/2020 at 9:05 AM, Resident #33 stated about 4 months ago I was lying in bed when [named CNA #1] came in and was going to get me up for bingo. He didn't have a lift and I told him 'No!' I'm not going without the lift. I asked him to please get the lift, but he wouldn't go get it. During further interview she stated CNA #1 proceeded to lift the resident by her arms to transfer her to a chair from the bed. Resident #33 stated, When he pulled me up, I heard a loud pop and I started having pain in my left arm. I told him it hurt, but he just said, 'You didn't break your arm!' Then he picked up my arm and moved it around and said, 'see' It really hurt when he did that. During further interview she stated she informed the Director of Nursing (DON) the next day that CNA #1 did not use the lift when he attempted to transfer her and she insisted for him to use the lift, but he didn't and when he pulled her up by her arms she heard a pop and began to have pain in her left arm. During a telephone Interview on 3/3/2020 at 1:13 PM, Resident #33's family member stated Resident #33 told her CNA #1 attempted to get her up for Bingo without assistance. During further interview she stated he didn't use the lift and she thought her arm was broke during the attempted transfer. During further interview she stated Resident #33 told her CNA #1 took her arm and moved it up and down after she told him she heard a pop and she stated she had pain in her left arm. During further interview she stated, [named Resident #33] cries every time she talks about the situation with her arm. During an interview on 3/4/2020 at 4:51 PM with the Director of Nursing (DON) she stated she had 24 hours to report an abuse allegation to the state survey agency after she investigated and determined it was qualified as abuse. Further interview she stated, I don't know what the policy is. During an interview on 3/6/2020 at 5:16 PM with the Administrator she stated the incident involving Resident #33 and CNA #1 on 10/22/2019 was not reported to the state survey agency. An Immediate Action Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/6/2020 at 2:55 PM and corrective actions were validated on site by the surveyors on 3/6/2020. The Immediate Action Removal Plan was verified by the surveyors on 3/6/2020 by: 1. The surveyors verified the facility's policy to report and investigate any events through review of staff education. Staff interviews on abuse allegation reporting and interview with the Administrator of events that occurred. Review of events reported on 3/4/2020. 2. The surveyors verified the facility's Incident Reporting System intake information regarding Resident #33 and CNA #1 was reported to the state agency on 3/4/2020. 3. The surveyors reviewed the facility's abuse policy and verified there were no changes made to the policy. The facility's noncompliance at F-609 continues at a scope and severity of D for the monitoring of 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 facility policy review, medical record review, and interview, the facility failed to investigate an abuse allegation for 1 of 38 residents (Resident #33) reviewed for abuse. The facility was cited Immediate Jeopardy at F-610. The facility was cited at F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. The facility's noncompliance at F-610 continues a 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: Review of the facility policy, Abuse Prohibition Plan, revised 5/2019, showed, .The policy of this facility is that reports of abuse, neglect, exploitation, misappropriation of resident's property and injuries of unknown origin are promptly and thoroughly investigated. The Administrator will investigate or assign the investigation to designated facility personnel such as the Director of Nursing [DON]. The investigation will begin immediately . Review of the medical record showed Resident #33 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis, Acute and Chronic Respiratory Failure, Polyneuropathy, and Fibromyalgia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #33 was cognitively intact. Further review revealed the resident required 2 person total assist with transfers. Review of the Radiology report dated 10/23/2019, showed, .Impacted nondisplaced left humeral [long bone that extends from the elbow to the shoulder] fracture . During an interview on 3/2/2020 at 9:05 AM, Resident #33 stated about 4 months ago I was lying in bed when [named CNA #1] came in and was going to get me up for bingo. He didn't have a lift and I told him 'No!' I'm not going without the lift. I asked him to please get the lift, but he wouldn't go get it. Further interview revealed CNA #1 proceeded to lift the resident by her arms to transfer her to a chair from the bed. Resident #33 stated, When he pulled me up, I heard a loud pop and I started having pain in my left arm. I told him it hurt, but he just said, 'You didn't break your arm!' Then he picked up my arm and moved it around and said, 'see' It really hurt when he did that. Further interview revealed Resident #33 informed the Director of Nursing (DON) the next day that CNA #1 did not use the lift when he attempted to transfer her and she insisted for him to use the lift, but he didn't and when he pulled her up by her arms she heard a pop and began to have pain in her left arm. During a telephone Interview on 3/3/2020 at 1:13 PM, Resident #33's family member stated Resident #33 told her CNA #1 attempted to get her up for Bingo without assistance. Further interview she stated he didn't use the lift and she thought her arm was broke during the attempted transfer. Further interview revealed Resident #33 told her CNA #1 took her arm and moved it up and down after she told him she heard a pop and she stated she had pain in her left arm. Further interview she stated, [named Resident #33] cries every time she talks about the situation with her arm. During an interview on 3/4/2020 at 4:51 PM with the Director of Nursing (DON) she stated an investigation involving Resident #33 on 10/22/2019 was not done. During an interview on 3/6/2020 at 5:16 PM with the Administrator confirmed the incident on 10/22/2019 involving Resident #33 was not investigated. An Immediate Action Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/6/2020 at 2:55 PM and corrective actions were validated on site by the surveyors on 3/6/2020. The Immediate Action Removal Plan was verified by the surveyors on 3/6/2020 by: The surveyors verified an abuse investigation was conducted on 3/4/2020. The surveyors verified interviews with interviewable residents and skin assessments were conducted on non interviewable residents. 1. The surveyors reviewed the facility's abuse policy and verified there were no changes made to the policy. 2. The surveyors verified through review of facility documentation dated 3/3/2020, 3/4/2020, and 3/5/2020 QAPI meetings were held regarding Residents #33. 3. The surveyors verified through review education was provided to staff concerning the Abuse Prohibition Plan/Policy. The facility's noncompliance at F-610 continues at a scope and severity of D for the monitoring of 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 facility policy review, medical record review and interview, the facility failed to develop and implement a person centered care plan with interventions related to blood sugar monitoring and tube feeding residual to prevent hypoglycemia for 1 of 38 residents (Resident #77) reviewed for implementation of care plans placing Resident #77 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) when Resident #77 became unresponsive, hypoglycemic, and required emergent hospitalization. