**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** HARM 2. Resident 29 was initially admitted to the facility on [DATE] and again on [DATE] with diagnoses which included type 2 diabetes mellitus, chronic obstructive pulmonary disease, cerebral infarction, acute myocardial infarction, unspecified dementia, anxiety disorder, and low back pain. On [DATE] at 11:15 AM an interview with resident 29 was conducted. Resident 29 stated that the staff rarely changed the dressing for his wounds. Resident 29 stated that the last time his dressings for his wounds were changed and cleaned was 3 days ago. On [DATE] an interview with resident 29's family member was conducted. Resident 29's family member stated that once resident 29 returned from the hospital on [DATE], they noticed that resident 29 was always lying in the same position. The family member stated that they asked the staff multiple times if resident 29 could be moved to a different position, along with asking staff if they have noticed any sores on his backside. The family member stated that the Certified Nursing Assistant (CNA) 's reported to her that they have not seen anything. Resident 29's medical record was reviewed on [DATE]. A progress note dated [DATE] revealed that resident 29 had a new order for wound care for a new wound on his coccyx. A document from the wound clinic [DATE] was reviewed. The document stated, Patient has a new wound on his coccyx/sacral area. There is an open area in the center that is into subcutaneous tissue. Therefore we will begin staging at a stage III however, the periwound tissue is dark, non-blanching and has characteristic so of deep tissue injury measuring approximately 15.0 [centimeters] x 15.0 [centimeters]. A review of resident 29's orders for wound care was conducted. A. The initial order for resident 29's wound care began on [DATE] and stated, Cleanse wound with wound cleanser. Cover wound on coccyx and buttock with large bordered foam dressing. Date and initial wound dressing. Change dressing daily. One time a day for wound healing. Start date was [DATE]. Discontinue date was [DATE]. a. According to the documentation, wound care was not completed on [DATE]. B. The wound care order was changed on [DATE] to, Cleanse wound with wound cleanser. Cover wound on coccyx, place silver alginate, cover with large bordered foam dressing. Date and initial wound dressing. Change dressing daily. One time a day for wound healing. Start date was [DATE]. Discontinue date was [DATE]. a. According to the documentation, wound care was not completed on the following dates: i. [DATE] ii. [DATE] iii. [DATE] iv. [DATE] v. [DATE] vi. [DATE] vii. [DATE] viii. [DATE] b. On [DATE] the wound care was documented as Other/See Progress Note. However, there was no progress note from [DATE] regarding the wound care order for resident 29. It is unclear if resident 29's wound care was completed on [DATE]. C. The wound care order was again changed to, Wound to coccyx, clean wound, Pak wound with kerlix soaked with ¼ strength Dakin's (fill cavity loosely) cover with bordered foam. Change daily one time a day for wound healing. Start date was [DATE]. The order was reviewed up until [DATE]. a. According to the documentation, wound care was not completed on the following dates: i. [DATE] ii. [DATE] iii. [DATE] iv. [DATE] v. [DATE] vi. [DATE] vii. [DATE] viii. [DATE] ix. [DATE] It should be noted that the orders for wound care to coccyx for resident 26 was documented as completed for 5 of the 25 days ordered. A document from the wound clinic dated [DATE] was reviewed. The document stated that the wound on resident 29's coccyx had been adjusted to a stage IV pressure ulcer do to exposed muscle and fossa in the wound bed base. The document also had recommendations for a surgical consult and debridement, a wound VAC, and nutritional interventions. An observation of would care for resident 29 was conducted on [DATE] at 1:35 PM. Licensed Nurse Practitioner (LPN) 1 was conducting the wound care order. Once resident was turned on his side, it was observed that there was no previous dressing on resident 29's pressure ulcer. LPN 1 stated that resident 29 required a daily change of his dressing. LPN 1 stated, maybe the previous dressing came off. It was observed that LPN 1 cleared fecal matter from the wound prior to packing the wound with Dakins soaked gauze. On [DATE] at 1:45 PM an interview with Registered Nurse (RN) 2 was conducted. RN 2 stated that she was often so busy during her shift that she would not be able to complete the wound care. RN 2 stated that she was busy today and most likely would not get to the wound care today. On [DATE] an interview with resident 29's family member was conducted. The family member stated that it did not seem like the facility cared about his wounds. The family member stated, I feel like he [resident 29] was neglected. A progress note from [DATE] revealed that resident 29 was going to be placed on hospice. 4. Resident 51 was admitted to the facility on [DATE], with a diagnosis that included polyneuropathy, quadriplegia, type 2 diabetes, viral hepatitis, chronic kidney disease, hypertension and arthritis. On [DATE] an interview was conducted with employees 12 and 13. During this interview, employee 12 stated that they see the residents frequently and were concerned with the treatment of certain residents. Employee 12 stated that one of these was resident 51. Employee 12 stated that resident 51 was dropped in the shower a couple of months ago hitting his right heel and sustained a wound on resident 51's heel. Employee 12 stated that the wound was ignored for a long time, and it was currently at the point of bone presentation and bone infection. Employee 12 stated that resident 51 was currently seeing a wound doctor, and that the wound doctor had stated that resident 12's foot my have to be amputated. Employee 12 stated that antibiotics were ordered and not given. Employee 12 stated that the wound nurse who is also the Assistant Director of Nursing (ADON) did not not treat the wound. On [DATE] a review of resident 51's medical record was completed. According to resident 12's record, the resident had weekly skin checks on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. None of these weekly checks identified any sort of wound on the resident's right heel. The first MD note in chart for resident 51's heel was on [DATE] which indicated antibiotics, offloading the heel and only weight bearing for Physical Therapy (PT). The second MD note for resident 51's heel was dated [DATE]. This note called for a boot to protect the heel. Wound care orders for resident's heel wound were first dated on [DATE] stated that the wound required daily wound dressing changes and cleanings. On [DATE] at 11:48 AM, an interview was conducted with resident 51. During this interview, resident 51 stated that he got the wound on his heel when they dropped him in the shower. Resident 51 stated that it happened in January. Resident 51 stated that nobody did anything until it was noticed that it was a problem. Resident 51 stated that he had seen a wound physician recently and that the physician was talking about amputating his right leg. As of [DATE] there are were no fall reports located for resident 51. On [DATE] it was observed that resident 51 had not had a wound dressing change since [DATE]. The Medical Doctors (MD) orders stated that the wound should be changed daily, per protocol. It was observed that residents wound covered the entire bottom of the heel of his right heel, with bone visible inside the wound. It was observed that a foul smell was coming from the wound. 5. Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy, end stage renal disease, essential hypertension, long-term use of insulin, latent tuberculosis, and chronic hepatitis. On [DATE] at 3:44 PM, resident 1 was observed in the hall, asking a nurse for a cotton swab. Resident 1 was immediately interviewed, and stated that he had foot pain on his left foot, on his second and third toe. Resident 1's foot was observed to be uncovered, and resident 1's toes had some black areas (eschar) on them, particularly between the second and third toes. Resident 1 stated that he wanted to put ointment on his toes and needed to have a swab or stick to apply it. The ADON was observed to tell resident 1 that the nurse would perform the wound care. Resident 1 stated that it hurt too much when the nurses performed the wound care. The ADON told resident 1 that the nurse would provide pain medication before completing his wound care. On [DATE], resident 1's medical record review was completed. On [DATE] at 4:12 PM, hospital discharge orders revealed the following wound care order: Every other day place foam dressing between the interspaces to keep them to becoming macerated with the dry broken down skin, and I would also recommend painting the interspaces with Betadine bilaterally [on toes] 1 through 4 if there is lambswool available in the hospital floor apply this in between the interspaces, if not the pink/white foam or gauze. For the left dorsal foot wound I recommend Iodosorb or Betadine gauze covered with foam. Recommend applying ammonium lactate or some other moisturizer cream that the hospital has the bilateral lower extremities to prevent breakdown of skin due to being too dry. On [DATE] at 6:00 PM, an order was initiated at the facility for Wound to Left Second Toe, Clean, apply betadine, Apply calcium Alginate between toes daily. Resident 1's care plan did not include wound care. A diabetic foot ulcer was identified, but no treatments were included in the care plan. On resident 1's Treatment Administration Record (TAR), the order for wound care was initiated on [DATE]. The TAR for March revealed that resident 1 refused treatment on [DATE], and was not offered wound care any other day. Resident 1's TAR for the month of April revealed that resident 1 did not receive wound care on the following dates: a. [DATE] b. [DATE] c. [DATE] d. [DATE] e. [DATE] On [DATE] at 8:52 AM, the ADON was interviewed. The ADON stated that for resident 1, he did not have much of a pedal pulse and was aware that he had used a stick on his wound. The ADON stated that his wound would not be as painful to him if it wasn't vascular. The ADON stated that when she was informed of the wound, she assessed it, put honey and a foam dressing on it, and let the provider know there was an issue. The ADON stated that the order for the honey and foam was not ordered by a physician, but honey is my number one best, it doesn't hurt anything. On [DATE] at approximately 10:00 AM, Employee (E) 12 was interviewed. E 12 stated that they worked with resident 1 and the left foot injuries appeared infected and was concerened that resident 1 may require amputation. E 12 stated that the wounds had been there since admission, but were not treated. E 12 stated that the wound nurse, who was now the Assistant Director of Nursing (ADON) did not follow up on staff member's concerns. On [DATE] at 12:42 PM, the Corporate Resource Nurse (CRN 1) was interviewed. CRN 1 stated that she was the acting infection preventionist at the facility. CRN 1 stated that she had not spoken to the Nurse Practitioner who comes to the building to see the resident, and did not assist with wound care. The CRN stated that the ADON was going to receive wound care training, and had been the wound nurse. CRN 1 stated that the ADON was not wound care certified. CRN 1 stated that resident 1 had necrotic areas on his feet due to his shoes, and a doctor should see his feet. CRN 1 stated that she noticed resident 1 did not wear slippers on his feet on Sunday. On [DATE] at 12:26 PM, an interview was conducted with MP 1. MP 1 stated that a wound care team worked in the building to address the residents' wound care needs, and the former wound nurse, now ADON coordinated those visits. MP 1 stated that residents had told him that their wound care was not completed by the nurses. On [DATE] at 10:47 AM, an interview was conducted with the Maintenance Director. The maintenance director stated that resident 1 had an appointment to see a podiatrist on [DATE]. Based on observation, interview and record review, it was determined the facility did not ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 5 of 51 sample residents. Specifically, wound care was not provided to residents as ordered, and one resident did not have physician evaluations or orders for a pressure injury. The deficient practice identified for resident 61 was found to have occurred at an immediate jeopardy level and deficient practice for residents 1. 15, 17, and 29 were found to have occurred at a harm level. Resident identifiers: 1, 17, 29, 51, and 61. NOTICE: On [DATE] at 1:10 PM, verbal notice of the Immediate Jeopardy findings with regard to F686 was given to the facility Administrator (ADM), Corporate Resource Nurse (CRN) 1, and the Regional [NAME] President (RVP). On [DATE], the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on [DATE] at 10:00 AM: 1. Resident #61 expired at the hospital; therefore, no individualized plan of correction is indicated. 2. Residents with a pressure injury have the potential to be affected by this deficient practice. A whole house skin assessment audit was completed by week ending [DATE] by the nurse management team. Any new concerns that were identified received orders, treatments, documentation on the pressure injury and the care plans will be updated by the DON/designee. Any residents with a pressure injury will be assessed by consultant RN ' s. 3. Education was initiated on [DATE] by the consultants with nursing staff regarding the community pressure injury policy and the expectation of completing and documenting skin assessments and monitoring of skin concerns weekly with each resident. Any time a new skin issue is identified, the physician and responsible party should be notified, new orders should be received and implemented, the care plan should be updated, and monitoring should continue weekly until the area has healed. The consultant RN ' s will round weekly for the next month to ensure documentation is thorough and complete and the community is following physician ordered treatments. DON/designee to complete weekly audit for three months(3) residents with wounds to ensure that the resident had a full skin assessment completed, new orders received for the identified areas, pain evaluated to ensure that it was being managed effectively, treatments initiated, documentation completed, positioning appropriate to promote wound healing, care plan accurate, and wound monitoring to be completed weekly until the areas healed. The consultants provided the community with a new daily standup meeting agenda. This agenda will include a pressure injury tracking log to track and trend pressure injuries and newly acquired pressure injuries. The consultants will be provided with a weekly pressure injury report for review and recommendations. 4. The DON/designee will report findings from the audits to the QAPI Committee monthly fosix (6) months. The QAPI committee will identify any trends and take corrective action as needed. On [DATE], while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on [DATE] at 10:00 AM. Findings include: IMMEDIATE JEOPARDY 1. Resident 61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anemia, sepsis, cellulitis, a stage 3 pressure ulcer of the sacral region, type II diabetes, chronic kidney disease, hypoxemia, hyperkalemia, and fluid overload. On [DATE], resident 61's medical record review was completed. On [DATE] at 11:09 AM, resident 61 had discharge orders printed from a regional care facility for wound care. The order for the coccyx wound stated: Bilateral buttocks and coccyx 1. Remove dressing 2. Clean wound with soap and water 3. Apply Santyl collagenase to the wound bed in a nickel thick consistency. 4. Cut and apply Xeroform or oil emulsion over Santyl. 5. Place large sacral dressing to each buttocks, and silicone bordered foam to coccyx. 6. Please change dressing daily and as needed with hygiene. On [DATE] at 6:32 PM, resident 61 was weight by a mechanical lift at 430 pounds. Resident 61's care plan did not include wound care. A nutrition care plan revealed that resident 61 was to have supplements to aide in wound healing. A regional hospital Progress Notes for [DATE] revealed that resident 61 had 4. Sacral decubitus ulcer, stage III. Chronic ulcer, present on arrival. Sacral wound itself is unstageable with black eschar and purulent sluff. CT showed fat stranding inferior, posterior and right of the midline. Also noted small scattered areas of gas without definitive drainable fluid collection. No signs of osteomyelitis. Plastics was curbsided and agrees with plan for continued wound care. - Continued aggressive wound care. - Patient will need frequent offloading/position changes. On [DATE] at 11:04 AM, the regional hospital Discharge Documentation for Discharge Wound Care Instructions were: coccyx 1. moisten a roll of gauze (kerlix) with Puracyn insert deep into undermining (12 cm toward anus) and depth of wound. On [DATE], a regional hospital discharge Progress Notes revealed that resident 61 had a stage 4 pressure ulcer on his coccyx, measuring 5.3 x 3.0 x 0 cm (centimeters) with undermining extending very close to anus. Description of the sacral ulcer revealed, Chronic ulcer, felt to be the cause of above noted bacteremia at his recent hospital stay. Currently, most wounds are looking reasonably clean without any purulence, exudate, or surrounding erythema. Sacral wound itself is unstageable with black eschar and purulent sluff . If he is not progressing then we will plan to get a CT (computerized tomography) abdomen and pelvis with contrast to look for deep wound infection. Wound care consultation requested. Patient will need frequent offloading/position changes. An order in resident 61's physician orders was created on [DATE] at 1:00 PM for Santyl ointment, 250/unit/gm (gram) (Collagenase) Apply to coccyx/buttocks topically as needed for as indicated in wound care orders. Resident 61's Treatment Administration Record (TAR) revealed that this wound care was completed two times, on [DATE] and on [DATE]. On [DATE] at 1:00 PM, an order for Venelex ointment ([NAME]-caster oil) Apply to coccyx wound topically as needed for as indicated in wound care order was created. This order was recorded in the TAR as completed on [DATE] at 8:09 PM. On [DATE] at 4:22 PM, an admission Summary revealed, .Skin Status/Interventions: Stage IV pressure ulcer to coccyx; cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of dressing .Incontinent of bowel and bladder . On [DATE] at 6:00 PM, an order was created to monitor the pressure ulcer to the coccyx each shift for signs and symptoms of infection or other complications. Nurses charted no complications on all checks, with the exception on 1/18 and 1/21 in the mornings, when the assessments were not completed. On [DATE] at 10:06 PM, a 72 hour charting after admission note revealed that resident 61 was adjusting well to returning to facility; appears to be in low spirits .Mental Status/Behavior: appears depressed and in low spirits; no behaviors noted . On [DATE] at 6:00 AM, an order for PU (pressure ulcer) to coccyx wound care: clean with NS (normal saline), dry with gauze. Apply skin prep barrier wipe to periwound skin. Pack undermining of wound w/ Kerlex soaked in Puracyn (squeeze out the excess). Apply Venelex to wound bed the apply Xeroform dressing. Secure with ABD (abdominal) pads. To be changed EOD (every other day) & PRN (as needed) if becomes soiled, saturated or accidentally removed one time a day every other day. This order was discontinued on [DATE]. The TAR revealed that this treatment was completed on 1/2, 1/4, 1/6, 1/8, 1/10, and [DATE]. On [DATE] at 9:56 AM, a skin/wound note revealed: Pressure ulcer to coccyx, undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . A referral was sent to a wound healing company to assess and treat. It was noted that the provider would be at the facility on [DATE]. On [DATE] at 11:50 AM, a physician's note revealed that resident 61 had an admission note created by a physician who performed a telehealth visit. A second note was entered at 8:44 PM. Skin status/interventions: Stage IV pressure ulcer to coccyx, cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100 (left lower side), surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . No other physician visits occurred during resident 61's stay. On [DATE] at 11:27 PM, a nurses note revealed: Changed dressing to buttocks. Moderate serosanguineous drainage (clear fluid) with odor. Cleansed peri with wound cleanser and dressing with ABD pads and medipore tape. On [DATE] at 9:35 AM, the resident advocate note revealed that resident 61 was admitted to the facility for anemia.According to resident discharge plan is to return home with home health. He is alert and orientated. He is currently using a wheelchair for locomotion and needs extensive assistance . His moods and behaviors have been cooperative, pleasant, and is compliant with cares since admission. On [DATE] at 10:30 AM, a Utilization Review (UR) note revealed that resident 61 .needs wound care (daily and PRN) .goal is to return home with HH (home health) . On [DATE] at 9:15 AM, a social services care conference note was started, and was not completed. Status stated In Progress. The note revealed that .wounds have no s/s (signs/symptoms) of infection .pleasant and cooperative with cares . On [DATE] at 11:00 AM, resident 61 had blood drawn for laboratory tests. On the results, a note was written that resident 61 needed a BMP (basic metabolic panel) completed in 1 week with a date [DATE]. Resident 61 had a white blood cell count of 11,300, with high neutrophils and immature granulocytes. [No additional blood tests were completed for resident 61 until [DATE].] [Wound physician did not see resident 61 on [DATE].] On [DATE] at 5:41 PM, resident 61 had a Nutritional Assessment. The assessment revealed that resident 61 had .increased nutritional needs d/t (due to) skin impairment to coccyx . Recommend adding . Juven BID (twice daily) and liquid protein . to support healing. Will monitor weight, intake, wound healing and will adjust nutritional interventions as needed. [No orders for Juven or liquid protein were initiated for resident 61.] On [DATE], a Mini Nutritional Assessment was completed. Resident 61 was At risk of malnutrition. [Note: No further nutrition assessments were completed.] Resident 61 had a nutritional care plan created on [DATE]. An intervention was to Provide supplements to promote wound healing. Resident 61 did not have a wound care plan included in his care plans. On [DATE], resident 61 was assessed in the Minimum Data Set (MDS) as requiring rehabilitation, urinary incontinence, fluid maintenance, fall risk, pain management, nutritional status management and pressure ulcer management. On [DATE], resident's niacin tablet order was not provided due to being out of supply, not in med cart. On [DATE] at 8:09 PM, an order for Venelex ointment, apply