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 3/5/2020 at 3:50 PM in the Administrators office. The facility was cited Immediate Jeopardy at F-656. The facility was cited F-656 at a scope and severity Level of J. The Immediate Jeopardy was effective from 10/2/2019 through 3/5/2020. The Immediate Jeopardy was removed onsite and was effective 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. The findings include: Review of the facility policy, Comprehensive Care Plan, revised 12/2019, showed .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team or in accordance with the resident's preferences and potential for discharge, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . Review of the medical record showed Resident #77 was admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy, Dysphagia, Malnutrition, and Constipation. Review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #77 was severely cognitively impaired. Continued review revealed Resident #77 required tube feeding for nutrition. Review of the hospital History of Present Illness dated 1/23/2020, showed .Today, the patient was altered and less interactive, and EMS [Emergency Medical Services] was called. EMS said they got a blood glucose of 12 at his home. He was brought to the emergency room where D5 was started and the patient's mental status recovered quickly to baseline .the patient's core temperature was also found to be 91 degrees . Review of the Comprehensive Care Plan dated 2/14/2020 showed Resident #77 had no care plan for hypoglycemia or for monitoring for signs and symptoms of hypoglycemia; length of time to hold tube feeding when residual was too high; and appropriate physician notification. Further review showed no new interventions were placed for monitoring signs and symptoms of hypoglycemia for Resident #77 after his return to the facility after his hospitalization on 2/29/2020. Review of the Nursing Notes dated 2/3/2020, showed, Resident #77 was receiving Jevity 1.5 at 40 ml/hr [milliliters per hour]. Review of the progress note dated 2/23/2020, showed, approximately 1435 [2:35 PM] resident became non responsive after having a second BM [bowel movement]. Resident had been disconnected from tube feeding after checking residual and having > [greater than] 110 ml residual [replaced] x's 2. NP [Nurse Practitioner] notified and gave orders to send resident out for evaluation and treatment. Medical record review of the vital signs dated for 2/23/2020, revealed no documented blood sugar prior to transfer to the hospital by the facility. Review of the Emergency Patient Record dated 2/23/2020, showed .Per EMS [Emergency Medical Service] The initial call was for an unresponsive PT [patient]. Nurses at this facility saw that he went unresponsive 40 minutes. Our glucometer read L0 for us. We gave him D10 [Dextrose 10%] infusion. He's had a low heart rate with 'us' and weak carotid pulses .Intraosseous special catheter [surgical steel IV (intravenous) catheter inserted directly into a patient's long bone in an emergency life threatening situation to provide rapid infusion of life saving medications/solutions] left tibia inserted at 1536 [3:36 PM] . Review of [Named Hospital] History of Present Illness dated 2/24/2020, showed, .TF had reportedly been temporarily stopped D/T [due to] high gastric residuals/apparent constipation. Ultimately staff found resident unresponsive and checked BS [blood sugar] which read low. He was also hypothermic -T-max 89 F [maximum temperature 89 degrees Fahrenheit]. Had significant BM today however TF was never resumed . Review of Emergency Provider Report dated 2/24/2020 showed, .1. Hypoglycemia 2. Hypothermia 3. Severe Protein-Calorie Malnutrition .Apparent difficulty tolerating TF which was ultimately held .Received multiple amps [unit dose vials] of D50 [dextrose 50 % (used in an emergency to treat hypoglycemia)] and started D5 drip [dextrose 5 % (IV infusion to sustain normal blood glucose level)] .Emergency warming blanket .Patient critically ill due to Hypothermia/Hypoglycemia . Review of Resident #77's Patient Medication Profile dated 2/29/2020, revealed, .Glucagon emergency kit 1 mg as needed for hypoglycemia . During an interview on 3/5/2020 at 11:12 AM with Licensed Practical Nurse (LPN) #4, confirmed Resident #77 had a residual of 200 mL at 12:00 PM on 2/23/2020 and she did not call the medical doctor or nurse practitioner to report the high residual. Continued interview LPN #4 stated when Resident #77 became unresponsive she did not think to check his blood sugar. During an interview on 3/5/2020 at 3:50 PM with the Director of Nursing (DON) she confirmed Resident #77 had a history of malnutrition and hypoglycemia. The DON also confirmed, the resident's tube feeding was held due to high residual, and the resident's blood glucose level should have been monitored. During a telephone interview with the Medical Director on 3/5/2020 at 5:19 PM, confirmed the paramedics checked Resident #77's blood sugar when they arrived on 2/23/2020. He stated, They checked it for us. During continued interview he confirmed the blood sugar dropped from the resident not receiving his tube feeding. An Immediate Action Removal Plan, which removed the Immediacy of the Jeopardy, was received on 3/6/2020 at 3:50 PM and corrective actions were validated on site by the surveyor on 3/6/2020. The surveyors verified the Removal Plan by: 1). Verified the care plans with interventions were in place for 17 residents at risk for developing low blood sugar. 2). Reviewed and validated staff education on recognizing signs and symptoms of low blood sugar. 3). Interviewed staff for returned knowledge of signs and symptoms of low blood sugar. The facility's noncompliance at F-656 continues at a scope and severity level 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 facility policy review, medical record review, and interview the facility failed to ensure a resident's Advance Directive preference was accurately reflected in the medical record for 2 of 91 residents (Resident #49 and #6) reviewed for Advance Directives, placing the residents in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The facility's failure to follow their procedures for processing Advance Directives, had the potential for staff not intervening with life saving measures, (CPR [Cardiopulmonary Resuscitation]) for Resident #49 when Resident #49 wanted CPR and intervening with life saving measures (CPR) for Resident #6, when Resident #6 wanted to be a DNR [Do Not Resuscitate]. The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate jeopardy on [DATE] at 9:20 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-678. The facility was cited at F-678 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from [DATE] through [DATE]. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 2:55 PM. The corrective actions were validated onsite by the surveyors on [DATE]. The facility's noncompliance at F-678 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: Review of the facility policy, Advance Directives, revised on 6/2018, showed, .The facility representative will assist the resident as needed to communicate any changes in the resident's Advance Directive to the physician and/or responsible party .The facility representative will discuss and provide written information explaining the Advance Directive Program, upon admission to the facility .The facility representative will periodically discuss the resident's Advance Directive to ensure the resident's wishes concerning end of life treatment have not changed . Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes with Nephropathy, Hyperlipidemia, Muscle Weakness, Peripheral Vascular Disease, and Vitamin B Deficiency. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #49 was cognitively intact. Review of the Physician Orders for Scope of Treatment (POST) for Resident #49 dated [DATE] located in the POST Form Book at the Nurses station showed the resident's code status was a DNR (Do not resuscitate). Review of Resident #49's EMR [Electronic Medical Record] showed the Code Status Ribbon [which displayed for quick reference at the top of the resident's EMR] was blank, which indicated the resident's code status was Full Code [Cardiopulmonary Resuscitation (CPR)]. Review of Resident #49's Comprehensive Care Plan dated [DATE], showed a Code Status of Full Code. Review of Resident #49's Face Sheet, the Advance Directives section showed the directive was listed as Full Code. During an interview on [DATE] at 6:44 PM, with Licensed Practical Nurse (LPN) #6, who was assigned to Resident #49, she stated she would refer to the POST Form Book located at the nurses' station to determine a resident's code status. During an interview on [DATE] at 6:45 PM, LPN #7 stated she would refer the POST Form Book located at the nurses' station to determine for a resident's code status. During an interview on [DATE] at 7:40 PM, Resident #49 stated he wanted CPR if his heart stopped and his decision had not changed since admission to the facility. Review of the medical record showed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Acute on Chronic Respiratory Failure, Acute Diastolic Heart Failure, Exacerbation COPD (Chronic Obstructive Pulmonary Disease) with Chest Pain, and Hyperkalemia. Review of Resident #6's admission MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident #6's POST dated [DATE] located in the Post Form book showed the resident code status was Full Code. Review of Resident #6's EMR showed the Code Status Ribbon displayed an Advance Directive status of Do Not Resuscitate (DNR). Review of Resident #6's Face Sheet, the Advance Directives section for showed the directive was listed as Do Not Resuscitate. Review of Resident #6's Care Plan dated [DATE] showed Resident #6's code status was DNR. During an interview on [DATE] at 5:43 PM with LPN #1, who was assigned to Resident #6, she stated she would look on the computer for a resident's code status. Further interview she stated, The code status is in bold right next to the resident's name on the computer. She then demonstrated this on the computer screen by opening the resident's EMR and pointing to the ribbon at the top of the screen where DNR was highlighted in yellow. During an interview on [DATE] at 6:27 PM with the Administrator confirmed code status on the POST forms for Resident #49 and Resident #6 conflicted with their code statuses in the EMR. During an interview with Registered Nurse (RN) #1 on [DATE] at 6:40 PM, who was assigned to Resident #6, he stated, If a resident coded [if the resident had no pulse and was not breathing] I would go to the computer and check the resident's code status. Further interview RN #1 stated, I can tell if a resident has a Full Code or DNR status by looking at the Code Status ribbon at the top of their EMR, it is in bold letters on the face sheet. Further interview RN #1 demonstrated obtaining Resident #6's code status by opening his computer and pointing to the ribbon at the top of the screen of Resident #6's EMR where DNR was highlighted in yellow. During an interview on [DATE] at 7:10 PM, with Admissions Clerk stated she was responsible to get the POST form signed by the resident and the doctor. Further interview revealed once the POST form was signed by the resident and the doctor, she would enter the code status selection in the computer. Further interview she stated if the resident was a full code the ribbon was blank and if the resident was a DNR it would display in yellow on the ribbon in the Resident's EMR. Further interview she stated she placed the original POST form in the POST form book at the nurses station. During an interview on [DATE] at 8:19 PM, the Administrator confirmed staff were not to rely on the computer, but refer to the POST Form book located at the nurses' station for a resident's code status. Further interview confirmed the staff had not been educated on referring to the POST Form book, not the computer, for a resident's code status. During an interview on [DATE] at 10:00 AM, the Administrator stated Admissions personnel were responsible for getting a POST form signed by the resident and the doctor, putting the code status in the Resident's EMR, and putting the POST form in the book at the nurses' station. Further interview she stated the MDS nurse was to go to the POST book at the nurses' station to get a resident's code status for implementation of an Advance Directive care plan. Further interview confirmed this process did not happen for Residents #49 and #6. During an interview on [DATE] at 11:52 AM, MDS Coordinator confirmed she looked in the computer for the POST form she did not refer to the book at the nurses' station when implementing a resident's Advance Directive Care Plan. Further interview confirmed the code statuses on the POST forms for Resident #49 and #6 conflicted with the code status on their care plans. She stated, There was a process failure. An Immediate Action Removal Plan which removed the immediacy of the Jeopardy was received on [DATE] at 2:55 PM and corrective actions were validated on site by the surveyors on [DATE]. The Immediate Action Removal Plan was verified by the surveyors on [DATE] by: 1. The surveyors verified through review of Resident #49 and #6's POST forms were accurately reflected in the electronic medical record. 2. The surveyors verified through review of all facility residents' POST forms and the EMR to ensure accuracy. No other resident was found to have a POST that was inaccurately reflected on the EMR. 3. The surveyors verified through review of the education completed on [DATE] to all on duty and off duty licensed nurses and certified nursing assistants regarding verifying a code status through the Disaster Readiness/POST form book located at the nurses' station. 4. The surveyors verified through review of the education completed on [DATE] and interviews with Social Services, Admissions, and Nursing Management regarding the process of updating a POST form and ensuring it was reflected in the electronic medical record. 5. The surveyors verified through review of the education completed on [DATE] and interviews with the Administrator and the Director of Nursing regarding the new process for auditing the POST form through the Code Status audit tool on new admissions/readmission and residents with annual, quarterly, or significant change assessments and to ensure their advanced directive preferences were accurate and reflected in the electronic medical record. Once the POST form is completed it is communicated with the staff and placed in the Disaster Readiness/POST form book located at the nurses' station. 