to coccyx wound topically as needed for as indicated in wound care order was initiated. On [DATE] at 9:32 AM, a MDS skin conditions evaluation that revealed resident 61 had 1 stage 4 pressure ulcer. Resident 61 had a pressure reducing device for the bed. Nutrition or hydration intervention to manage skin problems were noted as being in place. On [DATE] at 5:33 PM, a nurses note revealed that labs drawn [DATE] rec'd (received) w/ (with) noted abnormalities .NP (Nurse Practitioner) reviewed w/ N/O (new order) for BMP recheck in 1 week. [This lab was not redrawn.] On [DATE] at 3:25 PM, a Utilization Review (UR) note revealed that resident 61 .needs skilled wound care (daily and PRN) .goal is to return home with HH (home health) . On [DATE] at 4:30 PM, a skin/wound note revealed: Residents wound remains with deep 2 o'clock tunneling. with 5 X 6 (centimeters) opening. Wound has foul odor. Peri wound has improved. New order to fill wound bed with calcium alginate rope cover with bordered foam. Resident tolerated well . Resident 61 reported the following pain scores (out of 10) without reporting effective pain control: a. On [DATE] at 10:26 AM, 9 b. On [DATE] at 1:06 PM, 8 c. On [DATE] at 1:11 PM, 7 d. On [DATE] at 9:15 PM, 8 e. On [DATE] at 5:06 PM, 7 f. On [DATE] at 9:58 PM, 7 [No new interventions were noted.] On [DATE] at 8:37 PM, a skin/wound note revealed: Change resident dressing daily. Wound is 6 cm X 6.5 cm X 8.5 cm tunnel at 2 o'clock. Lots of blood drainage. Wound nurse's are following dressing change order from the hospital On [DATE] at 1:57 PM, a Utilization Review (UR) meeting revealed that resident 61's plan of care was to work with therapy and to return home with home health. The nursing update included .skilled wound care (daily and PRN), . On [DATE] at 6:28 AM, a nursing note revealed that resident 61's Wound remains open with foul odor. Wound is 6 cm X 5.5 CM x 2 CM. It tunnels at 2 o'clock 8 cm. Wound has necrotic tissue coming out of the tunnel area. Dressing change daily. Dakins soak 30 min. then Calcium alginate rope to tunnel with calcium alginate in wound bed. Cover with ABD pad and foam cover . On [DATE] at 6:00 AM, an order for Dakins (1/4 strength) solution (sodium hypochlorite) Apply to sacral wound topically one time a day for wound care 30 min soak to tunnel and wound bed was initiated. The TAR revealed that this order was completed on [DATE] and [DATE]. On [DATE], a Skilled Daily Review was performed for resident 61. Skilled need was wound to coccyx with tunneling at 2:00 position per wound care nurse. Pain mgmt (management). Assist with ADLs (activities of daily living). Resident 61 was incontinent of urine and bowel movements, and wore briefs with peri care provided with each brief change. [Note: There is no documentation about wound care changes with brief changes.] On [DATE] at 3:17 PM, resident complained of sacral pain for which PRN medication was provided. On [DATE] at 11:33 PM, a weekly skin review revealed no new skin integrity problems. The sacral pressure injury was noted. On [DATE] at 9:43 AM, a nurses' note revealed that the nurse had received report of resident 61 having increased confusion with shaking, high blood pressure, resident looking to the left to respond to the nurse w[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** POTENTIAL FOR HARM 5. Resident 43 was admitted to the facility on [DATE], with diagnoses that included alcohol dependence, peripheral neuropathy, hyperlipidemia, anxiety, depression, muscle weakness, lack of coordination, club foot and insomnia. On 3/30/22 at 2:51 PM, an interview with resident 43 was conducted. Resident 43 stated that his depression was getting worse, and he had asked the Administrator for a referral to get mental health counseling. Resident 43 stated that he asked the Administrator because there was no Social Worker or Resident Advocate working in the facility. Resident 43 stated that he asked for these services three weeks ago and had not heard anything yet. On 4/5/22 at 9:33 AM, a follow-up interview with resident 43 was conducted. Resident 43 stated that he had to take care of this himself by talking to the Medical Doctor about this, and call a mental health provider himself. Based on observation, interview, and record review it was determined, for 6 out of 51 sampled residents, that the facility failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, two residents with mental disorders required hospitalization after attempting suicide due to lack of interventions and behavioral health services. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. In addition, other residents with mental disorders had identified behaviors without interventions and behavioral health services implemented to accommodate or support the resident's loss of abilities. Resident identifiers: 4, 40, 43, 46, 49, and 111. NOTICE On 4/6/22 at 4:36 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to ensure that each resident received and that the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to identify that residents at risk for self-harm had interventions identified, implemented and revised, that behavioral health services were provided, that pharmacological interventions were implemented and that continued monitoring for safety was implemented. Notice of the IJ was given verbally to the facility Administrator (ADM) and the Corporate Resource Nurse (CRN), Director of Clinical Services (DCS), CRN 2, Corporate Registered Dietitian (CRD), and the Regional [NAME] President (RVP) and they were informed of the findings of IJ pertaining to F740 for resident 46. On 4/12/22 at 8:22 AM, notice of the IJ for resident 49 was given verbally to the RVP. On 4/12/22, the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 4/12/22 at 10:00 AM: 1. Resident #46 is now receiving medications per physician's order. The community made a referral for mental health services. 2. The DON [Director of Nursing] designee will be responsible to review the current medication regimen for newly admitted residents to ensure residents are receiving the medications ordered by the physician. The community is currently on an admissions hold. A consultant LCSW [Licensed Clinical Social Worker] will complete a review of other residents who trigger for a Level II to ensure mental health services are provided as needed. 3. The licensed nursing staff received education and training 4/11/2022 by the consultants on the importance of completing a comprehensive review on new admission orders to ensure they are complete and accurate. The IDT [Interdisciplinary Team] team will review daily (Monday through Friday) all new admission orders to ensure complete and accurate. The consultants provided the community with a new daily standup meeting agenda to include a review of new physician orders to ensure compliance is achieved with regulatory requirements. The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed. The consultants implemented a psych [psychotropic] pharmacy meeting. All residents on psychotropic medications will be reviewed quarterly and as needed. 4. The community DON or designee will report psych pharm meeting minutes to the QAPI [Quality Assurance and Performance Improvement] committee for review and recommendations. On 4/12/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/12/22 at 10:00 AM. Findings include: IMMEDIATE JEOPARDY 1. Resident 46 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of acute cerebrovascular insufficiency, enterocolitis due to clostridium difficile, altered mental status, type 2 diabetes mellitus, hypothyroidism, acute kidney failure, major depressive disorder, schizoaffective disorder, and anxiety disorder. On 4/6/22 resident 46's medical records were reviewed. On 11/12/21, resident 46's discharge orders from the hospital indicated that the resident should continue taking the following medications daily: Seroquel 300 milligrams (mg) each day (qd), Fluoxetine 40 mg qd, Vraylar 1.5 mg qd, Lorazepam (Ativan) 0.25 mg twice daily, Latuda 40 mg qd, and Depakote 500 mg q (every) 6 hours. On 11/12/21, the nursing progress documented that a medication reconciliation was performed with the Nurse Practitioner (NP) for resident 46. The no appropriate indications of use noted in documentation from hospital for use of some of meds; changes made: D/C [discontinue] vraylar [antipsychotic] . ativan [anxiolytic]. latuda [antipsychotic]. Seroquel [antipsychotic]. Review of the November 2021, December 2021, January 2022, February 2022 Medication Administration Record (MAR) revealed that resident 46 did not receive Vryalar, Ativan, Depakote Latuda, or Seroquel during those months. On 12/8/21, a Preadmission Screening Resident Review (PASRR) Level II was completed for resident 46. The PASRR indicated that resident 46 had a long history of mental health signs and symptoms, and has carried multiple mental health diagnoses over the years, including schizoaffective disorder, paranoid schizophrenia, personality disorders, generalized anxiety disorder, depression and psychosis. She has been hospitalized multiple times d/t [due to] her chronic mental health symptoms. She had her first episode of psychosis in her late teens after her first child was born; she began to experience recurring persucatory [sic] auditory hallucinations. Pt [patient] reports that her auditory hallucinations have persisted to this time. She reported dividing the hallucinations into the 'screamers' and the 'growler', which is a male voice that will growl at her. She has never been able to fully eliminate the AH [auditory hallucinations] even with the trials on multiple antipsychotic medications . ; she does report that she feels Haldol helped the most. She reports the voices are persucatory [sic] and negative, saying things 'like I'm terrible, I don't deserve anything. that's normal for me.' . she had a suicide attempt by swallowing mercury from a thermometer. She endorses excessive anxiety, worry, difficulty managing feelings of worry, trouble focusing and sleeping d/t anxiety, and feeling restless and tense often. reports seeing a new psychiatrist monthly and a therapist every 2 weeks. Pt's discharge orders from [name of hospital] prescriptions for Seroquel, Latuda, and Lorazepam; however, none of those medications are listed on pt's current SNF [skilled nursing facility] medication list. Per the SNF Resident Advocate it appears these were discontinued d/t concerns the medications were contributing to pt's weakness and falls. When asked if pt had been feeling different as these medications were discontinued she reported ongoing auditory hallucinations which are persucatory [sic] and derrogetory [sic] in nature, saying things such as 'I'm not worth anything, like I'm supposed to be stronger, stuff like that . She reports that 'I hear them all the time '; she feels her constant AH contritube [sic] to poor mood and increased anxiety and worry. She feels the voices have been stronger recently without her typical medications . she stated she 'noticed I haven't been sleeping well' and 'I could hear the voices more 'which has been disruptive to her sleep. Pt reported as she had previously that Haldol and Lorazapem [sic)] were very helpful in managing the voices and in 'keeping me calm '. She reported feeling 'fairly depressed' and 'You get depressed cause you get depressed in places like this.' . She feels that 'if there's any way I could get back on my meds [medications] that would be good.' She would likely benefit from a phone call with her outpatient mental health provider due to ensure adequate treatment of her psychiatric symptoms and to avoid decompensation from a psychiatric standpoint. On 1/5/22 at 2:34 PM, a facility staff documented on a re-admission assessment that resident 46 had scored a 15 on Brief Interview for Mental Status (BIMS), indicating that resident 46 was cognitively intact. On 2/9/22 at 9:23 AM, a physician documented that resident 46 States her voices are getting-scary voices are getting louder- causes anxiety. On 2/16/22 at 11:40 AM, facility staff completed a Personal Health Questionnaire 9 (PHQ-9) for resident 26. Staff documented that resident 46 had a score of 14, which indicated moderate depression. On 2/16/22 at 10:08 PM, nursing staff documented that resident 46 was having multiple episodes of screaming at the staff . at the top of her lungs and wouldn't stop. On 2/23/22 at 8:04 PM, a physician documented Consider antipsychoticsfor [sic] schizoaffective disorder and return of auditory voices. On 2/26/22 at 9:32 PM, a nursing staff member documented, Patient has History of Bipolar schizo affect disorder. and dependent personality disorder. I received a call from the patient's husband tonight he explained that she was on Seroquel 300 mg at HS [bedtime] At home. This is not in the current EMAR [Electronic Medication Administration Record] . Plan call the NP [Nurse Practitioner] or physician and notify. On 3/7/22 at 11:15 PM, a nursing staff member documented, Res [resident] having suicidal ideation's [at] 1820 [6:20 PM]. Aide notified nurses Res had call light around her neck. Aide removed cord from around neck. Nurses had to remove call light from her hand. Res stated she needs her psych meds which is why she did it. Res told aide Goodbye and informed aide that she has also said Goodbye to family. MD [Medical Doctor]/NP, appropriate staff and family notified. During cares Res stated she is losing hope. Res sent out via [name of ambulance company] to [name of hospital] for psych (psychiatric) evaluation. The consultant Licensed Clinical Social Worker (LCSW) notes for the last 6 months were reviewed. The LCSW did not address resident 46's behavioral concerns. Review of resident 46's medical record revealed that the resident did not receive any outside behavioral health services to evaluate her mental illness and medications. Resident 46 was readmitted to the facility on [DATE]. Resident 46 was admitted with the following medications: Seroquel 50 mg qd, Haldol 10 mg qd, Fluoxetine 20 mg qd, and Depakote 500 mg two times a day. On 1/7/22, facility staff created a care plan for resident 46's schizoaffective disorder and generalized anxiety disorder. The care plan indicated that the resident was to have her mental health needs met as outlined per the PASRR recommendations. The care plan also recommended that resident 46 meet with specialized services for mental illness treatment; and meet with outpatient mental health providers as needed while in the facility for psychiatric treatment/support. On 3/23/22 at 10:06 AM, an interview was conducted with the facility ADM. The ADM stated that the facility did not have a resident advocate or a social worker, so I'm doing all the work. On 3/26/22, after the resident returned from the hospital, care plans were developed for the following areas: depression with anxious features, mental health services through a local behavioral health provider, a history of auditory hallucinations, and a history of suicidal statements and actions. On 3/29/22 at 12:42 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1. CRN 1 confirmed that the facility did not have a resident advocate. On 3/30/22 at 9:15 AM, an interview was conducted with resident 46. The resident stated that she's upset that there isn't a social worker here, and feel like I'm losing hope. Resident 46 stated that there was one night recently that she was feeling really down so she called the crisis line because there was nobody to talk to here. On 4/04/22 at 9:52 AM, a follow-up interview was conducted with resident 46. Resident 46 stated that she called the suicide hotline a couple of times before attempting suicide in March 2022. Resident 46 stated that she wrapped the cord around her neck. I wanted to hang myself. I'm glad it didn't work now, but I gave up hope . There was no one here to talk to. On 4/6/22 at 10:28 AM, a follow-up interview was conducted with resident 46. The resident stated last month she was having a moment of hopelessness and tried to take her own life, stating they didn't give me my medication. Resident 46 stated that she told them in December that she needed her psychiatric medications, and they said here's this girl talk to her. Resident 46 stated that the staff member was the bookkeeper and not a mental health provider. Resident 46 stated that she asked the Administrator (ADM) to speak to a social worker and the ADM told her they did not have one at the facility. Resident 46 stated that was when she tried to strangle herself with the call light cord. Resident 46 stated that she had to go to the hospital for treatment after that. Resident 46 stated that while at the hospital they started her psychotropic medications again. Resident 46 stated that she had been on medications for depression and schizophrenia since she was [AGE] years old, and then when she came to the facility they took her off all of her psychotropic medications. Resident 46 stated that she told the facility nurses and physicians to restart the medications. Resident 46 stated that she thinks that the physician finally wrote it all down, but I couldn't believe how long it took. Resident 46 stated that she noticed changes in her mood while off of her medications the last several months. Resident 46 described these changes as it was up and down, then angry and then sad. It was terrible. They didn't have any social work or therapy services. Resident 46 stated she was seeing a psychiatrist outside of the facility prior to admission. Resident 46 stated that she requested from the ADM and the nurses to see her previous therapist and psychiatrist. Resident 46 stated that she had only seen her previous psychiatrist one time since requesting this. Resident 46 stated that since her suicide attempt facility staff have told her you didn't tell us you wanted to go. Resident 46 stated that after I tried to commit suicide they said we are going to send you to [name of a local behavioral health provider]. Resident 46 stated that before she attempted suicide she had asked to speak to someone about her mental health and was told no one was available, but now there was suddenly someone available. Resident 46 stated that after she attempted suicide, facility staff had restarted the antipsychotic medications she had been asking about. Resident 46 stated that when she attempted suicide she got mad at the staff member for removing the cord from around her neck, but now I thank [NAME] because I feel better. I am so, so happy that I didn't. I think I will get out of here some day, I hope soon. I have a daughter, a son, a grandson, a brother, sisters, a family, a life. I'm fine now, I take my medications and I'm fine. On 4/06/22 at 5:32 PM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated that she was the aide that was present when resident 46 attempted suicide. I'm the one who found her. CNA 6 stated that on the day of resident 46's attempted suicide she went to answer the resident's call light. CNA 6 stated that when she entered resident 46's room the resident had the call light wrapped around her neck two times, and she was trying to pull on it. CNA 6 stated that the call light was pulled out of the wall. CNA 6 stated that she tried to remove the call light from around resident 46's neck but the resident refused to let her take it. CNA 6 stated that the resident told her that she had already said goodbye to her family, and that she was saying goodbye to her also. CNA 6 stated that resident 46 had given up. CNA 6 stated that the resident had said to her, I don't want to be here. I just lost hope. CNA 6 stated that she calmed the resident down and attempted to take the call light from her, but the resident kept repeating no. CNA 6 stated that at that point she exited the resident room to notify the nurse. CNA 6 stated that when she went back to check on the resident she told her that people loved her and did not want her to die. CNA 6 stated that the resident was upset. CNA 6 stated that she noticed that once resident 46 was moved from the 3rd floor to the 2nd floor she became mad at everyone. CNA 6 stated that the resident would not talk to anyone and stated, I used to be nice, now I'm not. CNA 6 stated that the resident was unhappy at the facility and did not like several of the facility staff. CNA 6 stated that when resident 46 was re-admitted she was better, happy, and thankful to me that she was still here. CNA 6 stated that she had not received any training for resident behaviors from the facility. CNA 6 stated that as their caregiver they listen to the residents, and they get to know each person's behavior. I didn't get no training. You just learn as a CNA. The CNA stated that she reported everything to the resident's nurse. CNA 6 stated that they were not informed of any interventions that were available for resident behaviors, and that the nurse's did not provide that information to the aides. CNA 6 stated that the nurse's did not provide any direction on which residents had these types of behaviors or what to do when it occurred. CNA 6 stated that half of the facility staff were agency, we don't have staff. CNA 6 stated that agency staff come and go and they did not know the residents. CNA 6 stated this contributed to nurses not being able to communicate and train the aides on what the resident's behaviors and interventions were. CNA 6 stated, I think the problem is staffing. CNA 6 stated that the facility hired staff and then after the new employees worked, they decide they did not like it and leave. They see the type of behaviors and they run. CNA 6 stated that she had not received education on de-escalating resident behaviors. CNA 6 stated that the facility had a resident advocate (RA) and the residents would look for that person a lot. CNA 6 stated that the previous RA use to address the resident's concerns and handled a lot of their issues and problems. On 4/7/22 at 8:28 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated that the facility did not have a Social Service Worker (SSW). The ADM stated that the facility Resident Advocate left the faciity on January 17, 2022. The ADM stated that she was the staff member who was responsible for working with PASRR, and was unaware of some of the resident's PASRR recommendations until this week. On 3/29/22 at 12:42 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1. CRN 1 stated that there was not a resident advocate or social worker employed at the facility. On 4/7/22 at 11:01 AM, an interview was conducted with Employee 1. Employee 1 stated that they believed that much of the resident's behaviors would not have happened had the RA still been at the facility. Employee 1 stated that they recalled the RA giving the ADM grievances and the ADM did not following up on them. Some of the grievances were missing personal property, but some were bigger issues that involved resident behaviors in December 2021 or early January 2022. Employee 1 stated that resident 46 was transferred to the hospital due to a stroke, and progress notes confirmed this occurred in December 2021. Employee 1 stated that after resident 46 was re-admitted her demeanor changed and it looked like a conversion disorder. Employee 1 stated that resident 46 appeared more and more off, and then they came to find out that she went to the hospital with suicidal ideation. Employee 1 stated that since resident 46 had returned from the hospital, status post suicide attempt, she had been much better. Employee 1 stated that resident 46's past medical history and psychiatric history would have been beneficial for them to know so they could identify the resident's behavior and how it would impact the resident's mobility status. On 3/30/22, an interview was conducted with Medical Provider (MP) 3. MP 3 stated that prior to resident 46 being hospitalized , MP 3 had spoken with resident 46 while performing rounds. MP 3 stated that resident 46 reported she was feeling suicidal because they took me off medications and I need to go to the hospital. 2. Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE] diagnoses that included cerebral palsy, suicidal ideations, major depressive disorder, anxiety disorder, chronic pain syndrome, opioid use, and neuromuscular dysfunction of the bladder. Resident 49 was discharged from the facility on 4/10/22. Resident medical record was reviewed between 3/23/22 and 4/13/22. Resident 49's care plan was reviewed. On 3/2/21, after the resident's admission, the facility developed a care plan with regard to the resident becoming anxious. The care plan history revealed that this care plan was not revised throughout resident 49's stay at the facility. On 3/2/21, the facility also developed a care plan with regard to the resident feeling down or depressed. The care plan for depression indicated that the goal was to name at least one positive strength or ability each week. This goal was in place throughout the resident's stay at the facility, although no other documentation could be located to indicate this goal was being accomplished. In addition, interventions for the depression care plan were not revised throughout resident 49's stay at the facility. On 3/25/21, the facility developed a care plan resident 49 with regard to the resident having a PASRR Level II. The goal in place was to have the resident's mental health needs met by facility staff following PASRR II recommendations. In addition, interventions for the PASRR II care plan were not revised throughout resident 49's stay at the facility. On 3/2/21, facility staff completed an Evaluation for Community Access for resident 49 in which they determined that the resident had a history of being unsafe in the community and had a physical impairment which rendered the resident unsafe in the community. The resident met the criteria determining that resident should not be in community alone. A PASRR level II was completed for resident 49 on 3/22/21. The PASRR documented that resident 49 has a history of treatment for depression and anxiety, along with multiple maladaptive personality traits; all of these have caused pt (patient) significant functional impairment for many years. He also endorsed symptoms of PTSD (Post Traumatic Stress Disorder) that he reports are causing him significant disruption at this time. The PASRR indicated that resident 49 had a history of suicidal ideations and suicide attempts, beginning in his teens. The PASRR indicated that in September 2020, resident 49 was residing at a long term care facility and tried to strangle himself, which led to an inpatient psychiatric hospitalization. The PASRR continues He has also experienced excessive anxiety and worry, difficulty managing feelings of worry, restlessness/fatigue d/t (due to) excessive worry, irritability, tension, and trouble sleeping d/t anxiety. He has been diagnosed with bipolar in the past, but it appears that his symptoms are more consistent with borderline traits vs (versus) true manic sxs (signs and symptoms). he described very rapid mood swings but struggled to identify manic sxs. He has experienced and reported chronic fears of abandonment, a long standing pattern of dysfunctional interpersonal relationships and devaluation/elevations of others in relationships, impulsivity in multiple areas in his life . recurring and often impulsive suicidal gestures or threats (he purchased a knife on the Internet and had it delivered to his prior SNF (skilled nursing facility) in a suicidal gesture and later tried to strangle himself), anger/irritability w/o (without) provocation, and affective instability/emotional reactivity vs true mania (he describes going from depressed to angery (sic) very rapidly . ). He has also been diagnosed with antisocial personality disorder given his history of disregard for the rules (smoking marijuana in the SNF setting), being disrespectful to police w/o provocation, irritability and verbal aggression with staff, and reckless disregard for his own safety with his impulsivity and failure to plan ahead. He has taken flights impulsively to various places in the United States where he has no support, unable to provide for himself or without funds to pay for food and shelter. He has left multiple nursing homes AMA (against medical advice) without adequate planning for his needs, resulting in poor outcomes. He has often been deceptive/overreported symptoms in medication seeking behaviors (pain meds (medications) or benzos (benzodiazepenes)). He has also snuck friends into the SNF or has snuck out of SNF's in the past, violating COVID-19 protocols. He has feigned helplessness to get help or sympathy from staff. He has been physically assaulted on multiple occasions, including once being beaten up and left for dead in an abandoned house. Due to this incident among his other altercations he reports sxs of PTSD including recurring nightmares/intrusive memories (The nightmares don't stop and they haunt me), avoidant behaviors, feelings of distrust of others/detachment from others, persistent negative emotions, irritability/anger out of the blue (I don't know why I just get pissed and I want to fight or punch a wall or something), reckless/self-destructive behaviors, and difficulty sleeping d/t his nightmares. The PASRR also stated that Pt stated that he is willing to get a referral for mental health but that it can be difficult to re-establish rapport and trust with new mental health providers. Pt did state that he wants to have someone who can help him in his decision making, such as a guardian or POA (power of attorney) . He recognized that he needs help in his decision making, and stated I have walked away from too many places over nothing, and it is getting to the point where people are going to start saying we can't have him come here. I'm going to be in a lot worse place than where I'm at now If I don't get help. The SNF Resident Advocate was made aware of pt's wishes. Pt is on multiple psychotropic medications and he has been compliant in taking them. He reported that he has been depressed ever since leaving his prior SNF and that he hit bottom when he left there. He did not endorse SI (suicidal ideations) at this time; however given his history of impulsivity and multiple suicide attempts (and hospitalization d/t a suicide attempt in 2020) he should be closely monitored for any lethal means/means for self-harm that would be accessible to him. Given his online purchase of a knife in 2020 every package that might come to pt should be opened with staff present to ensure pt's safety. The PASRR listed the following recommendations for mental health treatment: He should be monitored closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. He should be referred for outpatient mental health treatment as well to him him learn better coping skills. He was getting treatment from [name of mental health provider] at his prior SNF. A second PASRR level II was completed for resident 49 on 3/22/21, that indicated resident 49 has profound motor deficits and has little assistive technology to help him. He would benefit greatly from assistive computer technology and an assistive communication device. He would also benefit from recreational activities that are geared to his age and interests. No indication could be located in the resident's EMR that these recommendations had been put into place. On 3/26/21, facility staff documented that Reported to administrator that resident confided in another resident that he was contemplating suicide. Nursing to monitor resident for behaviors/self harm and/or suicidal verbalizations. On 4/7/21, approximately 12 days later, the facility Licensed Clinical Social Worker (LCSW) Consultant documented the following in resident 49's progress notes: Special concerns and recommendations: 1:1, PRN (as needed), to address any concerns or issues. Provide support and validation. Encourage resident to participate in activities of his preference. Encourage and support family involvement. Remind resident of socially appropriate behavior. Praise resident when he deals with difficulties appropriately. Redirect resident to a quiet place to calm when aggressive or anxious. Encourage and help resident to participate in mental health therapy. Monitor resident closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. On 5/6/21, the Resident Advocate (RA) documented that resident 49 was having some hallucinations, and was talking to someone that wasn't there. He stated that a CNA (Certified Nursing Assistant) asked who he was talking to and [resident 49] stated another patients name, and CNA said there's no one here. RA informed DON and [mental health provider]. On 5/6/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 5/11/21 resident 49 attended a session with a local mental health provider. The provider documented that the resident reported feeling bored and lonelily (sic). We talked about activities to do in the room. On 5/27/21, a nursing note entry documented that resident reported to me that 3 weeks after his admit he had swallowed a razor and then threw it up. He states this was a razor that had been ordered [online] to cut his hair. He reported to me that he did not tell anyone at the time but he is now because he is worried that it may be a concerning factor to his recent sx and not feeling well. He denies having any suicidal ideations at this time. This was reported to the DON who stated pt has been having a lot of behaviors lately due to d/c (discharge) of pt's friend and that the bloodwork ordered this shift will be suffice (sic) indication to need for f[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 15. Resident 22 was initially admitted to the facility on [DATE] and again on 1/19/22 with diagnoses which included idiopathic peripheral autonomic neuropathy, endocarditis and heart valve disorders, history of COVID-19, major depressive disorder, muscle weakness, osteoarthritis of the left hip, and generalized anxiety disorder. On 3/29/22 at 2:25 PM an interview with resident 22 was conducted. Resident 22 stated that the facility was dysfunctional. Resident 22 stated that she had wounds on her legs which were painful. Resident 22 stated that she did not feel like she received good care at this facility. Resident 22's medical records were reviewed on 4/4/22 Resident 22 had an order that started on 2/10/22 and it stated wound care to right lower extremity, clean wound with wound cleaner or NS [normal saline], pat dry with gauze. Silver alginate to hold at 8'oclock, place medihoney over the whole wound, cover with bordered foam. Change Q [every] Tuesday, Thursday, Saturday, and PRN [as needed]. The Treatment Administration Record (TAR) for March was reviewed. Documentation for wound care was missing on 3/5/22, 3/10/22, 3/15/22, 3/17/22, 3/22/22, 3/29/22, and 3/31/22. It should be noted that, during the month of March, resident 22 received wound care treatment for 7 out of the 14 days that it was ordered to be completed. On 4/5/22 at 1:52 PM an interview was conducted with resident 22. Resident 22 was sitting on the side of her bed and appeared to be confused. Resident 22 was swaying back and forth while sitting on side of the bed. Resident 22 stated that she had fallen multiple times. Resident 22 stated that she thought she hit her head at least once when she fell. Resident 22 sounded groggy with slurred speech and could not focus during the interview. On 4/5/22 at 1:55 PM an interview with Registered Nurse (RN) 2 was conducted. RN 2 stated that she started work at 6:00 AM this morning and learned that resident 22 had multiple falls last night. RN 2 stated that resident 22 had fallen two or three times since she began working at 6:00 AM. RN 2 stated that she has asked the Assistant Director of Nursing (ADON) to send resident 22 to the hospital, but the ADON responded by saying that resident 22 is just drugged up. RN 2 stated that she had been conducting neurological checks for resident 22 but no new interventions have been put in place to prevent her from falling again. RN 2 stated that resident 22 had low oxygen and was non-compliant with wearing the nasal cannula for oxygen. RN 2 stated that she believes resident 22's low oxygen levels were making resident 22 more confused. On 4/5/22 at 2:04 PM resident 22 was observed to be left unsupervised. Resident 22 was observed dropping a cup and leaning over to pick it up. Resident 22 appeared to be unstable. On 4/5/22 at 2:14 PM the ADON entered resident 22's room and asked resident 22 if she wanted to go to the hospital. Resident 22 appeared to be confused and agreed to be sent to the hospital. The ADON then left the room leaving resident 22 unsupervised. On 4/5/22 at 2:20 PM RN 2 entered resident 22's room for a neurological check. Resident 22 stated that her back was hurting, and she could not stand up. On 4/5/22 at 2:47 PM the Emergency Medical Services (EMS) arrived and entered Resident 22's room. The EMS worker asked RN 2 how many times resident 22 had fallen. RN 2 stated that she did not have an exact number but resident 22 spent most of the night on the floor. On 4/5/22 at 3:05 PM an interview with the EMS worker was conducted. The EMS worker stated that resident 22 had an irregular heartbeat, irregular strength in her hands, and the EMS worker was concerned that resident 22 was having a cardiac event. The EMS worker stated that the facility should have sent resident 22 to the hospital sooner. On 4/5/22 at 3:55 PM an interview with the ADON was conducted. The ADON stated that she was first aware that resident 22 had falls and symptoms of confusion around 10:00 AM or 11:00 AM that day (4/5/22). The ADON reported that she did not think resident 22 had fallen today. The ADON stated that they did not have interventions in place to prevent resident 22 from falling again besides watching her closely and notifying the doctor of changes. A review of resident 22's medical record was conducted on 4/7/22. Resident 22's electronic medical record revealed that there was not documentation noting the first time resident 22 fell or how many times resident 22 fell. However, a document titled Vital Signs with Neuro Checks was reviewed and it was revealed that neurological checks for resident 22 began on 6:30 PM on 4/4/22. On 4/7/22 resident 22's hospital records from 4/5/22 were reviewed. It was revealed that a CT brain imaging showered resident 22 had suffered a small upper right frontal scalp hematoma but no intracranial bleeding. Hospital records revealed that resident 22 was being treated for cellulitis of the right leg, sepsis, acute kidney injury, and hyponatremia. The hospital records revealed the following statement, I'm concerned that her leg wounds do not appear to be particularly well-cared for and I suspect even if these chronic wounds were clean at one time they are now grossly infected, possibly due to inadequate wound care. I am also concerned there may be a deeper process such as osteomyelitis. 16. Resident 29 was initially admitted to the facility on [DATE] and again on 1/24/22 with diagnoses which included type 2 diabetes mellitus, chronic obstructive pulmonary disease, cerebral infarction, acute myocardial infarction, unspecified dementia, anxiety disorder, and low back pain. On 4/6/22 at 11:15 AM an interview with resident 29 was conducted. Resident 29 stated that the staff rarely changed the dressing for his wounds. Resident 29 stated that the last time his dressings for his wounds were changed and cleaned was 3 days ago. On 4/12/22 an interview with resident 29's family member was conducted. Resident 29's family member stated that once resident 29 returned from the hospital on 1/24/22, they noticed that resident 29 was always lying in the same position. The family member stated that they asked the staff multiple times if resident 29 could be moved to a different position, along with asking staff if they have noticed any sores on his backside. The family member stated that the Certified Nursing Assistant (CNA) 's reported to her that they have not seen anything. Resident 29's medical record was reviewed on 4/6/22. A progress note dated 3/9/22 revealed that resident 29 had a new order for wound care for a new wound on his coccyx. A document from the wound clinic 3/10/22 was reviewed. The document stated, Patient has a new wound on his coccyx/sacral area. There is an open area in the center that is into subcutaneous tissue. Therefore we will begin staging at a stage III however, the periwound tissue is dark, non-blanching and has characteristic so of deep tissue injury measuring approximately 15.0 [centimeters] x 15.0 [centimeters]. A review of resident 29's orders for wound care was conducted. A. The initial order for resident 29's wound care began on 3/10/22 and stated, Cleanse wound with wound cleanser. Cover wound on coccyx and buttock with large bordered foam dressing. Date and initial wound dressing. Change dressing daily. One time a day for wound healing. Start date was 3/10/22. Discontinue date was 3/11/22. a. According to the documentation, wound care was not completed on 3/11/22. B. The wound care order was changed on 3/12/22 to, Cleanse wound with wound cleanser. Cover wound on coccyx, place silver alginate, cover with large bordered foam dressing. Date and initial wound dressing. Change dressing daily. One time a day for wound healing. Start date was 3/12/22. Discontinue date was 3/24/22. a. According to the documentation, wound care was not completed on the following dates: i. 3/12/22 ii. 3/13/22 iii. 3/14/22 iv. 3/18/22 v. 3/19/22 vi. 3/21/22 vii. 3/22/22 viii. 3/23/22 b. On 3/15/22 the wound care was documented as Other/See Progress Note. However, there was no progress note from 3/15/22 regarding the wound care order for resident 29. It is unclear if resident 29's wound care was completed on 3/15/22. C. The wound care order was again changed to, Wound to coccyx, clean wound, Pak wound with kerlix soaked with ¼ strength Dakin's (fill cavity loosely) cover with bordered foam. Change daily one time a day for wound healing. Start date was 3/25/22. The order was reviewed up until 4/5/22. a. According to the documentation, wound care was not completed on the following dates: i. 3/25/22 ii. 3/27/22 iii. 3/28/22 iv. 3/29/22 v. 3/31/22 vi. 4/2/22 vii. 4/3/22 viii. 4/4/22 ix. 4/5/22 [It should be noted that the orders for wound care to coccyx for resident 26 was documented as completed for 5 of the 25 days ordered.] A document from the wound clinic dated 3/24/22 was reviewed. The document stated that the wound on resident 29's coccyx had been adjusted to a stage IV pressure ulcer do to exposed muscle and fossa in the wound bed base. The document also had recommendations for a surgical consult and debridement, a wound VAC, and nutritional interventions. An observation of would care for resident 29 was conducted on 4/6/22 at 1:35 PM. Licensed Nurse Practitioner (LPN) 1 was conducting the wound care order. Once resident was turned on his side, it was observed that there was no previous dressing on resident 29's pressure ulcer. LPN 1 stated that resident 29 required a daily change of his dressing. LPN 1 stated, maybe the previous dressing came off. It was observed that LPN 1 cleared fecal matter from the wound prior to packing the wound with Dakins soaked gauze. On 4/5/22 at 1:45 PM an interview with Registered Nurse (RN) 2 was conducted. RN 2 stated that she was often so busy during her shift that she would not be able to complete the wound care. RN 2 stated that she was busy today and most likely would not get to the wound care today. On 4/12/22 an interview with resident 29's family member was conducted. The family member stated that it did not seem like the facility cared about his wounds. The family member stated, I feel like he [resident 29] was neglected. A progress note from 4/9/22 revealed that resident 29 was going to be placed on hospice. [Cross refer to F609, F610, F684, F943, and F947] 11. Staff to resident verbal abuse Resident 51 was admitted to the facility on [DATE], with a diagnosis that included polyneuropathy, quadriplegia, type 2 diabetes, viral hepatitis, chronic kidney disease, hypertension and arthritis. On 3/29/22 at 1:04 PM, an interview with resident 51 was conducted. During this interview resident 51 stated that he had an argument with Certified Nursing Assistant (CNA) 8. Resident 51 stated that CNA 8 swore at him and lunged at him like he was going to attack him. Resident 51 stated that CNA 8 then flipped him off with both hands and left the room. Review of the facility ABUSE INVESTIGATION AND REPORTING LOG by the facility Administrator (ADM) documented CNA coordinator and administrator spoke with resident [51]; he said CNA [8] was upset about being asked to move things around in the room, and he was verbally abusive with the resident; CNA left the resident sitting up on the bed and came back a few minutes after and flipped him up. The resident could not tell the administrator what was said to him by CNA [8]. The administrator ensured resident (sic) [8] was suspended and had not access to the facility. Administrator asked resident if he was ok. Resident stated 'I am ok'. The report documented that the ADM was not able to reach CNA 8 by telephone for an interview. The report documented Cna that worked the shift with CNA [8] was working with a different patient at the time of incident, [CNA 8] stated that resident [51] was upset, and he walked out of the room and let the resident calm down. the CNA and nurse help the resident to get in bed and she took care of the resident the rest f (sic) the night. It should be noted that the ADM did not identify who the CNA was that gave this interview. The report documented that the facility substantiated the verbal abuse and CNA 8 was terminated. On 3/25/22 the facility investigation was documented as completed. 12. Resident interviews regarding abuse Resident 43 was admitted to the facility on [DATE]. He had a diagnosis that included alcohol dependence, peripheral neuropathy, hyperlipidemia, anxiety, depression, muscle weakness, lack of coordination, club foot and insomnia. On 3/26/22 at 7:20 AM an interview with resident 43 was conducted. Resident 43 stated that there was a huge discrepancy between agency and regular staff nurses in how staff treat resident. Resident 43 stated that last Friday night [3/18/22] there was an agency nurse and that she was very mean, the nurse stating that he wasn't getting his medication until later because he was at the end of the hall. Resident 43 stated that CNA 8 had called him names, and was rude to him to include lunging at him like he was going to attack him. Resident 43 stated that agency nurses are often rude and aggressive. Resident 43 stated that he has discussed this with the Administrator and that nothing changes. 13. Employee interviews regarding abuse On 3/29/22, Employee 1 was interviewed. E 1 stated that when they had asked staff about abuse in the facility, the ADON told them that it would be discussed by the administrative staff. E 1 stated that they never heard officially about abuse. E 1 stated that they were aware that the management team had received information about abuse in January, 2022, but nothing was investigated. On 3/29/22 at 12:42, Corporate Resource Nurse (CRN) 1 was interviewed. CRN 1 stated that there were social service concerns in the building that were referred to the ADM, and that the Licensed Clinical Social Worker (LCSW) who spoke with residents in the facility was unavailable by telephone. CRN 1 stated that she was aware of three physical altercations in the last week. CRN 1 stated that she was not informed about many altercations. CRN 1 stated that she was not aware of a resident being left unattended outside. CRN 1 stated that she did hear about the sexual abuse, and was not sure why she had been contacted until she found that the ADM had not done an investigation. CRN 1 stated that the ADM did not inform the management team about the sexual abuse. CRN 1 stated that whenever a resident punched another resident, it was abuse and should have been reported. On 3/29/22 at 1:32 PM, the Administrator was interviewed. The ADM stated that she was aware of some abuse in the facility but had not done training until February, and again in April, 2022. The ADM stated that she had not done any quality assurance on abuse. The ADM stated that resident 49 did not fit well in the building, but would do better in a group home, and has a lot of issues with some of the residents. The ADM stated that she had helped break up some of the arguments and fights between residents. The ADM stated that sometimes residents yelled at each other, but that was typical for this population. The ADM stated that when there were physical fights, there should have been reports, but sometimes the reports don't get finished. The ADM stated that she knew that a female resident had been laying down in another resident's room on the bed with him watching television when the roommate interrupted them, which caused a fight. The ADM stated that it was between resident 23 resident 51. The ADM stated that the police had been called for that altercation. The ADM stated that resident 51 had called a family member who then called the ADM. The family member of resident 51 told the ADM that the facility was not taking good care of resident 51. The ADM stated that she took the family member's concerns seriously. The ADM stated that she was told resident 51 was left outside on the patio in February. The ADM stated that she was aware that resident 16 was threatened, and the reports were on her desk. On 3/29/22 at 10:10 AM, the ADON was interviewed. The ADON stated that on the second floor of the facility, there were a lot of people from the streets. The ADON stated that it was normal for them to use language that would make other people gasp. The ADON stated that she was aware of abuse allegations, including previous staff members being abusive. The ADON stated that she was aware of various abuse allegations, but did not have any direct role in abuse unless she personally saw it. On 3/24/22 an interview was conducted with Employee 11. E 11 stated the ADON was borderline abusive, telling resident 21, you're never going to get out of here. E 11 stated that it took several hours to calm resident 21 after that incident. E 11 stated that therapy had talked about turning down the power on resident 111's wheel chair, because she ran into people. On 3/30/22 at approximately 11:00 AM, a Medical Provider (MP) 2 was interviewed. MP 2 stated that the providers were informed about some assaults, but other abuses were provided by hearsay. MP 2 stated that they were included on the group text, so they heard of some encounters through that method. MP 2 stated that the physician group wanted to be informed of the resident-to-resident interactions to help manage the needs of the residents. On 4/11/22 at 12:20 PM, the ADON was re-interviewed. The ADON stated that some residents had altercations over the previous weekend. The ADON stated that the residents utilized street language, but sometimes residents were upset about what the other residents said to them. The ADON stated that sometimes the residents yelled at each other, and she should have documented it. The ADON stated that she did not remember creating an incident report for the incidents. The ADON stated that she told the contending residents to avoid each other. The ADON stated, I have a hard time with these residents, just because they say swear words to one of them and they're upset and mortified by what they said, but they will turn around and say it back. NEGLECT 14. Resident 51 was admitted to the facility on [DATE], with a diagnosis that included polyneuropathy, quadriplegia, type 2 diabetes, viral hepatitis, chronic kidney disease, hypertension and arthritis. Resident 51's Quarterly MDS assessment dated [DATE] indicated that resident 52 required extensive physical assistance of two or more persons with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The MDS also indicated that the resident was totally dependent on staff for bathing. The MDS indicated that resident 51 required the use of a wheelchair, and had a functional limitation in his range of motion on both of his lower extremities. On 3/29/22 at 1:04 PM an interview with Employee 1 (E 1) was conducted. E 1 stated that there was an incident to resident altercation with resident 51 back in February. E 1 was unsure of the date but stated that resident 51 was left outside on the smoking patio for an extended time frame. E 1 stated that they were told that the resident was out there by another resident. E 1 stated that when resident 51 was brought back in E 1 noticed that resident 51's skin color was purple and resident 51 was shaking uncontrollably. E 1 stated that Employee 10 took resident and had to wrap him in blankets and place him in front of the heater in the Rehabilitation Gym for a couple hours to get resident 51 warm again. On 3/29/22 at 1:38 PM an interview was conducted with resident 51. During this interview, resident 51 stated that he was left on the smoking patio in February for about 4 hours. He stated that he was unable to get back in because he has limited mobility and could not move his wheelchair very well. Resident 51 stated that it was in February and very cold, but could not remember the date. Resident 51 stated that Employee 10 brought him in and provided blankets and put him in front of a heater. On 3/29/22 a review was conducted of nurses notes to identify the date of incident and the incident was not documented. On 3/29/22 at 1:48 PM an interview with CNA 2 was conducted. CNA 2 stated that he was not working the day of the incident, and could not remember the date, but stated that he remembers this occurred back in February. On 3/29/22 at 2:00 PM an interview with Employee 10 was conducted. Employee 10 stated that he moved the resident who had been outside upstairs to get warm, but that the resident was not really that cold. Employee 10 stated that he did not know how long resident had been out on the patio. Based on interview and record review, it was determined for 18 of 51 sample residents, that the facility did not ensure that residents were free from abuse and neglect. Specifically, two residents with severe cognitive impairment were engaged in sexual relationships of which the staff were aware, with no assessments to determine if this was consensual, appropriate or safe. Additionally, multiple residents were engaged in verbal and physical abuse altercations with other residents, and interventions were inconsistent or non-existent with regard to how facility staff addressed resident behaviors (prevention, re-direction, allowing privacy, and the administration of psychoactive medications). These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, incidents of verbal and physical abuse between staff and residents, and incidents of neglect with wound care, a resident's change in condition, and a dependent resident was exposed to inclement weather for an extended period of time were identified at a HARM level. Resident identifiers: 4, 6, 14, 16, 18, 20, 21, 22, 23, 25, 29, 31, 37, 43, 47, 51, 53 and 111. On 4/4/22 at 1:10 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally to the facility Administrator (ADM), Corporate Resource Nurse (CRN) 1, and the Regional [NAME] President (RVP). On 4/12/22, the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 4/12/22 at 10:00 AM: 1. Resident #14 no longer resides at the community, therefore, the community does not have an individualized plan of correction. Resident #31 was placed on a 1:1 and remains on a 1:1. 2. All residents shall be assessed for signs and symptoms of abuse. The assessments shall be conducted by an LCSW [Licensed Clinical Social Worker] or CSW [Clinical Social Worker] with experience interviewing victims of abuse, as well as a registered nurse or advanced practice clinician. 3. Education was initiated on 4/11/2022 by the consultants regarding the community abuse policy including reporting allegations of abuse to the abuse prevention coordinator, reporting allegations of abuse to the proper authorities, and conducting thorough investigations. Thorough investigations to include immediate protection of the residents, interviewing the alleged victim, alleged assailant, any witnesses, other residents who could potentially be affected by the alleged violation, family/visitors if there are any who may have pertinent information, conducting an assessment of the alleged victim, conducting observations of cares if pertinent, conducting searches if necessary, and implementing pertinent interventions to attempt to prevent recurrence. Progress notes to be reviewed (M-F) by the DON [Director of Nursing]/designee daily to ensure that any allegations of abuse are being reported per community expectations to management and to the appropriate authorities, and that allegations of abuse are thoroughly investigated. Identified concerns to be addressed immediately and investigations initiated. NHA [Nursing Home Administrator] /designee will be responsible for contacting the appropriate authorities for allegations of abuse. Each allegation will be discussed verbally with the consultants and the consultants will have access to the report to ensure they are submitted timely to the health department. The consultants provided the community with a new daily standup meeting agenda. This agenda will include an abuse reporting log to track and trend all reported allegations for the month. The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed. NHA/designee to complete review of three (3) abuse allegations a week for three (3) months to ensure that the investigation was thorough, that there were interventions implemented to correct the alleged violations, and that there was protection of the alleged victim while the investigation was ongoing. 4. The NHA/designee will report findings from the audits to the QAPI Committee monthly for three (3) months. The QAPI committee will identify any trends and take corrective action as needed. On 4/12/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/12/22 at 10:00 AM. IMMEDIATE JEOPARDY: 1. Resident to resident sexual abuse Resident 14 was admitted to the facility on [DATE] with diagnoses that included an intercranial injury, Post-Traumatic Stress Disorder (PTSD), adjustment disorder, hypertension, pseudobulbar effect, osteoarthritis, history of a traumatic brain injury, and urinary incontinence. Resident 31 was admitted to the facility on [DATE] and readmitted after two days away from the facility on 11/8/21 with diagnoses that included chronic obstructive pulmonary disease (COPD), emphysema, heart failure, depression, essential hypertension, and an unspecified mood disorder. On 3/24/22 at 9:10 AM, Certified Nursing Assistant (CNA) 17 was interviewed. CNA 17 stated that on 2/20/22, she was walking in the hall at the facility when she saw resident 31 in the hallway, walking toward his room. CNA 17 stated that when she returned from going into a resident's room, she came back out and he was not in the hallway anymore. CNA 17 stated that when she looked for resident 31, he was found in resident 14's room, leaning over the side rail of her bed and sucking on her bare breast. CNA 17 reported that she immediately separated the two residents and reported to the other CNA working at that time and to the nurse on duty, Licensed Practical Nurse (LPN) 2. CNA 17 stated that LPN 2 talked to the administrator on duty. CNA 17 stated that resident 31 would lean across residents to brush against their breasts and would smack people on the butt. CNA 17 stated that she texted the Administrator (ADM) when it happened and she had expected to follow up with the ADM the following Monday. On 3/29/22 at 3:55 PM, an interview was conducted with DON 2. DON 2 stated that she was no longer employed at the facility but was the DON at the time of the sexual abuse between residents 14 and 31. DON 2 stated that at breakfast time on 2/20/22 that LPN 2 had received a report from CNA 17 regarding resident 31 being in resident 14's room. DON 2 stated she spoke with LPN 2, and then called the ADM immediately to notify her. DON 2 stated that she was working the day of the incident and the whole day was crazy because I was trying to get another room for [resident 31]. DON 2 stated that the ADM was trying to transfer resident 31 to a different facility. DON 2 stated that she also reported the incident to CRN 1 on 2/28/22. DON 2 provided records from her mobile phone provider to show the phone call from her phone to the Administrator's mobile phone on 2/20/22 at 8:08 AM. The call lasted 12:08 minutes. DON 2 also stated that on 2/22/22 she sent a text message to the Administrator asking the Administrator if she had spoken to CNA 3. The former ADON provided a screenshot of the text message from her mobile phone to the mobile phone of the Administrator. The text was, Did you talk to (CNA 3) today about (resident 31)? On 3/25/22 at 8:35 AM, resident 14 was observed in her room and was immediately interviewed. Resident 14 was pleasant and unable to answer questions about her cares and situation. Resident 14's room smelled strongly of urine and black flecks and smears were observed on the wall above the headboard of the bed. On 4/13/22, medical record reviews were completed for residents 14 and 31.<[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined for 14 of 51 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, entity reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy Level. Resident identifiers: 4, 6, 14, 16, 18, 20, 23, 25, 31, 38, 49, 51, 53, and 111. NOTICE: On 4/4/22 at 1:10 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to report all allegations of resident abuse. This notice was given verbally to the facility Administrator (ADM), Regional [NAME] President (RVP), and the Corporate Registered Dietician (CRD). On 4/12/22, the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 4/12/22 at 10:00 AM: F609 1, Resident #14 no longer resides at the community, therefore, the community does not have an individualized plan of correction. Resident #31was placed on a 1:1 and remains on a 1:1. 2. All residents shall be assessed for signs and symptoms of abuse. The assessments shall be conducted by an LCSW or CSW with experience interviewing victims of abuse, as well as a registered nurse or advanced practice clinician. 3. Education was initiated on 4/11/2022 by the consultants regarding the community abuse policy including reporting allegations of abuse to the abuse prevention coordinator, reporting allegations of abuse to the proper authorities, and conducting thorough investigations. On 4/11/2022 the consultants provided education and training with the Interdisciplinary Team (IDT) and well as community staff. The NHA/designee will be responsible for contacting the appropriate authorities for allegations of abuse. Each allegation will be discussed verbally with the consultants and the consultants will have access to the report to ensure that reports are submitted timely to the health department. Progress notes to be reviewed (M-F) by the DON/designee daily to ensure that any allegations of abuse are being reported per community expectations to management and to the appropriate authorities, and that allegations of abuse are thoroughly investigated. Identified concerns to be addressed immediately and investigations initiated. The consultants provided the community with a new daily standup meeting agenda. This agenda will include an abuse reporting log to track and trend all reported allegations for the month. The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed. 4. The NHA/designee will report findings from the audits to the QAPI Committee monthly for three (3) months. The QAPI committee will identify any trends and take corrective action as needed. On 4/12/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/12/22 at 10:00 AM. IMMEDIATE JEOPARDY 1. Resident to resident sexual abuse Resident 14 was admitted to the facility on [DATE] with diagnoses that included an intercranial injury, Post-Traumatic Stress Disorder (PTSD), adjustment disorder, hypertension, pseudobulbar effect, osteoarthritis, history of a traumatic brain injury, and urinary incontinence. Resident 31 was admitted to the facility on [DATE] and readmitted after two days away from the facility on 11/8/21 with diagnoses that included chronic obstructive pulmonary disease (COPD), emphysema, heart failure, depression, essential hypertension, and an unspecified mood disorder. On 3/24/22 at 9:10 AM, Certified Nursing Assistant (CNA) 17 was interviewed. CNA 17 stated that on 2/20/22, she was walking in the hall at the facility when she saw resident 31 in the hallway, walking toward his room. CNA 17 stated that when she returned from going into a resident's room, she came back out and he was not in the hallway anymore. CNA 17 stated that when she looked for resident 31, he was found in resident 14's room, leaning over the side rail of her bed and sucking on her bare breast. CNA 17 reported that she immediately separated the two residents and reported to the other CNA working at that time and to the nurse on duty, Licensed Practical Nurse (LPN) 2. CNA 17 stated that LPN 2 talked to the administrator on duty. CNA 17 stated that resident 31 would lean across residents to brush against their breasts and would smack people on the butt. CNA 17 stated that she texted the Administrator (ADM) when it happened and she had expected to follow up with the ADM the following Monday. On 3/29/22 at 3:55 PM, an interview was conducted with DON 2. DON 2 stated that she was no longer employed at the facility but was the DON at the time of the sexual abuse between residents 14 and 31. DON 2 stated that at breakfast time on 2/20/22 that LPN 2 had received a report from CNA 17 regarding resident 31 being in resident 14's room. DON 2 stated she spoke with LPN 2, and then called the ADM immediately to notify her. DON 2 stated that she was working the day of the incident and the whole day was crazy because I was trying to get another room for [resident 31]. DON 2 stated that the ADM was trying to transfer resident 31 to a different facility. DON 2 stated that she also reported the incident to CRN 1 on 2/28/22. On 3/25/22 at 8:35 AM, resident 14 was observed in her room and was immediately interviewed. Resident 14 was pleasant and unable to answer questions about her cares and situation. Resident 14's room smelled strongly of urine and black flecks and smears were observed on the wall above the headboard of the bed. On 4/13/22, medical record reviews were completed for residents 14 and 31. Resident 14's Minimum Data Set (MDS) was completed on 11/12/21, and revealed that her BIMS score was 7, with severely impaired cognition. Resident 31's MDS was completed on 1/28/22, and revealed that his BIMS score was 10, with moderately impaired cognition. Resident 14's nursing notes were reviewed and did not include information about the abuse. Resident 31's nursing notes were reviewed and did not include information about the abuse. Resident 14's care plan was reviewed and did not reveal any interventions regarding the abuse. Resident 31's care plan was reviewed. On 3/30/22, resident 31's care plan was updated to include the following: a focus that he wanders into others' rooms uninvited and may touch them inappropriately. Goals were that the resident would not enter other resident's rooms uninvited, and that he would not touch other residents. The interventions were to Monitor whereabouts closely, ensure his room is close to his smoking area, remind him he cannot go into others' rooms, if actively observed, tell him to 'stop' and notify administrator immediately. Assist him out of room and keep in line of sight monitoring for next hour. Resident 14's monitoring was located in the CNA Task list included monitoring for sexual behaviors. The task list was available for the previous 30 days and included the dates of 3/1/22 to 3/30/22. Resident 14 had two documented sexual behaviors. Resident 31's monitoring was located in the MAR/TAR and revealed that nurses were monitoring for mood swings, sleep, shortness of breath, depression, and pain. Resident 31 did not have monitoring for sexual behaviors. On 3/5/22, an incident report was completed for resident 14. The incident report revealed that on 2/27/22 at 12:00 PM, resident 31 might touch resident 14 inappropriately on her breast area. [Note: The date of the abuse listed on the report was not consistent with the date that the ADM had received the report of the abuse, and the incident report was completed approximately 2 weeks after the incident occurred.] The final investigation completed by the facility documented the following: It was reported to the administrator that a report of abuse was made on 2/27/22 to the nurse and did not get reported to the administrator until a later date. The abuse report was made to the agency nurse that failed to report to the administrator. The administrator talked to CNA (Certified Nursing Assistant) doing the report. CNA said to the administrator she was walking doing her rounds when she saw [resident 31] in [resident 14 ' s] room leaning over and appeared to her the [resident 31] was touching [resident 14 ' s] breast. CNA asked [resident 31] to