6. The surveyors verified through review of the education completed on [DATE] to on duty and off duty licensed nurses and certified nursing assistants regarding verifying a code status no longer be entered in the ribbon or in the resident care needs (Customized Approach to Care for an individual resident's needs for Certified Nursing Assistants) and to utilize the signed POST form in the Disaster Readiness/POST form book located at the nurses' station to advise of residents' advanced directive preferences. Alerts placed at the nurses' station as a reminder to no longer reference the ribbon and/or resident care needs. 7. The surveyors verified through interviews with various licensed nurses and certified nursing assistants regarding verifying a resident's code status and the location of the Disaster Readiness/POST form book. The facility's noncompliance at F-678 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to ensure the prescribed tube feeding formula was available for 1 of 5 residents (Resident #77) reviewed for tube feedings when Resident #77's prescribed tube feeding was substituted with a tube feeding formula that required an increase in rate to equal the nutritional value. The increase in the tube feeding rate resulted in Resident #77's increased residuals, tube feedings held frequently, and rate had to be decreased, so the resident was not provided the required caloric intake to sustain him in his severely malnourished state, which resulted in unresponsiveness, hypoglycemia, and emergent hospitalization. The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate Jeopardy (IJ) on 3/3/2020 at 7:31 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-693. The facility was cited at F-693 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. The facility's noncompliance at F-693 continues a 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: Medical record review revealed Resident #77 was admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy, Dysphagia, Hypoglycemia, Malnutrition, and Constipation. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was severely cognitively impaired. Continued review revealed Resident #77 required tube feeding for nutrition. Medical record review of the Care Plan dated 2/14/2020 revealed Resident #77 was at risk for compromised nutritional status related to tube feeding. Interventions included to calculate caloric needs/fluid requirements and adjust based on weight, tolerance, and hydration status. Continued interventions included check tube placement by aspiration before giving feeding/meds; elevate head of bed; monitor and document weight; and report diarrhea, decreased urine output, and dry mucous membranes to dietitian. Review of Physician's admission Orders dated 2/3/2020, showed, .Jevity 1.5 at 40 ml/hr [milliliters per hour] with 30 ml/hr water flush . Review of the Progress Notes dated 2/19/2020, showed, .Unit Manager advised, currently out of Jevity 1.5, using Jevity 1.2. Unit Manager working with supply company to get Jevity 1.5 as soon as possible . Review of a Dietary Note dated 2/19/2020, showed, .Unit Manager advised currently out of Jevity 1.5, using Jevity 1.2. Unit Manager working with supply company to get Jevity 1.5 as soon as possible. Currently running Jevity 1.2 @ 40 ml/hr x 24 hours with 30 ml water autoflush and 30 ml water flush before and after meds BID [twice daily] providing 1152 calories. Recommend increasing rate to 45 ml/hr x 24 hours. Increased rate along with flushes will provide 1286 calories. Once Jevity 1.5 available recommend going back to previous TF orders . Review of the Physician Orders dated 2/19/2020, showed, .Until Jevity 1.5 available, run Jevity 1.2 @ [at] 45 mL [milliliter] / hr [hour] x 24 hours w /[with] 30 mL H20 [water] autoflush. Once Jevity 1.5 available, return to previous TF [tube feeding] order of Jevity 1.5 @ 40 mL /hr x 24 w/ 30 mL H20 autoflush . Review of the medical record showed Resident #77 had significant amounts of residual with his feedings. The rate ordered was 40 ml/hr, but the rate was decreased as low as 25 ml/hr to compensate for the large residuals. The resident, with a history of malnutrition, failed to receive the necessary calories to sustain him and prevent low blood sugar as evidenced by hypoglycemia, unresponsiveness, and emergent hospitalization on 2/23/2020. Medical record review of the Treatment Record dated 3/3/2020 revealed .Jevity 1.5 @ [at] 40 mL [milliliter] / HR [hour] x 20 hours (off from 1 PM-5 PM) with 30 mL H20 [water] autoflush . Medical record review of Nursing Notes dated 3/4/2020 at 10:36 PM revealed .earlier today, approximately 1 pm [1:00 PM] resident's mother informed this nurse that the resident was having a birthday party around 3 pm [3:00 PM] and would like to turn his enteral feeding off around 3 pm instead of 1 pm. approximately 245 pm [2:45 PM] resident was disconnected from feeding, reported to oncoming nurse that feeding should be reconnected at approximately 7 pm [7:00 PM] instead of 5 pm [5:00 PM] . Observation on 3/4/2020 at 7:36 PM and 8:16 PM revealed Resident #77 was not receiving the tube feeding. Review of the medical record revealed no documentation the physician was notified for a one-time order to change the times the tube feeding was off. Interview with Licensed Practical Nurse (LPN) #6 on 3/4/2020 at 8:16 PM, revealed Resident #77's tube feeding had not been restarted since the beginning of the shift. Continued interview revealed Resident #77 did not receive tube feeding from 1:00 PM to 5:00 PM as ordered and LPN #6 stated she did not know why the tube feeding was not restarted at 5:00 PM as scheduled. Continued interview revealed LPN #6 stated she did not receive report from the previous nurse who cared for Resident #77. Interview with the Assistant Director of Nursing on 3/4/2020 at 8:25 PM, confirmed she was the nurse from 8:00 AM to 3:00 PM and another nurse took over care on that hall. Continued interview confirmed Resident #77's tube feeding was turned off at approximately 2:30 PM instead of 1:00 PM as ordered. During an interview with the Registered Dietician (RD) on 3/5/2020 at 10:19 AM, confirmed she was not notified until 2/19/2020 when the Unit Manger contacted her to inform her the facility supply of Jevity 1.5 was depleted. During further interview confirmed she expected the formula to be overnighted to the facility at the latest, however Resident #77 was still receiving Jevity 1.2 the day he was found unresponsive and was transferred to the hospital via ambulance. The Immediate Action Removal Plan was verified by the surveyors on 3/6/2020 by: 1. The surveyors verified through record review, observations and interviews Resident #77 received the correct tube feeding at the correct rate. 2. The surveyors verified through review of facility documentation dated 3/3/2020, 3/4/2020, and 3/5/2020 QAPI meetings were held regarding corrective action plans for Resident #77 to include auditing for correct feeding and rates as prescribed . 