leave the room and return to his room. CNA reported to the nurse and continued monitoring the resident and making sure [resident 31] did not enter [resident 14 ' s] room. CNA stated since the incident happened until the day it was reported to the administrator, the incident between [resident 31] and [resident 14] hasn ' t occurred again between residents involved or with any other female resident to the CNA ' s knowledge. The Administrator later documented that a CNA witnessed resident 31 with resident 14 ' s breast in his mouth, and that the CNA reported this to the Director of Nursing and Assistant Director of Nursing. The Administrator documented that we substantiated sexual abuse . Both residents are confused and [resident 31] do this out of confusion than a sexual abuse intent. A review was performed of the facility's Entity Report, which was submitted to the State Survey Agency (SSA). The report was submitted at 12:53 AM on 3/6/22. The Administrator documented the incident occurred at 12:00 PM on 2/27/22. The ADM described the allegation as follows: resident 2 (resident 31) allegedly inappropriately touched resident 1's (resident 14) breast area. An investigation into the incident to ensure that the incident actually occurred. physician and family notified. A review of the SSA database revealed that no final report had been submitted. The census for resident 14 revealed that she was in room [ROOM NUMBER] at the time of the abuse. Resident 31's census revealed that he was in room [ROOM NUMBER]. room [ROOM NUMBER] was located between resident 31's room and the smoking patio. Resident 31's census revealed that he was moved to room [ROOM NUMBER] on 3/21/22, 22 days after the abuse occurred. [Note: No evidence could be located to indicate that resident 14 was being appropriately protected from further sexual abuse, that other potential victims had been identified, or that prompt interventions were put into place to prevent sexual abuse perpetrated by resident 31 from re-occurring.] On 3/29/22 Employee (E) 11 was interviewed. E 11 stated that she was working on the day of 2/20/22. E 11 stated that there were no open rooms that day, so resident 31 was not moved away from resident 14. E 11 stated that the ADM did not come to the building to do an investigation that day. E 11 stated that they talked to the ADM the next day and the ADM asked E 11 and the other staff to stop talking about the abuse incident. E 11 stated that they talked to the other staff, and to their knowledge, no staff was interviewed about the incident by the ADM. E 11 stated that the ADM asked CNA 16 to keep an eye on resident 31, but CNA 16 was busy helping other residents. E 11 stated that the Assistant Director of Nursing (ADON) reported to E 11 that resident 31 had also massaged resident 14's breasts in a subsequent encounter after 2/20/22. E 11 stated that when they had reported any issues to the ADM, the ADM would say something like Well I will take care of it because we don't want State in the building right now. On 3/24/22, Employee (E) 13 was interviewed. E 13 stated that there were no official statements made to staff about the abuse from resident 31 to resident 14, but there had been rumors in the facility. E 13 stated that there were no interventions implemented immediately, and they had not been provided specific interventions, monitoring or official reports. E 13 stated that they would have liked to know what monitoring should have been done to protect resident 14. On 3/29/22 at 8:52 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that resident 14 did not have a roommate at the time of the abuse. The ADON stated that at one time, resident 31 was sitting by resident 14's bed with his hand above her breast. The ADON stated that she had heard about the abuse from the previous Director of Nursing (DON 1). The ADON stated that resident 14 was very innocent. The ADON stated that she did not tell other staff about the incident because they were still investigating. The ADON stated that the Administrator wanted resident 31 watched more closely. The ADON stated that whether or not resident 14 and resident 31 were confused, I guess they're both adults. The ADON stated that she did not know what was done with the investigation. The ADON stated that she didn't think abuse had happened so she did not tell other staff about it. The ADON stated that resident 31 went in and was sitting by resident 14's bed and his hand looked like it was above her breast. The ADON stated that because resident 31 was very short of breath, he probably just wanted to sit in resident 14's room for a while, so it probably wasn't anything. On 3/29/22 at 12:42 PM, an interview was conducted with the CRN 1. CRN 1 stated that abuse at the facility was reported to her unless it was just a little scuffle. CRN 1 stated that she was not always notified about abuse. CRN 1 stated that she received an email on 3/3/22 about the abuse between resident 31 and resident 14, but had not heard about the abuse prior to that. CRN 1 stated that she had forwarded this email to the ADM and the RVP that day. CRN 1 stated that the email reported that on the weekend of 2/18/22, a staff member reported that resident 31 was observed to be sucking on resident 14's breasts. CRN 1 stated that she was told that during that weekend, the ADM had placed resident 31 on 1:1 staffing. CRN 1 stated that she was told the ADM had not investigated the abuse before that time. CRN 1 stated that it was reported to her that there was a report of both the sucking on boobies and resident 31 massaging resident 14's breasts twice by the time she became aware of the incident on 2/20/22. CRN 1 stated she was not sure why the ADM had not investigated the sexual abuse incident(s) between residents 14 and 31. On 3/29/22 at 1:32 PM, an interview was conducted with the Administrator (ADM). The ADM stated that she was managing all the abuse, along with complaints, discharges, and social work concerns in the building. The ADM stated that she did not recall when she was notified about the abuse between resident 31 and resident 14. The ADM stated that she investigated the incident in March and had substantiated the abuse. The ADM stated that she had moved the patient around so resident 31 was not close to resident 14. The ADM stated that she moved resident 31 closer to the smoking patio where he smoked. The ADM stated that the CNAs did rounds every two hours, so they would be checking on the residents when they rounded. The ADM stated that both residents were confused, and that resident 31 was too frail to walk down to resident 14's room, so abuse was probably not happening. 2. Resident to Resident physical and verbal abuse A. Resident 20 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure, type 2 diabetes mellitus, cerebral infarction, hypertension, major depressive disorder, anxiety disorder, acute kidney failure, alcohol dependence, and myelopathy. On 3/25/22 at approximately 10:00 AM, an interview was conducted with resident 20. Resident 20 stated that there was a fight in the hallway between resident 6 and resident 25. Resident 20 stated that resident 6 tried to hit resident 25. Resident 20 stated that she intervened and told resident 6, don't you hit him. Resident 20 stated that resident 6 replied, you shut up you fucking bitch or I'll get you next. Resident 20 stated that she returned to her room scared. Resident 20 stated that as a result of the fight, they moved resident 6 away from resident 25, but this move placed resident 6 in a room across the hallway from resident 20. Resident 20 stated that since the room change for resident 6 she was too scared to leave her room. Resident 20 stated that resident 6 was a big guy. Resident 20 stated that she informed the facility Administrator (ADM) of the incident and threat made by resident 6 against her. On 4/4/22 at 2:35 PM, a follow-up interview was conducted with resident 20. Resident 20 stated she was still nervous to leave her room with resident 6 still being around. Resident 20 stated that resident 6 was still residing in the room across the hall from her. Resident 20 stated that the ADM responded to her reports by saying that resident 6 was going to be discharged soon, and that she just needed to hold tight until it happened. On 4/11/22 resident 20's medical records were reviewed. Review of the facility census revealed that resident 20 resided in room [ROOM NUMBER]. It should be noted that resident 20's room was located directly across the hall from resident 6's room. B. Resident 6 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included peripheral vascular disease, systemic lupus erythematosus, opioid dependence, chronic obstructive pulmonary disease, lymphedema, morbid obesity, asthma, non-pressure chronic ulcer of right and left lower leg, insomnia, chronic pain syndrome, mood disorder, personality disorder, anxiety disorder, and alcohol abuse. On 4/11/22 resident 6's medical records were reviewed. Review of the facility census revealed that resident 6 resided in room [ROOM NUMBER]. It should be noted that resident 6's room was located directly across the hall from resident 20's room. On 1/6/21, resident 6 had a care plan developed for a focus area of struggles with controlling his anger and may become verbally or physically aggressive with others. Interventions identified were: Encourage the resident to focus on achievement of his discharge planning goals; Encourage resident to take time to collect his thoughts when upset with others so he can communicate more effectively; Encourage resident to utilize coping skill such as going for a walk, reading his bible, smoking, listening to music; If agitated allow resident personal space; If resident becomes rude or yelling or intimidating ensure safety and walk away and seek additional staff; and Reinforce verbal praise of any positive behaviors and utilization of coping skills. On 4/6/22 at 1:00 AM, the nursing progress note documented that resident 6 was on 1:1 monitoring due to physical and verbal aggression towards other residents. The note further documented that resident 6 stated to the Nurse Practitioner, You better get me out of this place before I hurt someone. The note documented that resident 6 was taken by ambulance for a behavioral evaluation but did not state the location that resident 6 was discharged to. On 4/12/22 11:03 AM, a interview was conducted with the Regional [NAME] President (RVP). The RVP stated that he was looking for the facility investigation for resident 20 and resident 6, but he was not hopeful he would find any abuse investigation documentation. 3. Resident to resident verbal abuse A. Resident 16 was admitted to the facility on [DATE], with a diagnosis that included COVID-19, pneumonia, type 2 diabetes mellitus, asthma, benign prostatic hyperplasia, anxiety, depression, idiopathic neuropathy and failure to thrive. On 3/23/22 at 10:00 AM, an interview was conducted with resident 16. Resident 16 reported he was fearful of resident 53 because resident 53 regularly entered his room and threatened him. Resident 16 stated that it had happened approximately 4 times in the past month. Resident 16 stated that resident 53 resided in the room next to his. Resident 16 reported resident 53 threatened to hit him while raising his fists. Resident 16 stated he believed resident 53 made the threats because resident 16 speaks with a loud voice. Resident 16 stated he reported resident 53's threats to his assigned certified nurse aide (CNA) every time it happened. Resident 16 stated that the facility staff had removed resident 53 from his room in the past. Resident 16's roommate, resident 38, was present during the interview with resident 16. Resident 38 confirmed that resident 53 came into the room and threatened resident 16. Resident 38 stated he had tried to stand up for resident 16 because resident 16 can not protect himself. Resident 38 stated he was very upset because the facility staff do not do anything about the threats resident 53 made towards resident 16. Resident 16 stated that he had spoken to the Administrator and that she had done nothing. Resident 16 stated that he was afraid that resident 53 would actually hit him. Resident 16 stated that he had observed residents attempt to hit staff and that the staff protected themselves. Resident 16 stated the staff will protect themselves but not the residents. Resident 16 stated that he was bed bound, and had told staff multiple times to assist with the situation. On 3/25/22 at 10:38 PM, an interview with resident 16 was conducted. Resident 16 stated that they moved resident 53 to another room down the hall. Resident 16 stated that this was following an incident on 3/24/22 during the night when resident 53 threatened to hit resident 16 again. On 3/26/22 at approximately 9:30 AM, a follow-up interview was held with resident 16. Resident 16 reported on 3/25/22, that resident 53 came into his room and threatened him again. Resident 16 stated he then called the police. Resident 16's medical records were reviewed. On 1/7/22, a Quarterly MDS Assessment documented that resident 16's BIMS score was a 14, which would indicate cognitively intact. The assessment documented that a resident 16's PHQ-9 score was a 5, which would indicate minimal depression. The assessment documented that resident 16 did not have any indicators of hallucinations or delusions and did not exhibit any symptoms of physical behaviors towards others. The assessment documented that resident 16's functional status for bed mobility, locomotion on the unit, and dressing was an extensive two person assist. Resident 16 was assessed as a extensive one person assist for transfers and toilet use. The assessment documented that resident 16's mobility devices that were utilized was a wheelchair. On 1/28/21, a PASRR Level II was conducted with resident 16. The PASRR documented that resident 16 reported being treated for bipolar schizophrenia manic depressive and multiple personality disorder. Resident 16 reported that he had been involved with psychiatric treatment since childhood and was currently seeing a counselor that he, .mostly just talk on the phone. Resident 16 reported severe depression with anhedonia, decreased motivation and psychomotor retardation where the patient did not want to get out of bed. Resident 16 also reported chronic and daily anxiety and stated that he was constantly anxious. Resident 16 stated that the anxiety caused him to .worry about many things and difficulty managing feelings of worry, filling tense and on edge all the time, and trouble sleeping d/t [due to] this anxiety. At the time of the assessment, resident 16 reported constant visual hallucinations that he had learned to put to the side and tried to ignore. Resident 16 also reported chronic auditory hallucinations that could be persucatory in nature. On 4/8/2022 at 7:36 AM, a Social Service Note documented, LCSW [Licensed Clinical Social Worker] met with resident for abuse screening and identification of immediate psychosocial concerns. Resident reported a prior altercation with another resident who 'threatened' him. Resident stated that the other resident moved rooms after the incident and that he feels 'safe' but expressed interest in referral for ongoing counseling. Review of the facility census revealed that resident 16 resided in room [ROOM NUMBER] and resident 53 resided in room [ROOM NUMBER]. Resident 53 was moved from 322 to 307 on 3/25/22. The facility abuse investigation documentation for the incidents between resident 16 and resident 53 were requested. No documentation of the abuse investigations were provided. Review of the State Survey Agency (SSA) entity reports revealed that on 3/26/22 at 7:00 AM, resident 16 woke resident 53 up when he was talking too loudly with another resident. The entity report documented that resident 53 became very angry and went through the bathroom to tell resident 16 to shut up or he's going to break his arm, jaw or leg. It should be noted that the SSA facility reported incidents (FRI) tracking system did not contain a facility final investigation summary report of the incident. B. Resident 53 was admitted on the facility on 8/29/21 with diagnoses that included metabolic encephalopathy, chronic obstructive pulmonary disease, altered mental status, and muscle weakness. Resident 53's care plan dated 12/7/21 that the resident is verbally and physically aggressive at times. The goal indicated was verbalize understanding of need to control verbally abusive behavior. No Psychosocial Reviews were completed for resident 53 after 9/6/21. Nursing notes for resident 53 revealed the following: a. On 9/16/21 at 12:06 AM, patient refusing care, refusing pain meds, calling nurse and cna bitch and witch stating thaat (sic) both are liars despite trying to give him care. b. On 9/16/21 at 1:43 AM, patient being verbally abusive, kicking staff out when he requests help for care. c. On 9/16/21 at 2:13 AM, ptient (sic) becoming physically aggressive, charging at nurse and CNA while naked. d. On 9/16/21 at 2:33 AM, Called [name of family member omitted] to see if he will calm down. Patient has been striking his walker against the floor in his room and bathroom. Patient now taling (sic) with daughter and claiming we [NAME] caring for him. I explained to her that we cant physically get near him since he is charging at us. e. On 9/16/21 at 2:35 AM, patient also scaring other patients with behavior. Nursing staff is also fearful. f. On 9/20/21 at 12:00 PM, patient yelling in middle of the night accusing staff of lying how frequently he can have tylenol. Patient waking up residents. Refuses to listen to nurses explanation of why he must wit (sic) for pain medications for 6 hrs (hours). g. On 1/7/22 at 1:40 AM, Resident this NOC (night) got in a verbal altercation with another resident and was very agitated. Denied getting his blood pressure taken this NOC. DON notified to reconsider room assignments. [Note: Review of the facility census revealed that resident 53 resided in room [ROOM NUMBER] from 8/29/21 until 3/25/22.] h. On 1/28/22 at 1:38 AM, Aggression towards staff. Review of resident 53's MARS since admission revealed no monitoring of behaviors for verbal or physical aggression towards others. 4. Resident to resident physical and verbal abuse A. Resident 4 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, paraplegia, traumatic brain injury (TBI), convulsions, chronic pain syndrome, muscle wasting and atrophy, dependence on wheelchair, history of falling, major depressive disorder, and alcohol abuse. On 3/23/22 at 7:02 AM, an interview was conducted with resident 4. Resident 4 stated that resident 111 and her had an argument in the hallway three days ago. Resident 4 stated that she asked resident 111 to move and resident 111 then threw hot coffee on resident 4's lap. Resident 4 stated that she did not receive any burns from the hot liquid. Resident 4 stated that it was witnessed by Licensed Practical Nurse (LPN) 2. Resident 4 stated that she had spoken to the Administrator about this and nothing was being done. Resident 4 stated that this made her feel irritable. On 3/23/22 at 7:38 AM, an interview was conducted with LPN 2. LPN 2 stated that she witnessed the incident between resident 4 and resident 111. LPN 2 stated that resident 4 was moving down the hallway and that resident 111 was standing in front of the medication cart. LPN 2 stated that resident 4 told resident 111 to move and that resident 111 turned and called resident 4 a fucking bitch and threw coffee on resident 4's groin area. LPN 2 stated that she separated the two and took resident 4 to her room. LPN 2 examined resident 4's burned area. LPN 2 stated that resident 4 was in pain and had a red raised skin on the area where coffee was thrown on her. LPN 2 stated that resident 4 did not require any treatment for this injury. On 3/23/22 at 10:35 AM, an observation was made in the hallway, on the second floor. Resident 4 was propelling herself in an electric wheelchair from her room to the patio. Resident 111 was propelling herself in a wheelchair and was behind resident 4. Resident 111 yelled, Get out of the way, you Mother Fucker! This incident occurred in front of LPN 2 and CNA 17. Neither staff member reacted to the interaction between these residents. Review of the facility initial entity report documented that resident 4 complained of resident 111 .being upset this morning at her and purposely throwing hot chocolate at her face. The report documented that the incident occurred on 2/23/22 at 8:00 AM. The report documented that resident 4 was not injured or burned. The report documented the action taken was to move resident 111 to a different room. Review of the State Survey Agency (SSA) Incident Investigation Report documented, On 03/24/2022 at 12:09 am, the facility reported that, on 03/23/2022 at 8:00 am, resident [4] complained that resident [111] was upset with resident [4], that morning, and purposely threw hot chocolate in her face. The residents were assessed and no injuries or burns were found. Resident [111] has been moved to another room. APS [Adult Protective Services] was notified, case# 135662. The family and physician was notified. Review of the APS report documented that the incident occurred on 3/23/22 at 8:00 AM and stated, Resident [4] complained of resident [111] being upset this morning at her and purposely throwing hot chocolate at her face. Resident [4] wasn't injured or burned. Resident [111] is OK. It should be noted the inconsistencies between the dates of the incident that were reported on the facility initial entity report, the SSA Incident Investigation Report, and the APS report. Resident 4's medical records were reviewed. On 3/22/22, a Quarterly MDS Assessment documented that resident 4's BIMS was not conducted due to resident is rarely/never understood. The assessment do[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. Resident to resident physical abuse A. Resident 6 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included peripheral vascular disease, systemic lupus erythematosus, opioid dependence, chronic obstructive pulmonary disease, lymphedema, morbid obesity, asthma, non-pressure chronic ulcer of right and left lower leg, insomnia, chronic pain syndrome, mood disorder, personality disorder, anxiety disorder, and alcohol abuse. On 4/11/22 resident 6's medical records were reviewed. On 4/2/22, a Quarterly MDS Assessment documented that resident 6's BIMS was not conducted due to resident is rarely/never understood. The assessment documented that a resident mood interview or PHQ-9 was not conducted for resident 6 due to resident is rarely/never understood. The assessment documented that resident 6 did not have any indicators of hallucinations or delusions and did not exhibit any symptoms of physical or verbal behaviors or behaviors towards others. The assessment documented that resident 6's functional status for walking in the corridor and locomotion on the unit was setup help only with supervision, and resident 6 did not utilize any mobility devices. On 12/1/20, a