3. The surveyors verified through record review education provided to licensed nurses regarding administering enteral tube feedings per Physician orders. The facility's noncompliance at F-693 continues at a scope and severity of D for the monitoring of 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 facility policy review, facility documentation review, medical record review, and interview facility administration failed to recognize, report, and investigate an abuse allegation for 1 resident (Resident #33) reviewed for reporting an abuse allegation and failed to ensure the residents' Physician Orders for Scope of Treatment (POST) forms for 2 residents (Resident #6 and #49) reviewed for Advance Directives were accurately reflected in the resident's Electronic Medical Record (EMR) regarding the residents' Code status preferences, and failed to implement a Comprehensive care plan for hypoglycemia for 1 of 38 residents (Resident #77) reviewed for Comprehensive care plans. The facility's deficient practice placed 4 residents (Resident #33, #6, #49, and #77) of 91 residents reviewed in Immediate Jeopardy (a situation where 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) and had the potential to affect all residents in the facility. The Administrator, Director of Nursing (DON) and Regional Nurse Consultants were notified of the Immediate Jeopardy for the Advance Directives on [DATE] at 9:20 PM, for the Abuse on [DATE] 2020 at 7:31 PM, and for the Care Plan on [DATE] at 3:50 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-600 and F-678 were cited at a scope and severity of J, which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-600, F-656, F-678, F-835, and F-867 were cited at a scope and severity of J. The Immediate Jeopardy was removed onsite and was effective [DATE] through [DATE]. An Immediate Action Removal Plan which removed the immediacy of the jeopardy, was received on [DATE] at 2:55 PM. The corrective actions were validated onsite by the surveyors on [DATE]. The findings include: Review of the facility policy, Abuse Prohibition Plan, revised [DATE], revealed .The facility has a zero-tolerance policy for abuse. Verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion is prohibited. The resident will not be subjected to mistreatment, neglect, exploitation or misappropriation of property. The facility will attempt to identify and will investigate any reported violation or allegation of abuse. Willful means the individual deliberately, not that the individual must have intended to, inflict injury or harm .reports of abuse, neglect, exploitation, misappropriation of resident's property and injuries of unknown origin are promptly and thoroughly investigated .The Administrator will investigate or assign the investigation to designated facility personnel such as the Director of Nursing. The investigation will begin immediately .abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Regulations and Law . Review of the facility policy, Advance Directives, revised on 6/2018 revealed, .The facility representative will assist the resident as needed to communicate any changes in the residents Advance Directive to the physician and/or responsible party .The facility representative will discuss and provide written information explaining the Advance Directive Program, upon admission to the facility .The facility representative will periodically discuss the resident's Advance Directive to ensure the resident's wishes concerning end of life treatment have not changed . Review of the facility policy, Comprehensive Care Plan, revised 12/2019, showed .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team or in accordance with the resident's preferences and potential for discharge, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis, Acute and Chronic Respiratory Failure, Polyneuropathy, and Fibromyalgia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #33 was cognitively intact. Further review revealed the resident required 2 person total assist with transfers. Review of Resident #33's Physician Visit note dated [DATE] showed Resident #33 was having left shoulder pain and an X-ray was ordered. Review of Resident #33's Mobile Radiology report dated [DATE], showed, .Impacted nondisplaced left humeral fracture .NP [Nurse Practitioner] made aware . Review of Resident #33's Physician Visit note dated [DATE], showed Resident #33 had a contusion to her left arm and the X-ray showed fracture. Further review showed, .Send to Ortho [Orthopedic] Urgent Care for further evaluation of L [Left] Shoulder pain to eval [evaluation] and fx[fracture]/treatment . Review of Resident #33's ER Note dated [DATE] showed, .a tech was transferring her from her wheelchair to a bed 2 days ago. He tried to lift her under her arms. When this occurred she felt a pop in her left shoulder. She has had pain ever since then. It is sharp and throbbing, 10 out of 10 in severity, it is worse with movement. She has noticed some increased bruising, she denies any other injuries . During an interview on [DATE] at 9:05 AM, Resident #33 stated about 4 months ago I was lying in bed when [named CNA #1] came in and was going to get me up for bingo. He didn't have a lift and I told him 'No!' I'm not going without the lift. I asked him to please get the lift, but he wouldn't go get it. During further interview revealed CNA #1 proceeded to lift the resident by her arms to transfer her to a chair from the bed. Resident #33 stated, When he pulled me up, I heard a loud pop and I started having pain in my left arm. I told him it hurt, but he just said, 'You didn't break your arm!' Then he picked up my arm and moved it around and said, 'see' It really hurt when he did that. During further interview revealed Resident #33 informed the Director of Nursing (DON) the next day that CNA #1 did not use the lift when he attempted to transfer her and she insisted for him to use the lift, but he didn't and when he pulled her up by her arms she heard a pop and began to have pain in her left arm. During an interview on [DATE] at 4:19 PM with Nurse Practitioner #1 she stated the facility told her this injury was chronic. However on her [DATE]'s assessment she found fresh bruising and contusions on her left arm. That's when I ordered for [named Resident #33] to be sent to Orthopedic Urgent care for further evaluation of left shoulder pain and fracture. During an interview on [DATE] at 4:51 PM with the Director of Nursing (DON) confirmed Resident #33 was a 2 person assist transfer with a mechanical lift, since admission. Further interview she stated Resident #33 felt CNA #1 was a little rough during the transfer when her arm was broken. During further interview the DON confirmed she was notified by Resident #33 on [DATE] that CNA #1 was rough with her during the attempted transfer on [DATE]. During an interview on [DATE] at 5:16 PM with the Administrator confirmed the incident involving Resident #33 was reported to her by the DON in [DATE] but was not considered abuse at that time. Refer to F-600, F-609, and F-610 Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes with Nephropathy, Hyperlipidemia, Muscle Weakness, Peripheral Vascular Disease, and Vitamin B Deficiency. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #49 was cognitively intact. Review of the Physician Orders for Scope of Treatment (POST) for Resident #49 dated [DATE] located in the POST Form Book at the Nurses station showed the resident's code status was a DNR (Do not resuscitate). Review of Resident #49's EMR [Electronic Medical Record] showed the Code Status Ribbon [which displayed for quick reference at the top of the resident's EMR] was blank, which indicated the resident's code status was Full Code [Cardiopulmonary Resuscitation (CPR)]. During an interview on [DATE] at 6:44 PM, with Licensed Practical Nurse (LPN) #6, who was assigned to Resident #49, she stated she would refer to the POST Form Book located at the nurses' station to determine a resident's code status. During an interview on [DATE] at 7:40 PM, Resident #49 stated he wanted CPR if his heart stopped and his decision had not changed since admission to the facility. Review of the medical record showed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Acute on Chronic Respiratory Failure, Acute Diastolic Heart Failure, Exacerbation COPD (Chronic Obstructive Pulmonary Disease) with Chest Pain, and Hyperkalemia. Review of Resident #6's admission MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident #6's POST dated [DATE] located in the Post Form book showed the resident code status was Full Code. Review of Resident #6's EMR showed the Code Status Ribbon displayed an Advance Directive status of Do Not Resuscitate (DNR). During an interview on [DATE] at 5:43 PM with LPN #1, who was assigned to Resident #6, she stated she would look on the computer for a resident's code status. Further interview she stated, The code status is in bold right next to the resident's name on the computer. She then demonstrated this on the computer screen by opening the resident's EMR and pointing to the ribbon at the top of the screen where DNR was highlighted in yellow. During an interview on [DATE] at 6:27 PM with the Administrator confirmed code status on the POST forms for Resident #49 and Resident #6 conflicted with their code statuses in the EMR. Refer to F-678 Review of the medical record showed Resident #77 was admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy, Dysphagia, Malnutrition, and Constipation. Review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #77 was severely cognitively impaired. Continued review revealed Resident #77 required tube feeding for nutrition. Review of the hospital History of Present Illness dated [DATE], showed .Today, the patient was altered and less interactive, and EMS [Emergency Medical Services] was called. EMS said they got a blood glucose of 12 at his home .the patient's core temperature was also found to be 91 degrees . Review of the Comprehensive Care Plan dated [DATE] showed Resident #77 had no care plan for hypoglycemia or for monitoring for signs and symptoms of hypoglycemia; length of time to hold tube feeding when residual was too high; and appropriate physician notification. Review of the progress note dated [DATE], showed, approximately 1435 [2:35 PM] resident became non responsive after having a second BM [bowel movement]. Resident had been disconnected from tube feeding after checking residual and having > [greater than] 110 ml residual [replaced] x's 2. NP [Nurse Practitioner] notified and gave orders to send resident out for evaluation and treatment. Medical record review of the vital signs dated for [DATE], revealed no documented blood sugar prior to transfer to the hospital by the facility. Review of the Emergency Patient Record dated [DATE], showed .Per EMS [Emergency Medical Service] The initial call was for an unresponsive PT [patient]. Nurses at this facility saw that he went unresponsive 40 minutes. Our glucometer read L0 for us. We gave him D10 [Dextrose 10%] infusion. He's had a low heart rate with 'us' and weak carotid pulses .Intraosseous special catheter [surgical steel IV (intravenous) catheter inserted directly into a patient's long bone in an emergency life threatening situation to provide rapid infusion of life saving medications/solutions] left tibia inserted at 1536 [3:36 PM] . Review of [Named Hospital] History of Present Illness dated [DATE], showed, .TF had reportedly been temporarily stopped D/T [due to] high gastric residuals/apparent constipation. He was also hypothermic -T-max 89 F [maximum temperature 89 degrees Fahrenheit]. Had significant BM today however TF was never resumed . During an interview on [DATE] at 3:50 PM with the Director of Nursing (DON) she confirmed Resident #77 had a history of malnutrition and hypoglycemia. The DON also confirmed, the resident's tube feeding was held due to high residual, and the resident's blood glucose level should have been monitored. Refer to F-656 During an interview on [DATE] at 2:00 PM with the Administrator confirmed she was the abuse coordinator. Further interview confirmed the incident for Resident #33 on [DATE] was not identified, reported, or investigated as an abuse allegation, and the advance directive preference inaccuracy for Resident #6 and Resident #49 were not identified until [DATE]. The Immediate Action Removal Plan, which removed the immediace of the Jeopardy, was received on [DATE] at 2:55 PM and corrective actions were validated onsite by the surveyors on [DATE]. The Immediate Action Removal Plan was verified by the surveyors on [DATE] by: 1. The surveyors verified through review of facility documentation dated [DATE], [DATE], and [DATE] QAPI meetings were held regarding Residents #6, #33, #49, and #77. 2. The surveyors verified the care plans with interventions were in place for 17 residents at risk for developing low blood sugar. 3. The surveyors reviewed the facility's abuse policy and verified there were no changes made to the policy. The facility's noncompliance at F-600, F-656, F-678, F-835, and F-867 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility's Quality Assurance Performance Improvement (QAPI) Plan review, policy review, medical record review, and interview, the QAPI committee failed to identify deficient practice for investigating allegations of abuse for 1 of 38 residents (Resident #33) reviewed for abuse; failed to identify no person centered care plan was implemented for 1 of 38 residents (Resident #77) reviewed for care plan implementation and interventions; and failed to identify the prescribed tube feeding formula was unavailable for 1 of 5 residents (Resident #77) reviewed for tube feedings which resulted in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON) and Regional Nurse Consultants were notified of the Immediate Jeopardy on [DATE] 2020 at 7:31 PM. The facility was cited Immediate Jeopardy at F-600 and F-678 were cited at a scope and severity of J, which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-600, F-656, F-678, F-835, and F-867 were cited at a scope and severity of J. The Immediate Jeopardy was removed onsite and was effective [DATE] through [DATE]. An Immediate Action Removal Plan which removed the immediacy of the jeopardy, was received on [DATE] at 2:55 PM. The corrective actions were validated onsite by the surveyors on [DATE]. The findings include: Review of the facility policy, Abuse Prohibition Plan, revised 5/2019, revealed, .The facility has a zero-tolerance policy for abuse. Verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion is prohibited. The resident will not be subjected to mistreatment, neglect, exploitation or misappropriation of property. The facility will attempt to identify and will investigate any reported violation or allegation of abuse .Willful means the individual deliberately, not that the individual must have intended to, inflict injury or harm . Review of the facility's Quality Assurance Performance Improvement (QAPI) Plan dated 11/2019 revealed, .The Quality Assurance Performance Improvement (QAPI) Plan is designed to establish and maintain an organized facility wide program that is data driven and utilizes a proactive approach to improving throughout the facility .The governing body and the facility administration shall provide general oversight for Quality Assurance and Performance Improvement activities related to resident care and services throughout the facility . Review of the facility policy, Comprehensive Care Plan, revised 12/2019, showed .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team or in accordance with the resident's preferences and potential for discharge, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . Review of the facility policy, Advance Directives, revised on 6/2018, showed, .The facility representative will assist the resident as needed to communicate any changes in the resident's Advance Directive to the physician and/or responsible party .The facility representative will discuss and provide written information explaining the Advance Directive Program, upon admission to the facility .The facility representative will periodically discuss the resident's Advance Directive to ensure the resident's wishes concerning end of life treatment have not changed . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis, Acute and Chronic Respiratory Failure, Polyneuropathy, and Fibromyalgia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #33 was cognitively intact. Further review revealed the resident required 2 person total assist with transfers. Review of the Comprehensive Care Plan dated [DATE], showed, .Transfers-[Mechanical] Lift Assist . Review of Resident #33's Physician Visit note dated [DATE] showed Resident #33 was having left shoulder pain and an X-ray was ordered. Review of Resident #33's Mobile Radiology report dated [DATE], showed, .Impacted nondisplaced left humeral fracture .NP [Nurse Practitioner] made aware . Review of Resident #33's Physician Visit note dated [DATE], showed Resident #33 had a contusion to her left arm and the X-ray showed fracture. Further review showed, .Send to Ortho [Orthopedic] Urgent Care for further evaluation of L [Left] Shoulder pain to eval [evaluation] and fx[fracture]/treatment . Review of Resident #33's ER Note dated [DATE] showed, .a tech was transferring her from her wheelchair to a bed 2 days ago. He tried to lift her under her arms. When this occurred she felt a pop in her left shoulder. She has had pain ever since then. It is sharp and throbbing, 10 out of 10 in severity, it is worse with movement. She has noticed some increased bruising, she denies any other injuries . During an interview on [DATE] at 9:05 AM, Resident #33 stated about 4 months ago I was lying in bed when [named CNA #1] came in and was going to get me up for bingo. He didn't have a lift and I told him 'No!' I'm not going without the lift. I asked him to please get the lift, but he wouldn't go get it. During further interview revealed CNA #1 proceeded to lift the resident by her arms to transfer her to a chair from the bed. Resident #33 stated, When he pulled me up, I heard a loud pop and I started having pain in my left arm. I told him it hurt, but he just said, 'You didn't break your arm!' Then he picked up my arm and moved it around and said, 'see' It really hurt when he did that. During further interview revealed Resident #33 informed the Director of Nursing (DON) the next day that CNA #1 did not use the lift when he attempted to transfer her and she insisted for him to use the lift, but he didn't and when he pulled her up by her arms she heard a pop and began to have pain in her left arm. During an interview on [DATE] at 4:19 PM with Nurse Practitioner #1 she stated the facility told her this injury was chronic. However on her [DATE]'s assessment she found fresh bruising and contusions on her left arm. That's when I ordered for [named Resident #33] to be sent to Orthopedic Urgent care for further evaluation of left shoulder pain and fracture. During an interview on [DATE] at 4:51 PM with the Director of Nursing (DON) confirmed Resident #33 was a 2 person assist transfer with a mechanical lift, since admission. Further interview she stated Resident #33 felt CNA #1 was a little rough during the transfer when her arm was broken. During further interview the DON confirmed she was notified by Resident #33 on [DATE] that CNA #1 was rough with her during the attempted transfer on [DATE]. During an interview on [DATE] at 5:16 PM with the Administrator confirmed the incident involving Resident #33 was reported to her by the DON in [DATE] but was not considered abuse at that time and an investigation was not done. Review of the medical record showed Resident #77 was admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy, Dysphagia, Malnutrition, and Constipation. Review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #77 was severely cognitively impaired. Continued review revealed Resident #77 required tube feeding for nutrition. Review of the hospital History of Present Illness dated [DATE], showed .Today, the patient was altered and less interactive, and EMS [Emergency Medical Services] was called. EMS said they got a blood glucose of 12 at his home. He was brought to the emergency room where D5 was started and the patient's mental status recovered quickly to baseline .the patient's core temperature was also found to be 91 degrees . Review of the Comprehensive Care Plan dated [DATE] showed Resident #77 had no care plan for hypoglycemia or for monitoring for signs and symptoms of hypoglycemia; length of time to hold tube feeding when residual was too high; and appropriate physician notification. Further review showed no new interventions were placed for monitoring signs and symptoms of hypoglycemia for Resident #77 after his return to the facility after his hospitalization on [DATE]. Review of the Nursing Notes dated [DATE], showed, Resident #77 was receiving Jevity 1.5 at 40 ml/hr [milliliters per hour]. Review of the progress note dated [DATE], showed, approximately 1435 [2:35 PM] resident became non responsive after having a second BM [bowel movement]. Resident had been disconnected from tube feeding after checking residual and having > [greater than] 110 ml residual [replaced] x's 2. NP [Nurse Practitioner] notified and gave orders to send resident out for evaluation and treatment. Medical record review of the vital signs dated for [DATE], revealed no documented blood sugar prior to transfer to the hospital by the facility. Review of the Emergency Patient Record dated [DATE], showed .Per EMS [Emergency Medical Service] The initial call was for an unresponsive PT [patient]. Nurses at this facility saw that he went unresponsive 40 minutes. Our glucometer read L0 for us. We gave him D10 [Dextrose 10%] infusion. He's had a low heart rate with 'us' and weak carotid pulses .Intraosseous special catheter [surgical steel IV (intravenous) catheter inserted directly into a patient's long bone in an emergency life threatening situation to provide rapid infusion of life saving