PASRR Level II was conducted with resident 6. The PASRR indicated that resident 6 tended to downplay or deny most mental health symptoms, or has varied in what he has reported to the same evaluator. What has been consistent throughout his evaluations and his current SNF [Skilled Nursing Facility] stay has been problems with interpersonal dysfunction, irritability, and anger management In the past pt has also endorsed excessive worry about many things, difficulty managing feeling of worry, restlessness, sleep disturbance/insomnia, trouble concentrating, and irritability due to anxiety. The current psychiatric functioning documented that at the time of the evaluation resident 6 continued to be argumentative. On 1/6/21, resident 6 had a care plan developed for a focus area of struggles with controlling his anger and may become verbally or physically aggressive with others. Interventions identified were: Encourage the resident to focus on achievement of his discharge planning goals; Encourage resident to take time to collect his thoughts when upset with others so he can communicate more effectively; Encourage resident to utilize coping skill such as going for a walk, reading his bible, smoking, listening to music; If agitated allow resident personal space; If resident becomes rude or yelling or intimidating ensure safety and walk away and seek additional staff; and Reinforce verbal praise of any positive behaviors and utilization of coping skills. On 3/21/22, a nurses note for resident 6 indicated, At 1100, Nurse and CNA's hear commotion down the hallway. Resident was standing in the hallway swearing at another resident. Resident yelling because there was feces smeared on the toilet seat in the shared bathroom. Other resident screams and swears back at the resident stating it wasn't his fault. This nurse did not witness this, but two others report that [resident 6] punched the other resident in the face and walked back into his room. ADON and administrator notified. Administrator called the police and officers came in to question the two residents. Resident placed on 24hr checks to monitor for safety. On 4/6/22 at 1:00 AM, the nursing progress note documented that resident 6 was on 1:1 monitoring due to physical and verbal aggression towards other residents. The note further documented that resident 6 stated to the Nurse Practitioner, You better get me out of this place before I hurt someone. The note documented that resident 6 was taken by ambulance for a behavioral evaluation but did not state the location that resident 6 was discharged to. B. Resident 25 was admitted to the facility on [DATE] with diagnoses that included pseudobulbar affect, adjustment disorder with depressed mood, anxiety disorder, chronic pain syndrome, cognitive social or emotional deficit following cerebral infarction, and hemiplegia. On 4/11/22, nurses notes for resident 25 were reviewed. On 3/21/22, a nurses note for resident 25 indicated, Another resident was upset at this resident and started yelling at him, staff tried to intervene. The other resident punched [resident 25] in the face. The two resident (sic) where (sic) separated by staff and officers called. Resident has no bruise, redness or swelling to the area hit. On 3/22/22 at 11:00 AM, the facility abuse investigation documented an initial entity report of a physical altercation between resident 6 and resident 25. The summary documented a verbal altercation between the residents that resulted in resident 6 attempting to strike resident 25 in the face. The report documented that a facility department head intervened which resulted in resident 6 only brushing resident 25 on the neck. [Note: It should be noted that the entity report was dated 3/22/22, however the nurses notes documented that it occurred 3/21/22.] The facility abuse investigation for this incident was reviewed. The investigation was dated 3/22/22, and had a completion date of 3/24/22. The ADM documented that there was no physical contact between the residents, and that there was only brushing [resident 25] on his neck, which is different than what the nurses notes for both residents indicated. Resident 6 was subsequently moved to a different room. The facility ADM documented that 3 residents were interviewed, but provided interview summaries for only resident 6 and resident 25. The investigation revealed that, The administrator substantiated physical abuse. Both residents will be encouraged as much as possible to express their frustrations so CNAs can help them with matters that can trigger outburst (sic). 11. Staff to resident verbal abuse Resident 51 was admitted to the facility on [DATE], with a diagnosis that included polyneuropathy, quadriplegia, type 2 diabetes, viral hepatitis, chronic kidney disease, hypertension and arthritis. On 3/29/22 at 1:04 PM, an interview with resident 51 was conducted. During this interview resident 51 stated that he had an argument with Certified Nursing Assistant (CNA) 8. Resident 51 stated that CNA 8 swore at him and lunged at him like he was going to attack him. Resident 51 stated that CNA 8 then flipped him off with both hands and left the room. Review of the facility ABUSE INVESTIGATION AND REPORTING LOG by the facility Administrator (ADM) documented CNA coordinator and administrator spoke with resident [51]; he said CNA [8] was upset about being asked to move things around in the room, and he was verbally abusive with the resident; CNA left the resident sitting up on the bed and came back a few minutes after and flipped him up. The resident could not tell the administrator what was said to him by CNA [8]. The administrator ensured resident (sic) [8] was suspended and had not access to the facility. Administrator asked resident if he was ok. Resident stated 'I am ok'. The report documented that the ADM was not able to reach CNA 8 by telephone for an interview. The report documented Cna that worked the shift with CNA [8] was working with a different patient at the time of incident, [CNA 8] stated that resident [51] was upset, and he walked out of the room and let the resident calm down. the CNA and nurse help the resident to get in bed and she took care of the resident the rest f (sic) the night. It should be noted that the ADM did not identify who the CNA was that gave this interview. The report documented that the facility substantiated the verbal abuse and CNA 8 was terminated. On 3/25/22 the facility investigation was documented as completed. On 3/29/22, Employee 1 was interviewed. E 1 stated that when they had asked staff about abuse in the facility, the ADON told them that it would be discussed by the administrative staff. E 1 stated that they never heard officially about abuse. E 1 stated that they were aware that the management team had received information about abuse in January, 2022, but nothing was investigated. On 3/29/22 at 12:42, Corporate Resource Nurse (CRN) 1 was interviewed. CRN 1 stated that there were social service concerns in the building that were referred to the ADM, and that the Licensed Clinical Social Worker (LCSW) who spoke with residents in the facility was unavailable by telephone. CRN 1 stated that she was aware of three physical altercations in the last week. CRN 1 stated that she was not informed about many altercations. CRN 1 stated that she was not aware of a resident being left unattended outside. CRN 1 stated that she did hear about the sexual abuse, and was not sure why she had been contacted until she found that the ADM had not done an investigation. CRN 1 stated that the ADM did not inform the management team about the sexual abuse. CRN 1 stated that whenever a resident punched another resident, it was abuse and should have been reported. On 3/29/22 at 1:32 PM, the Administrator was interviewed. The ADM stated that she was aware of some abuse in the facility but had not done training until February, and again in April, 2022. The ADM stated that she had not done any quality assurance on abuse. The ADM stated that resident 49 did not fit well in the building, but would do better in a group home, and has a lot of issues with some of the residents. The ADM stated that she had helped break up some of the arguments and fights between residents. The ADM stated that sometimes residents yelled at each other, but that was typical for this population. The ADM stated that when there were physical fights, there should have been reports, but sometimes the reports don't get finished. The ADM stated that she knew that a female resident had been laying down in another resident's room on the bed with him watching television when the roommate interrupted them, which caused a fight. The ADM stated that it was between resident 23 resident 51. The ADM stated that the police had been called for that altercation. The ADM stated that resident 51 had called a family member who then called the ADM. The family member of resident 51 told the ADM that the facility was not taking good care of resident 51. The ADM stated that she took the family member's concerns seriously. The ADM stated that she was told resident 51 was left outside on the patio in February. The ADM stated that she was aware that resident 16 was threatened, and the reports were on her desk. On 3/29/22 at 10:10 AM, the ADON was interviewed. The ADON stated that on the second floor of the facility, there were a lot of people from the streets. The ADON stated that it was normal for them to use language that would make other people gasp. The ADON stated that she was aware of abuse allegations, including previous staff members being abusive. The ADON stated that she was aware of various abuse allegations, but did not have any direct role in abuse unless she personally saw it. On 3/24/22 an interview was conducted with Employee 11. E 11 stated the ADON was borderline abusive, telling resident 21, you're never going to get out of here. E 11 stated that it took several hours to calm resident 21 after that incident. E 11 stated that therapy had talked about turning down the power on resident 111's wheel chair, because she ran into people. On 3/30/22 at approximately 11:00 AM, a Medical Provider (MP) 2 was interviewed. MP 2 stated that the providers were informed about some assaults, but other abuses were provided by hearsay. MP 2 stated that they were included on the group text, so they heard of some encounters through that method. MP 2 stated that the physician group wanted to be informed of the resident-to-resident interactions to help manage the needs of the residents. On 4/11/22 at 12:20 PM, the ADON was re-interviewed. The ADON stated that some residents had altercations over the previous weekend. The ADON stated that the residents utilized street language, but sometimes residents were upset about what the other residents said to them. The ADON stated that sometimes the residents yelled at each other, and she should have documented it. The ADON stated that she did not remember creating an incident report for the incidents. The ADON stated that she told the contending residents to avoid each other. The ADON stated, I have a hard time with these residents, just because they say swear words to one of them and they're upset and mortified by what they said, but they will turn around and say it back. [Cross refer F600 and F609] Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 14 of 51 sample residents. Specifically, based on a review of Entity Reports, filed with the State Survey Agency (SSA), between 8/22/21 and 3/31/22, the facility has submitted multiple initial Entity Reports with no subsequent final investigation report. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level. Resident identifiers: 4, 6, 14, 16, 18, 20, 23, 25, 31, 37, 49, 51, 53, and 111. NOTICE: On 4/4/22 at 1:10 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices This notice was given verbally to the facility Administrator (ADM), Regional [NAME] President (RVP), and the Corporate Registered Dietician (CRD) regarding On 4/12/22, the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 4/12/22 at 10:00 AM: 1. Resident #14 no longer resides at the community, therefore, the community does not have an individualized plan of correction. Resident #31 was placed on a 1:1 and remains on a 1:1. 2. All residents shall be assessed for signs and symptoms of abuse. The assessments shall be conducted by an LCSW or CSW with experience interviewing victims of abuse, as well as a registered nurse or advanced practice clinician. 3. Education was initiated on 4/11/2022 by the consultants regarding the community abuse policy including reporting allegations of abuse to the abuse prevention coordinator, reporting allegations of abuse to the proper authorities, and conducting thorough investigations. Thorough investigations to include immediate protection of the residents, interviewing the alleged victim, alleged assailant, any witnesses, other residents who could potentially be affected by the alleged violation, family/visitors if there are any who may have pertinent information, conducting an assessment of the alleged victim, conducting observations of cares if pertinent, conducting searches if necessary, and implementing pertinent interventions to attempt to prevent recurrence. NHA/designee will be responsible for contacting the appropriate authorities for allegations of abuse. Each allegation will be discussed verbally with the consultants and the consultants will have access to the report to ensure that reports are submitted timely to the health department. NHA/designee to complete review three(3) abuse allegations a week for three (3) months to ensure that the investigation was thorough, that there were interventions implemented to correct the alleged violations, and that there was protection of the alleged victim while the investigation was ongoing. The consultants provided the community with a new daily standup meeting agenda. This agenda will include an abuse reporting log to track and trend all reported allegations for the month. The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed. 4. The NHA/designee will report findings from the audits to the QAPI Committee monthly for three (3) months. The QAPI committee will identify any trends and take corrective action as needed. On 4/12/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/12/22 at 10:00 AM. IMMEDIATE JEOPARDY 1. Resident to resident sexual abuse Resident 14 was admitted to the facility on [DATE] with diagnoses that included an intercranial injury, Post-Traumatic Stress Disorder (PTSD), adjustment disorder, hypertension, pseudobulbar effect, osteoarthritis, history of a traumatic brain injury, and urinary incontinence. Resident 31 was admitted to the facility on [DATE] and readmitted after two days away from the facility on 11/8/21 with diagnoses that included chronic obstructive pulmonary disease (COPD), emphysema, heart failure, depression, essential hypertension, and an unspecified mood disorder. On 3/24/22 at 9:10 AM, Certified Nursing Assistant (CNA) 17 was interviewed. CNA 17 stated that on 2/20/22, she was walking in the hall at the facility when she saw resident 31 in the hallway, walking toward his room. CNA 17 stated that when she returned from going into a resident's room, she came back out and he was not in the hallway anymore. CNA 17 stated that when she looked for resident 31, he was found in resident 14's room, leaning over the side rail of her bed and sucking on her bare breast. CNA 17 reported that she immediately separated the two residents and reported to the other CNA working at that time and to the nurse on duty, Licensed Practical Nurse (LPN) 2. CNA 17 stated that LPN 2 talked to the administrator on duty. CNA 17 stated that resident 31 would lean across residents to brush against their breasts and would smack people on the butt. CNA 17 stated that she texted the Administrator (ADM) when it happened and she had expected to follow up with the ADM the following Monday. On 3/29/22 at 3:55 PM, an interview was conducted with DON 2. DON 2 stated that she was no longer employed at the facility but was the DON at the time of the sexual abuse between residents 14 and 31. DON 2 stated that at breakfast time on 2/20/22 that LPN 2 had received a report from CNA 17 regarding resident 31 being in resident 14's room. DON 2 stated she spoke with LPN 2, and then called the ADM immediately to notify her. DON 2 stated that she was working the day of the incident and the whole day was crazy because I was trying to get another room for [resident 31]. DON 2 stated that the ADM was trying to transfer resident 31 to a different facility. DON 2 stated that she also reported the incident to CRN 1 on 2/28/22. DON 2 provided records from her mobile phone provider to show the phone call from her phone to the Administrator's mobile phone on 2/20/22 at 8:08 AM. The call lasted 12:08 minutes. DON 2 also stated that on 2/22/22 she sent a text message to the Administrator asking the Administrator if she had spoken to CNA 3. The former ADON provided a screenshot of the text message from her mobile phone to the mobile phone of the Administrator. The text was, Did you talk to (CNA 3) today about (resident 31)? On 3/25/22 at 8:35 AM, resident 14 was observed in her room and was immediately interviewed. Resident 14 was pleasant and unable to answer questions about her cares and situation. Resident 14's room smelled strongly of urine and black flecks and smears were observed on the wall above the headboard of the bed. On 4/13/22, medical record reviews were completed for residents 14 and 31. Resident 14's Minimum Data Set (MDS) was completed on 11/12/21, and revealed that her BIMS score was 7, with severely impaired cognition. Resident 31's MDS was completed on 1/28/22, and revealed that his BIMS score was 10, with moderately impaired cognition. Resident 14's nursing notes were reviewed and did not include information about the abuse. Resident 31's nursing notes were reviewed and did not include information about the abuse. Resident 14's care plan was reviewed and did not reveal any interventions regarding the abuse. Resident 31's care plan was reviewed. On 3/30/22, resident 31's care plan was updated to include the following: a focus that he wanders into others' rooms uninvited and may touch them inappropriately. Goals were that the resident would not enter other resident's rooms uninvited, and that he would not touch other residents. The interventions were to Monitor whereabouts closely, ensure his room is close to his smoking area, remind him he cannot go into others' rooms, if actively observed, tell him to 'stop' and notify administrator immediately. Assist him out of room and keep in line of sight monitoring for next hour. Resident 14's monitoring was located in the CNA Task list included monitoring for sexual behaviors. The task list was available for the previous 30 days and included the dates of 3/1/22 to 3/30/22. Resident 14 had two documented sexual behaviors. Resident 31's monitoring was located in the MAR/TAR and revealed that nurses were monitoring for mood swings, sleep, shortness of breath, depression, and pain. Resident 31 did not have monitoring for sexual behaviors. On 3/5/22, an incident report was completed for resident 14. The incident report revealed that on 2/27/22 at 12:00 PM, resident 31 might touch resident 14 inappropriately on her breast area. [Note: The date of the abuse listed on the report was not consistent with the date that the ADM had received the report of the abuse, and the incident report was completed approximately 2 weeks after the incident occurred.] The final investigation completed by the facility documented the following: It was reported to the administrator that a report of abuse was made on 2/27/22 to the nurse and did not get reported to the administrator until a later date. The abuse report was made to the agency nurse that failed to report to the administrator. The administrator talked to CNA (Certified Nursing Assistant) doing the report. CNA said to the administrator she was walking doing her rounds when she saw [resident 31] in [resident 14 ' s] room leaning over and appeared to her the [resident 31] was touching [resident 14 ' s] breast. CNA asked [resident 31] to leave the room and return to his room. CNA reported to the nurse and continued monitoring the resident and making sure [resident 31] did not enter [resident 14 ' s] room. CNA stated since the incident happened until the day it was reported to the administrator, the incident between [resident 31] and [resident 14] hasn ' t occurred again between residents involved or with any other female resident to the CNA ' s knowledge. The Administrator later documented that a CNA witnessed resident 31 with resident 14 ' s breast in his mouth, and that the CNA reported this to the Director of Nursing and Assistant Director of Nursing. The Administrator documented that we substantiated sexual abuse . Both residents are confused and [resident 31] do this out of confusion than a sexual abuse intent. A review was performed of the facility's Entity Report, which was submitted to the State Survey Agency (SSA). The report was submitted at 12:53 AM on 3/6/22. The Administrator documented the incident occurred at 12:00 PM on 2/27/22. The ADM described the allegation as follows: resident 2 (resident 31) allegedly inappropriately touched resident 1's (resident 14) breast area. An investigation into the incident to ensure that the incident actually occurred. physician and family notified. A review of the SSA database revealed that no final report had been submitted. The census for resident 14 revealed that she was in room [ROOM NUMBER] at the time of the abuse. Resident 31's census revealed that he was in room [ROOM NUMBER]. room [ROOM NUMBER] was located between resident 31's room and the smoking patio. Resident 31's census revealed that he was moved to room [ROOM NUMBER] on 3/21/22, 22 days after the abuse occurred. [Note: No evidence could be located to indicate that resident 14 was being appropriately protected from further sexual abuse, that other potential victims had been identified, or that prompt interventions were put into place to prevent sexual abuse perpetrated by resident 31 from re-occurring.] On 3/29/22 Employee (E) 11 was interviewed. E 11 stated that she was working on the day of 2/20/22. E 11 stated that there were no open rooms that day, so resident 31 was not moved away from resident 14. E 11 stated that the ADM did not come to the building to do an investigation that day. E 11 stated that they talked to the ADM the next day and the ADM asked E 11 and the other staff to stop talking about the abuse incident. E 11 stated that they talked to the other staff, and to their knowledge, no staff was interviewed about the incident by the ADM. E 11 stated that the ADM asked CNA 16 to keep an eye on resident 31, but CNA 16 was busy helping other residents. E 11 stated that the Assistant Director of Nursing (ADON) reported to E 11 that resident 31 had also massaged resident 14's breasts in a subsequent encounter after 2/20/22. E 11 stated that when they had reported any issues to