medications/solutions] left tibia inserted at 1536 [3:36 PM] . Review of [Named Hospital] History of Present Illness dated [DATE], showed, .TF had reportedly been temporarily stopped D/T [due to] high gastric residuals/apparent constipation. Ultimately staff found resident unresponsive and checked BS [blood sugar] which read low. He was also hypothermic -T-max 89 F [maximum temperature 89 degrees Fahrenheit]. Had significant BM today however TF was never resumed . During an interview on [DATE] at 3:50 PM with the Director of Nursing (DON) she confirmed Resident #77 had a history of malnutrition and hypoglycemia. The DON also confirmed, the resident's tube feeding was held due to high residual, and the resident's blood glucose level should have been monitored. During an interview on [DATE] at 2:00 PM with the Administrator confirmed the incident involving Resident #33 was not recognized, reported and investigated as abuse but should have been and a person centered care plan was not implemented for Resident #77 to reflect the resident care needs. Further interview confirmed an AdHoc QAPI [an immediate Quality Assurance Performance Improvement Plan] meeting did not take place for these concerns until the IJ notification was given to them by the surveyors on [DATE]. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes with Nephropathy, Hyperlipidemia, Muscle Weakness, Peripheral Vascular Disease, and Vitamin B Deficiency. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #49 was cognitively intact. Review of the Physician Orders for Scope of Treatment (POST) for Resident #49 dated [DATE] located in the POST Form Book at the Nurses station showed the resident's code status was a DNR (Do not resuscitate). Review of Resident #49's EMR [Electronic Medical Record] showed the Code Status Ribbon [which displayed for quick reference at the top of the resident's EMR] was blank, which indicated the resident's code status was Full Code [Cardiopulmonary Resuscitation (CPR)]. Review of Resident #49's Comprehensive Care Plan dated [DATE], showed a Code Status of Full Code. Review of Resident #49's Face Sheet, the Advance Directives section showed the directive was listed as Full Code. During an interview on [DATE] at 6:44 PM, with Licensed Practical Nurse (LPN) #6, who was assigned to Resident #49, she stated she would refer to the POST Form Book located at the nurses' station to determine a resident's code status. During an interview on [DATE] at 6:45 PM, LPN #7 stated she would refer the POST Form Book located at the nurses' station to determine for a resident's code status. During an interview on [DATE] at 7:40 PM, Resident #49 stated he wanted CPR if his heart stopped and his decision had not changed since admission to the facility. Review of the medical record showed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Acute on Chronic Respiratory Failure, Acute Diastolic Heart Failure, Exacerbation COPD (Chronic Obstructive Pulmonary Disease) with Chest Pain, and Hyperkalemia. Review of Resident #6's admission MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident #6's POST dated [DATE] located in the Post Form book showed the resident code status was Full Code. Review of Resident #6's EMR showed the Code Status Ribbon displayed an Advance Directive status of Do Not Resuscitate (DNR). Review of Resident #6's Face Sheet, the Advance Directives section for showed the directive was listed as Do Not Resuscitate. Review of Resident #6's Care Plan dated [DATE] showed Resident #6's code status was DNR. During an interview on [DATE] at 5:43 PM with LPN #1, who was assigned to Resident #6, she stated she would look on the computer for a resident's code status. Further interview she stated, The code status is in bold right next to the resident's name on the computer. She then demonstrated this on the computer screen by opening the resident's EMR and pointing to the ribbon at the top of the screen where DNR was highlighted in yellow. During an interview on [DATE] at 6:27 PM with the Administrator confirmed code status on the POST forms for Resident #49 and Resident #6 conflicted with their code statuses in the EMR. During an interview with Registered Nurse (RN) #1 on [DATE] at 6:40 PM, who was assigned to Resident #6, he stated, If a resident coded [if the resident had no pulse and was not breathing] I would go to the computer and check the resident's code status. Further interview RN #1 stated, I can tell if a resident has a Full Code or DNR status by looking at the Code Status ribbon at the top of their EMR, it is in bold letters on the face sheet. Further interview RN #1 demonstrated obtaining Resident #6's code status by opening his computer and pointing to the ribbon at the top of the screen of Resident #6's EMR where DNR was highlighted in yellow. During an interview on [DATE] at 7:10 PM, with Admissions Clerk stated she was responsible to get the POST form signed by the resident and the doctor. Further interview revealed once the POST form was signed by the resident and the doctor, she would enter the code status selection in the computer. Further interview she stated if the resident was a full code the ribbon was blank and if the resident was a DNR it would display in yellow on the ribbon in the Resident's EMR. Further interview she stated she placed the original POST form in the POST form book at the nurses station. During an interview on [DATE] at 8:19 PM, the Administrator confirmed staff were not to rely on the computer, but refer to the POST Form book located at the nurses' station for a resident's code status. Further interview confirmed the staff had not been educated on referring to the POST Form book, not the computer, for a resident's code status. During an interview on [DATE] at 10:00 AM, the Administrator stated Admissions personnel were responsible for getting a POST form signed by the resident and the doctor, putting the code status in the Resident's EMR, and putting the POST form in the book at the nurses' station. Further interview she stated the MDS nurse was to go to the POST book at the nurses' station to get a resident's code status for implementation of an Advance Directive care plan. Further interview confirmed this process did not happen for Residents #49 and #6. During an interview on [DATE] at 11:52 AM, MDS Coordinator confirmed she looked in the computer for the POST form she did not refer to the book at the nurses' station when implementing a resident's Advance Directive Care Plan. Further interview confirmed the code statuses on the POST forms for Resident #49 and #6 conflicted with the code status on their care plans. She stated, There was a process failure. REFER TO TAG #'S F-600, F-609, F-610, F-656, F-678, F-693, and F-835. The Immediate Action Removal Plan was verified by the surveyors on [DATE] by: 1. The surveyors verified through review of facility documentation dated [DATE], [DATE], and [DATE] QAPI meetings were held regarding Residents #6, #33, #49, and #77. 2. Verified the care plans with interventions were in place for 17 residents at risk for developing low blood sugar. 3. The surveyors verified the facility's Incident Reporting System intake information regarding Resident #33 and CNA #1 was reported to the state agency on [DATE]. The facility's noncompliance at F-867 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.