the ADM, the ADM would say something like Well I will take care of it because we don't want State in the building right now. On 3/24/22, Employee (E) 13 was interviewed. E 13 stated that there were no official statements made to staff about the abuse from resident 31 to resident 14, but there had been rumors in the facility. E 13 stated that there were no interventions implemented immediately, and they had not been provided specific interventions, monitoring or official reports. E 13 stated that they would have liked to know what monitoring should have been done to protect resident 14. On 3/29/22 at 8:52 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that resident 14 did not have a roommate at the time of the abuse. The ADON stated that at one time, resident 31 was sitting by resident 14's bed with his hand above her breast. The ADON stated that she had heard about the abuse from the previous Director of Nursing (DON 1). The ADON stated that resident 14 was very innocent. The ADON stated that she did not tell other staff about the incident because they were still investigating. The ADON stated that the Administrator wanted resident 31 watched more closely. The ADON stated that whether or not resident 14 and resident 31 were confused, I guess they're both adults. The ADON stated that she did not know what was done with the investigation. The ADON stated that she didn't think abuse had happened so she did not tell other staff about it. The ADON stated that resident 31 went in and was sitting by resident 14's bed and his hand looked like it was above her breast. The ADON stated that because resident 31 was very short of breath, he probably just wanted to sit in resident 14's room for a while, so it probably wasn't anything. On 3/29/22 at 12:42 PM, an interview was conducted with the CRN 1. CRN 1 stated that abuse at the facility was reported to her unless it was just a little scuffle. CRN 1 stated that she was not always notified about abuse. CRN 1 stated that she received an email on 3/3/22 about the abuse between resident 31 and resident 14, but had not heard about the abuse prior to that. CRN 1 stated that she had forwarded this email to the ADM and the RVP that day. CRN 1 stated that the email reported that on the weekend of 2/18/22, a staff member reported that resident 31 was observed to be sucking on resident 14's breasts. CRN 1 stated that she was told that during that weekend, the ADM had placed resident 31 on 1:1 staffing. CRN 1 stated that she was told the ADM had not investigated the abuse before that time. CRN 1 stated that it was reported to her that there was a report of both the sucking on boobies and resident 31 massaging resident 14's breasts twice by the time she became aware of the incident on 2/20/22. CRN 1 stated she was not sure why the ADM had not investigated the sexual abuse incident(s) between residents 14 and 31. On 3/29/22 at 1:32 PM, an interview was conducted with the Administrator (ADM). The ADM stated that she was managing all the abuse, along with complaints, discharges, and social work concerns in the building. The ADM stated that she did not recall when she was notified about the abuse between resident 31 and resident 14. The ADM stated that she investigated the incident in March and had substantiated the abuse. The ADM stated that she had moved the patient around so resident 31 was not close to resident 14. The ADM stated that she moved resident 31 closer to the smoking patio where he smoked. The ADM stated that the CNAs did rounds every two hours, so they would be checking on the residents when they rounded. The ADM stated that both residents were confused, and that resident 31 was too frail to walk down to resident 14's room, so abuse was probably not happening. 2. Resident to Resident altercation with Verbal Abuse allegation. A. Resident 20 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure, type 2 diabetes mellitus, cerebral infarction, hypertension, major depressive disorder, anxiety disorder, acute kidney failure, alcohol dependence, and myelopathy. On 3/25/22 at approximately 10:00 AM, an interview was conducted with resident 20. Resident 20 stated that there was a fight in the hallway between resident 6 and resident 25. Resident 20 stated that resident 6 tried to hit resident 25. Resident 20 stated that she intervened and told resident 6, don't you hit him. Resident 20 stated that resident 6 replied, you shut up you fucking bitch or I'll get you next. Resident 20 stated that she returned to her room scared. Resident 20 stated that as a result of the fight, they moved resident 6 away from resident 25, but this move placed resident 6 in a room across the hallway from resident 20. Resident 20 stated that since the room change for resident 6 she was too scared to leave her room. Resident 20 stated that resident 6 was a big guy. Resident 20 stated that she informed the facility Administrator (ADM) of the incident and threat made by resident 6 against her. On 4/4/22 at 2:35 PM, a follow-up interview was conducted with resident 20. Resident 20 stated she was still nervous to leave her room with resident 6 still being around. Resident 20 stated that resident 6 was still residing in the room across the hall from her. Resident 20 stated that the ADM responded to her reports by saying that resident 6 was going to be discharged soon, and that she just needed to hold tight until it happened. On 4/11/22 resident 20's medical records were reviewed. Review of the facility census revealed that resident 20 resided in room [ROOM NUMBER]. It should be noted that resident 20's room was located directly across the hall from resident 6's room. B. Resident 6 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included peripheral vascular disease, systemic lupus erythematosus, opioid dependence, chronic obstructive pulmonary disease, lymphedema, morbid obesity, asthma, non-pressure chronic ulcer of right and left lower leg, insomnia, chronic pain syndrome, mood disorder, personality disorder, anxiety disorder, and alcohol abuse. On 4/11/22 resident 6's medical records were reviewed. Review of the facility census revealed that resident 6 resided in room [ROOM NUMBER]. It should be noted that resident 6's room was located directly across the hall from resident 20's room. On 1/6/21, resident 6 had a care plan developed for a focus area of &qu[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident 57 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, chronic venous hypertension with ulcer of left lower extremity, lymphedema, muscle weakness, major depressive disorder. On [DATE] at 11:55 AM an interview with resident 57 was conducted. Resident 57 stated that that wounds on his leg gets treated about once a week. Resident 57 stated that he was worried about the MASD wound on his buttocks. Resident 57 stated that his wound care sometimes was skipped. A review of resident 57's medical record was conducted. Resident 57's treatment administration record (TAR) from [DATE] to [DATE] was reviewed and revealed that the following wound care orders had missing days of treatment. 1. Upper thighs breakdown, apply Venelex bid [twice a day] and prn [as needed] one time a day for wound care. Start day [DATE]. Documentation for wound care was missing on the following days a. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 2. Excoriation area to inner upper thighs: clean, apply venelex ointment bid two times a day for wound care. Start date [DATE]. Documentation for wound care was missing on the following days a. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 3. Wound to left posterior calf area: Clean with wound cleaner, xeroform, cover with Foam, then Velcro garment. No black compression socks this week. Be consistent with wearing Velcro lymphedema wraps. Change 3x week and prn. One time a day every Tue, Thu, Sat for Wound Care. Start date [DATE] Documentation for wound care was missing on the following dates a. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 4. Buttock area, clean, apply small amount for prevention zinc based cream BID and PRN two times a day for wound care. Start date [DATE] Documentation for wound care was missing on the following dates a. [DATE], [DATE], [DATE], [DATE]. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] On [DATE] at 1:45 PM an interview with Registered Nurse (RN) 2 was conducted. RN 2 stated that she was often so busy during her shift that she would not be able to complete the wound care. RN 2 stated that she was busy today and most likely would not get to the wound care today. 8. Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure, diabetes mellitus type II, peripheral vascular disease, primary hypertension, history of myocardial infarction, depression, spinal stenosis, cervical disc degeneration, and bilateral osteoarthritis of the knee. On [DATE] at approximately 11:00 AM, resident 18 was observed outside the facility in the covered area near the entrance of the facility. Resident 18 was observed to have a bandage on his left lateral shin. Resident 18 was interviewed and stated that resident 49 ran into his leg with his electric wheelchair on purpose. Resident 18 stated that he was talking to resident 23 near the main entrance when resident 49 told me to 'shut the fuck up' and rammed into my legs on purpose. Resident 18 stated that resident 49 apologized to him a few days later. Resident 18 stated that resident 23 had hit him approximately two weeks prior. On [DATE], resident 18's medical record reviews were completed. On [DATE], a wound clinic note revealed that the wound on resident 18's leg had characteristics of a venous ulcer, but may have been due to trauma. A Weekly Wound Observation Tool created on [DATE] at 4:13 PM revealed that resident 18 had a new wound to lateral left posterior lower leg. The wound measured 5 cm (centimeters) in length by 2.8 cm in width by 0.1 cm deep. An order was initiated to apply honey (medihoney), bordered foam and change three times weekly. On [DATE], a wound clinic note revealed the left lower leg wound was 6.0 cm by 2.8 cm, by 0.2 cm. In resident 18's Treatment Administration Record (TAR) for April, 2022, wound care monitoring was charted as not completed for [DATE] through 3. A new order was initiated on [DATE] for left lateral lower leg. This order was not completed on [DATE], [DATE], [DATE], A new order was initiated on [DATE] and was not completed on [DATE] or [DATE]. In resident 18's Treatment Administration Record (TAR) for March, 2022, wound care monitoring was charted as not completed for: a. [DATE] b. [DATE] c. [DATE] Wound care monitoring was ordered for every shift, for two shifts daily. The following monitoring was not completed: a. [DATE] in the morning b. [DATE] in the morning c. [DATE] in the morning d. [DATE] in the morning e. [DATE] in the morning f. [DATE] in the morning g. [DATE] in the morning h. [DATE] in the morning i. [DATE] in the morning j. [DATE] in the morning k. [DATE] in the morning l. [DATE] in the morning m. [DATE] in the morning n. [DATE] in the morning o. [DATE] in the morning p. [DATE] in the morning Nursing notes revealed the following: a. On [DATE] at 11:09 PM, a skin/wound note revealed that resident 18's left lateral leg wound had reopened and recommend previous tx (treatment) of honey . [Note: The physician examined resident 18 on [DATE].] b. On [DATE] at 5:04 PM, resident 18 had follow up by the wound nurse for a .chronic, recurring stage III PU (pressure ulcer) of L lat LE (left lateral lower extremity) . . On [DATE] at 6:23 AM, .reoccurring stage 3 pressure ulcer of the left lateral lower leg . d. On [DATE], a skin and wound note revealed that resident 81 had Left lateral proximal lower leg, 0.8 cm X 0.4 cm X 0 cm. e. On [DATE], Wound care provider to assess and treat resident wound to left lateral lower leg f. On [DATE] at 5:35 PM, the nurse reported .No wound care order--that I could find-- for the left outer shin wound . On [DATE] at 11:21 AM, Licensed Practical Nurse (LPN) 2 was observed changing the dressing on resident 18's left lower leg wound. LPN 2 brought wound care supplies to resident 18's room and placed them on resident 18's bedside table without cleaning or placing a barrier on the table. LPN 2 stated that there was a bit of a smell and dry skin. LPN 2 was observed to remove the dirty bandage, clean the wound, brush off some of resident 18's dry skin with her gloves, and replace the bandage without completing a glove change. Resident 18 was observed to request lotion on his legs, but did not receive lotion. LPN 2 was observed to place the roll of compression sleeve on resident 18's bedside table, and cut the sleeve to the length of resident 18's lower leg and foot, handling the roll with her soiled gloves. Following the wound care, LPN 2 removed her gloves, performed hand hygiene, and placed the roll of compression sleeves in her cart. LPN 2 stated that the compression stocking roll was also utilized by another resident. LPN 2 stated that she changed her gloves if they became soiled, and when the wound care was finished, not while doing wound care. LPN 2 stated that the MediHoney that was placed on resident 18's wounds required nurses to clean it with some force, and the wound bled a little bit. LPN 2 stated that the order stated bordered foam, but bordered gauze was the same, but it had less padding. LPN 2 stated that the facility had foam, but the gauze worked better for her, and it's considered a foam. LPN 2 stated that she was told it was the same by the ADON who trained LPN 2 on how to treat resident 18's wound. On [DATE] at 11:35 AM, Employee 11 was interviewed. E 11 stated that resident 49 ran into resident 18's leg on purpose and did some damage to his leg. E 11 stated that the Administrator (ADM) talked to resident 49, but did not share information with staff about what was to be done. On [DATE] at 1:32 PM, the Administrator was interviewed. The ADM stated that she was not aware the wound on resident 18's leg was caused by another resident. The ADM stated that she was unaware of what was being done for resident 18. On [DATE] at 3:25 PM, a follow-up interview was conducted with resident 18. Resident 18 stated that he was not receiving wound care until approximately two weeks prior because staff didn't notice it. On [DATE] at 12:14 PM, RN 2 was interviewed. RN 2 stated that the second nurse on the 200 hall rarely completed their treatments, and there were 40 residents on the hall. RN 2 stated that she was not positive all the agency nurses completed wound care. On [DATE] at 3:21 PM, the Medical Records Director (MRD) stated that resident 18 had an infection control issue that was triggered during his wound dressing change. The MRD stated that an alert would be generated if a resident had a new infection. The MRD stated that she had no additional information. Based on observation, interview, and record review, it was determined for 9 of 51 sample residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, residents had pressure ulcers that were not treated as ordered and one resident's that was not examined by a physician, and residents who underwent change of condition that were not treated timely. These findings were determined to have resulted in Immediate Jeopardy for residents 22, 41, and 61; and Harm for residents 29 and 40. Resident Identifiers: 17, 18, 22, 29, 40, 41, 49, 57, and 61. NOTICE On [DATE] at 1:10 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to provide residents quality of care to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This notice was given verbally to the facility Administrator (ADM), Regional [NAME] President (RVP), and the Corporate Registered Dietician (CRD) regarding resident 61. On [DATE] notice of the IJ for residents 22 and 41 was given verbally to the ADM. On [DATE], the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on [DATE] at 10:00 AM: 1. Resident #61 expired at the hospital; therefore, no individualized plan of correction is indicated. 2. The community RN's completed resident assessments for changes of condition. Any resident identified with a change from baseline will have the identified change of condition reported to the MD and the plan of care will be revised or implemented with specific interventions to address the concern. The community will begin to review daily progress notes (Monday through Friday) to ensure any documented changes of condition have adequate communication to the physician and responsible person. Residents with a pressure injury have the potential to be affected by this deficient practice. A whole house skin audit was completed by week ending [DATE] by the nurse management team. Any new pressure injury concerns that were identified received orders, treatments,documentation on the pressure injury and the care plans were updated by the DON/designee. 3. The community staff and agency staff received education and training on the Change of Condition Policy. The community also uses the Stop and Watch & SBAR tool to timely identify changes of condition to ensure any changes are quickly identified and reported to the physician. The community will review daily progress notes (Monday through Friday) to ensure any documented changes of condition have adequate communication to the physician and responsible person. The community will have AM huddles with staff after the morning stand up meeting to ensure staff are also aware of these changes of condition for close monitoring. Additionally, education was initiated on [DATE] by the consultants with nursing staff regarding the community pressure injury policy and the expectation of completing and documenting skin assessments and monitoring of skin concerns weekly with each resident. Any time a new skin issue is identified, the physician and responsible party should be notified, new orders should be received and implemented, the care plan should be updated, and monitoring should continue weekly until the area has healed. The consultants also provided training and education specifically on timely notification to the physicians when a pressure injury shows signs and symptoms of worsening condition. The consultants provided the community with a new daily standup meeting agenda. This agenda will include a pressure injury tracking log to track and trend pressure injuries and newly acquired pressure injuries. The DON/designee to complete weekly audit for three (3) months of three (3) residents with pressure injuries to ensure that the resident had a full skin assessment completed, new orders received for the identified areas, pain evaluated to ensure that it was being managed effectively, treatments initiated, documentation completed, positioning appropriate to promote wound healing, care plan accurate, and wound monitoring to be completed weekly until the areas healed. The consultants will be provided with a weekly pressure injury report for review and recommendations. 4. The DON/Designee will be responsible to report findings from the audits for review and recommendations. On [DATE], while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on [DATE] at 10:00 AM. Findings include: IMMEDIATE JEOPARDY 1. Resident 61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anemia, sepsis, cellulitis, a stage 3 pressure ulcer of the sacral region, type II diabetes, chronic kidney disease, hypoxemia, hyperkalemia, and fluid overload. On [DATE], resident 61's medical record review was completed. On [DATE] at 11:09 AM, resident 61 had discharge orders printed from a regional care facility for wound care. The order for the coccyx wound stated: Bilateral buttocks and coccyx 1. Remove dressing 2. Clean wound with soap and water 3. Apply Santyl collagenase to the wound bed in a nickel thick consistency. 4. Cut and apply Xeroform or oil emulsion over Santyl. 5. Place large sacral dressing to each buttocks, and silicone bordered foam to coccyx. 6. Please change dressing daily and as needed with hygiene. On [DATE] at 6:32 PM, resident 61 was weight by a mechanical lift at 430 pounds. A regional hospital Progress Notes for [DATE] revealed that resident 61 had 4. Sacral decubitus ulcer, stage III. Chronic ulcer, present on arrival. Sacral wound itself is unstageable with black eschar and purulent sluff. CT showed fat stranding inferior, posterior and right of the midline. Also noted small scattered areas of gas without definitive drainable fluid collection. No signs of osteomyelitis. Plastics was curbsided and agrees with plan for continued wound care. - Continued aggressive wound care. - Patient will need frequent offloading/position changes. On [DATE] at 11:04 AM, the regional hospital Discharge Documentation for Discharge Wound Care Instructions were: coccyx 1. moisten a roll of gauze (kerlix) with Puracyn insert deep into undermining (12 cm toward anus) and depth of wound. On [DATE], a regional hospital discharge Progress Notes revealed that resident 61 had a stage 4 pressure ulcer on his coccyx, measuring 5.3 x 3.0 x 0 cm (centimeters) with undermining extending very close to anus. Description of the sacral ulcer revealed, Chronic ulcer, felt to be the cause of above noted bacteremia at his recent hospital stay. Currently, most wounds are looking reasonably clean without any purulence, exudate, or surrounding erythema. Sacral wound itself is unstageable with black eschar and purulent sluff . If he is not progressing then we will plan to get a CT (computerized tomography) abdomen and pelvis with contrast to look for deep wound infection. Wound care consultation requested. Patient will need frequent offloading/position changes. An order in resident 61's physician orders was created on [DATE] at 1:00 PM for Santyl ointment, 250/unit/gm (gram) (Collagenase) Apply to coccyx/buttocks topically as needed for as indicated in wound care orders. Resident 61's Treatment Administration Record (TAR) revealed that this wound care was completed two times, on [DATE] and on [DATE]. On [DATE] at 1:00 PM, an order for Venelex ointment ([NAME]-caster oil) Apply to coccyx wound topically as needed for as indicated in wound care order was created. This order was recorded in the TAR as completed on [DATE] at 8:09 PM. On [DATE] at 4:22 PM, an admission Summary revealed, .Skin Status/Interventions: Stage IV pressure ulcer to coccyx; cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of dressing .Incontinent of bowel and bladder . On [DATE] at 6:00 PM, an order was created to monitor the pressure ulcer to the coccyx each shift for signs and symptoms of infection or other complications. Nurses charted no complications on all checks, with the exception on 1/18 and 1/21 in the mornings, when the assessments were not completed. On [DATE] at 10:06 PM, a 72 hour charting after admission note revealed that resident 61 was adjusting well to returning to facility; appears to be in low spirits .Mental Status/Behavior: appears depressed and in low spirits; no behaviors noted . On [DATE] at 6:00 AM, an order for PU (pressure ulcer) to coccyx wound care: clean with NS (normal saline), dry with gauze. Apply skin prep barrier wipe to periwound skin. Pack undermining of wound w/ Kerlex soaked in Puracyn (squeeze out the excess). Apply Venelex to wound bed the apply Xeroform dressing. Secure with ABD (abdominal) pads. To be changed EOD (every other day) & PRN (as needed) if becomes soiled, saturated or accidentally removed one time a day every other day. This order was discontinued on [DATE]. The TAR revealed that this treatment was completed on 1/2, 1/4, 1/6, 1/8, 1/10, and [DATE]. On [DATE] at 9:56 AM, a skin/wound note revealed: Pressure ulcer to coccyx, undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . A referral was sent to a wound healing company to assess and treat. It was noted that the provider would be at the facility on [DATE]. On [DATE] at 11:50 AM, a physician's note revealed that resident 61 had an admission note created by a physician who performed a telehealth visit. A second note was entered at 8:44 PM. Skin status/interventions: Stage IV pressure ulcer to coccyx, cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100 (left lower side), surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . No other physician visits occurred during resident 61's stay. On [DATE] at 11:27 PM, a nurses note revealed: Changed dressing to buttocks. Moderate serosanguineous drainage (clear fluid) with odor. Cleansed peri with wound cleanser and dressing with ABD pads and medipore tape. On [DATE] at 9:35 AM, the resident advocate note revealed that resident 61 was admitted to the facility for anemia.According to resident discharge plan is to return home with home health. He is alert and orientated. He is currently using a wheelchair for locomotion and needs extensive assistance . His moods and behaviors have been cooperative, pleasant, and is compliant with cares since admission. On [DATE] at 10:30 AM, a Utilization Review (UR) note revealed that resident 61 .needs wound care (daily and PRN) .goal is to return home with HH (home health) . On [DATE] at 9:15 AM, a social services care conference note was started, and was not completed. Status stated In Progress. The note revealed that .wounds have no s/s (signs/symptoms) of infection .pleasant and cooperative with cares . On [DATE] at 11:00 AM, resident 61 had blood drawn for laboratory tests. On the results, a note was written that resident 61 needed a BMP (basic metabolic panel) completed in 1 week with a date [DATE]. Resident 61 had a white blood cell count of 11,300, with high neutrophils and immature granulocytes. [No additional blood tests were completed for resident 61 until [DATE].] [Wound physician did not see resident 61 on [DATE].] On [DATE] at 5:41 PM, resident 61 had a Nutritional Assessment. The assessment revealed that resident 61 had .increased nutritional needs d/t (due to) skin impairment to coccyx . Recommend adding . Juven BID (twice daily) and liquid protein . to support healing. Will monitor weight, intake, wound healing and will adjust nutritional interventions as needed. [No orders for Juven or liquid protein were initiated for resident 61.] On [DATE], a Mini Nutritional Assessment was completed. Resident 61 was At risk of malnutrition. [Note: No further nutrition assessments were completed.] Resident 61 had a nutritional care plan created on [DATE]. An intervention was to Provide supplements to promote wound healing. Resident 61 did not have a wound care plan included in his care plans. On [DATE], resident 61 was assessed in the Minimum Data Set (MDS) as requiring rehabilitation, urinary incontinence, fluid maintenance, fall risk, pain management, nutritional status management and pressure ulcer management. On [DATE], resident's niacin tablet order was not provided due to being out of supply, not in med cart. On [DATE] at 8:09 PM, an order for Venelex ointment, apply to coccyx wound topically as needed for as indicated in wound care order was initiated. On [DATE] at 9:32 AM, a MDS skin conditions evaluation that revealed resident 61 had 1 stage 4 pressure ulcer. Resident 61 had a pressure reducing device for the bed. Nutrition or hydration intervention to manage skin problems were noted as being in place. On [DATE] at 5:33 PM, a nurses note revealed that labs drawn [DATE] rec'd (received) w/ (with) noted abnormalities .NP (Nurse Practitioner) reviewed w/ N/O (new order) for BMP recheck in 1 week. [This lab was not redrawn.] On [DATE] at 3:25 PM, a Utilization Review (UR) note revealed that resident 61 .needs skilled wound care (daily and PRN) .goal is to return home with HH (home health) . On [DATE] at 4:30 PM, a skin/wound note revealed: Residents wound remains with deep 2 o'clock tunneling. with 5 X 6 (centimeters) opening. Wound has foul odor. Peri wound has improved. New order to fill wound bed with calcium alginate rope cover with bordered foam. Resident tolerated well . Resident 61 reported the following pain scores (out of 10) without reporting effective pain control: a. On [DATE] at 10:26 AM, 9 b. On [DATE] at 1:06 PM, 8 c. On [DATE] at 1:11 PM, 7 d. On [DATE] at 9:15 PM, 8 e. On [DATE] at 5:06 PM, 7 f. On [DATE] at 9:58 PM, 7 [No new interventions were noted.] On [DATE] at 8:37 PM, a skin/wound note revealed: Change resident dressing daily. Wound is 6 cm X 6.5 cm X 8.5 cm tunnel at 2 o'clock. Lots of blood drainage. Wound nurse's are following dressing change order from the hospital On [DATE] at 1:57 PM, a Utilization Review (UR) meeting revealed that resident 61's plan of care was to work with therapy and to return home with home health. The nursing update included .skilled wound care (daily and PRN), . On [DATE] at 6:28 AM, a nursing note revealed that resident 61's Wound remains open with foul odor. Wound is 6 cm X 5.5 CM x 2 CM. It tunnels at 2 o'clock 8 cm. Wound has necrotic tissue coming out of the tunnel area. Dressing change daily. Dakins soak 30 min. then Calcium alginate rope to tunnel with calcium alginate in wound bed. Cover with ABD pad and foam cover . On [DATE] at 8:15 AM, resident 61 had an order for niacin, which was not available in the facility. On [DATE] at 6:00 AM, an order for Dakins (1/4 strength) solution (sodium hypochlorite) Apply to sacral wound topically one time a day for wound care 30 min soak to tunnel and wound bed was initiated. The TAR revealed that this order was completed on [DATE] and [DATE]. On [DATE] at 8:02 AM, resident 61 had an order for niacin, which was not available in the facility. On [DATE], a Skilled Daily Review was performed for resident 61. Skilled need was wound to coccyx with tunneling at 2:00 position per wound care nurse. Pain mgmt (management). Assist with ADLs (activities of daily living). Resident 61 was incontinent of urine and bowel movements, and wore briefs with peri care provided with each brief change. [Note: There is no documentation about wound care changes with brief changes.] On [DATE] at 3:17 PM, resident complained of sacral pain for which PRN medication was provided. On [DATE] at 11:33 PM, a weekly skin review revealed no new skin integrity problems. The sacral pressure injury was noted. On [DATE] at 9:43 AM, a nurses note revealed that the nurse had received report of resident 61 having increased confusion with shaking, high blood pressure, resident looking to the left to respond to the nurse who was on the left side of the bed, and confusion about how to drink water. Nurse contacted physician who ordered STAT blood and urine tests along with a chest X-ray to rule out infection. Resident was given 1 liter of normal saline over 5 hours. On [DATE], blood pressure obtained was 139/127, followed by 155/60. On [DATE] at 10:36 AM, a nurses notes revealed that resident 61 had an IV (intravenous access line) placed in the right hand for blood draw. On [DATE] at 1:59 PM, a higher-than-normal respiratory rate was noted at 22 breaths per minute and heart rate was 124 beats per minute, irregular, and was identified as a new finding. [There was no documentation that a physician was contacted.] On [DATE], resident 61's lab results were faxed to the facility at 4:43 PM. Resident 61's white blood cell count was 25,100, with segmented neutrophils. RN 1 noted the results on [DATE]. [There was no documentation that this report was forwarded to a medical provider until the following day.] On [DATE] at 7:37 PM, an order was initiated for resident 61 to assess resident 61's pressure ulcer and notify the physician if any complications. On [DATE] at 3:55 AM, an order for STAT (as quickly as possible) labs. The order was noted as done by previous shift. [No documentation of providing the results to the physician was noted.] On [DATE] at 4:44 AM, a nursing note revealed a blood pressure of 98/50, heart rate of 99 beats per minute, and oxygen saturation at 93% on a Continuous Positive Airway Pressure (CPAP) device. The nursing note stated no changes res (resident's) health status from yesterday. Asked res if he would like to go to the hospital for checkup but he refused it. Encouraged res to increase fluid intake. PRN (as needed) pain med was given for pain on both knees. will continue to monitor. On [DATE], on the final lab results report, a note written at the bottom of the report revealed that one of the medical providers made an order to send resident 61 to the Emergency Department. On [DATE] at 11:41 PM, an order was entered/discontinued for a wound care company to eval and tx (treatment) r/t pressure wounds to coccyx and bilateral buttocks. On [DATE] at 12:36 PM, a nursing not revealed that resident 61 was sent to the hospital. On [DATE] at 1:32 PM, a regional hospital Emergency Documentation was initiated for resident 61. The documentation revealed that resident 61 had chief complaints of: a. altered level of consciousness b. high heart rate c. not looking to the right He apparently was acting abnormally this morning according to rehab facility staff but what that means is a little bit unclear. He was transported and there was no mention of increased work of breathing or tachycardia I was called to the room because of high heart rate and tachypnea (rapid breathing). Looks like he is in atrial fibrillation with RVR (rapid ventricular rate of response) but does not endorse any chest pain at all. He is noted to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Resident 38 was admitted to the facility on [DATE] with diagnoses that included a history of cerebral infarction, cardiomyopathy, difficulty walking, depression, anxiety, and a history of falls. On 3/27/22 at 3:30 PM, resident 38 was interviewed. Resident 38 stated that he'd fallen 6 or 7 times at the facility, with part of the problem being that he needed new glasses. Resident 38 stated that he wanted to leave the facility to go to an assisted living facility. On 4/13/22, resident 38's medical record review was completed. On 12/20/21 at 3:03 AM, an administration note revealed that resident 38 was on alert charting for a fall. Nursing notes revealed the following: a. On 12/13/21 at 10:44 AM, resident 38 had a fall note. Patient had no neuro problem or any discomfort at this time. Patient still walks around the hall way. Will continue to monitor. b. On 12/16/21 at 1:14 PM, a Utilization Review note revealed that resident 38 had a history of falls and was admitted for strengthening. Staff to anticipate needs and assist PRN (as needed) w/ frequent orientation to place/time/situation. Plan of care in place and will be reviewed in one week. c. On 2/3/22 at 5:05 PM, a Nursing Practitioner note revealed resident 38 was examined for pain. An X-ray was obtained at 9:42 PM, and revealed that resident 38 had a Fracture which involves the fifth proximal phalanx noted d. On 3/3/22 at 1:05 PM, Resident report a fall, resident claims it happened 4-5 days ago. Resident claims he got dizzy and fell in hallway. Resident showed nurse two bruise's to right leg front below knee and right arm above elbow with noted swelling Fall reports revealed that on 11/12/21 at 11:23 PM, resident fell in his room without injury. On 3/3/22 at 8:33 AM, resident 38 claimed to fall without observation. Resident 38 had a right lower leg hematoma. Resident 38's care plan revealed actual falls on 11/12/21 and 3/4/22. No other falls were included in resident 38's care plan. On 3/24/22 at approximately 11:30 AM, a former DON (DON 2) was interviewed. DON 2 stated that resident 38 fell in December and there was no fall report created. DON 2 stated that resident 38 had some serious bruises with increased pain, but no broken bones at that time. On 3/29/22 at 1:32 PM, the Administrator (ADM) was interviewed. The ADM stated that she was responsible to report falls and should have created a fall report for each fall. Based on observation, interview and record review it was determined, for 10 out of 51 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident with a history of suicidal ideation (SI) and major depressive disorder eloped from the facility and was gone for 24 hours before staff notified administration and the local police department, a resident with suicidal ideation and homicidal ideation (HI) was found with multiple weapons in his possession, and a resident was found in the unsecured laundry area near cleaning chemicals and the unlocked broiler room. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level Additionally, a resident sustained a head laceration during a staff assisted transfer, a resident had complaints of increased pain after a fall from a Hoyer lift, and a dependent resident was left outside during inclement/cold weather for an unknown extended period of time by staff. These identified deficient practices were found to have occurred at a Harm Level. Lastly, a resident sustained a fall after slipping on floors that were wet from drainage that had leaked from their wounds, a resident had multiple falls without interventions identified to prevent the falls, and a resident with right sided hemiplegia was observed ambulating and hopping up the stairs while a staff member carried the resident's wheelchair behind them. Resident identifiers: 4, 18, 23, 27, 28, 38, 40, 43, 49, and 51. NOTICE On 4/5/22 at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure that residents identified at risk for elopement and self-harm and harm towards others were evaluated, that interventions were identified and monitoring for safety was implemented. Additionally, environmental hazards such as unsecured chemicals and the unlocked broiler room posed toxic and caustic hazards for the residents. Notice of the IJ was given verbally to the facility Administrator (ADM) and the Corporate Resource Nurse (CRN) and they were informed of the findings of IJ pertaining to F689 for resident 40 only. On 4/7/22 at 8:28 AM, notice of the IJ for resident 49 was given verbally to the ADM, Regional [NAME] President (RVP), and the Corporate Registered Dietician (CRD). On 4/7/22 at 3:40 PM, notice of the IJ for resident 28 was given verbally to the Director of Clinical Services (DCS). On 4/12/22, the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 4/12/22 at 10:00 AM: 1. Resident #40 was placed on a 1:1 for close supervision and oversight. Resident #40 will remain on 1:1 until alternative placement can be found. 2. Resident who have the history of or who have been assessed to be high risk for elopement have the potential to be affected by this deficient practice. The community DON [Director of Nursing] or designee completed an audit of other residents to determine risk factors per H & P [History and Physical] and Elopement Assessments. 3. The staff received education and training on 4/11/12 regarding the Elopement Policy and Procedure. Education to be completed with licensed nursing staff regarding complete minimally every 2 hours visual checks of all residents who are at high risk for eloping to ensure that we know where they are at. If we are unable to locate them, the NHA [Nursing Home Administrator] and DON must be notified immediately and search of the building and surrounding area initiated. Failure to complete q2h [every 2 hour] checks will lead to disciplinary action. The consultants initiated an Elopement Binder on 4/11/2022. An audit will be completed of all resident's Wander Risk assessment to ensure that they completed and anyone identified as High Risk has an appropriate intervention in place, a care plan regarding the high risk, order, and that they are in the Elopement Binder at the front desk and on each nursing station. An audit will be completed on the Elopement Binder to ensure all residents identified as high risk are included in the Elopement binder and Elopement Identification Sheets are current and up to date. Any incidents of Elopement attempts will be reviewed in the IDT [interdisciplinary team] morning meeting including documentation of discussion and care plans will be updated appropriately. Elopement drills will be performed monthly for the following quarter, If the community sustains compliance, elopement drills can be conducted on a quarterly basis. The laundry room door was immediately locked upon identification by the survey team. The identified resident with with (sic) suicidal ideation was sent to the hospital and will not return to the community due to the community cannot provide care and services to meet his psychosocial needs. 4. The community will review with the QAPI [Quality Assurance and Performance Improvement] committee any elopement attempts/exit seeking behavior or reportable missing person occurrence report for the month for review or recommendation to follow up on. The DON or designee will report findings from the elopement drill. The NHA or designee will be responsible to follow up on any recommendations. On 4/12/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/12/22 at 10:00 AM. Findings include: IMMEDIATE JEOPARDY 1. Resident 40 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, malignant neoplasm, Klinefelter Syndrome, major depressive disorder, suicidal ideation, mood disorder, hepatitis B, hepatitis C, acute kidney failure, and glaucoma. On 4/5/22 resident 40's medical records were reviewed. Review of resident 40's physician orders revealed that the resident was receiving Trazadone 150 milligrams (mg) each day (qd) for insomnia, Hydroxyzine 50 mg qd for anxiety, Sertraline 150 mg qd for major depressive disorder, and Quetiapine 400 mg at night and 200 mg in the morning for mood disorder. On 10/20/21, facility staff completed a document entitled Evaluation for Community Access for resident 40. Staff documented that resident 40 should not be in the community alone and based on the evaluation determined the resident was disoriented to person, place, time or situation; and the resident was easily confused. The physician reviewed the evaluation and concurred with the assessment on 10/21/21. On 10/25/21, an admission Minimum Data Set (MDS) Assessment documented that resident 40's Brief Interview for Mental Status (BIMS) score was a 12, which indicated a moderate cognitive impairment. On 10/26/21, a Montreal Cognitive Assessment (MOCA) was completed for resident 40. The MOCA score documented was a 18/30, which indicated a mild cognitive impairment. On 10/27/21 at 9:52 AM, the Resident Advocate (RA) progress note documented that the resident was deemed unsafe to go into the community without supervision. Evaluation will continue on a routine basis to determine if there is a need for the resident to be accompanied when out of the facility. All paperwork can be found in residents med (medical) records. It should be noted that no other documentation could be found that resident 40 was re-assessed for the ability to safely go out into the community without supervision. On 10/27/21, staff developed a care plan for resident 40 stating that the resident had a history of suicidal statements, feelings of depression, impaired thought processes and delusions. Interventions identified for the focus area of suicidal statements were to monitor resident 40's mood daily for self-isolation and negative statements; giving away of personal possessions or hoarding items to self-harm; initiate immediate referral to a mental health professional; verify that medications were swallowed; if actively concerned for safety initiate transfer to inpatient psychiatric facility; search resident's room for weapons or items to be used for self-harm, place resident on 15 minute safety checks; and provide gentle/sensitive support. Interventions identified for the focus area of depression were that social services would meet with resident 40 for supportive visits as needed; staff would identify personal strengths and abilities; praise resident 40 for accomplishments; support positive statements resident 40 makes; encourage involvement in chosen pursuits and hobbies; and refer for review by psychotropic committee and medical doctor (MD) or mental health professional. Interventions identified for the focus area of delusions were, do not argue, criticize or correct the resident, help resident 40 to feel safe, and use validation/therapy techniques to redirect to another topic or activity. Interventions identified for the focus area of impaired thought processes were to communicate with the resident regarding their capabilities and needs, review medications for possible causes of cognitive deficits, and use task segmentation to support short term memory deficits. On 11/18/21, a Preadmission Screening Resident Review (PASRR) Level II was conducted with resident 40. The PASRR indicated that resident 40 had a history of recurring depression with psychosis and that the resident had been hospitalized multiple times due to depression and suicidal ideation, stating he would cut his throat with his knife or jumping off of a building. The PASRR also indicated a history of suicidal ideation with multiple suicide attempts in the past. Resident 40 had a history of bouts of severe paranoia and visual hallucinations. Resident 40 will see people he believes are following him for unknown reasons who are not there. He has been noted to be suspicious of medical and psychiatric treatment staff who are trying to help and treat him. he reported being diagnosed with schizoaffective disorder in the past, but he does not 'see myself in the category of schizophrenia'. Notes from resident 40's behavioral health provider dated 11/19/21 documented that resident 40 stated I'm tired of the ruminating thoughts, I need to manage them, and reported multiple psychiatric hospitalizations since his last treatment episode with [name of behavioral health provider] for issues related to 'depression and suicide ideation'. The notes also stated that the resident stated he has multiple personality disorder. On 2/14/22 at 8: 43 AM, a psychosocial review was completed for resident 40. Staff documented that resident 40's mood appeared unstable. He has suicide ideation and has cut his wrists several times in the past. Staff also documented that resident 40 had been diagnosed with major depressive disorder, mood affective disorder, and suicide ideation. On 2/14/22 at 1:25 PM, a Patient Health Questionnaire-9 (PHQ-9) was completed for resident 40. The PHQ-9 indicated that resident 40 had a score of 10, which indicated moderate depression. Review of the facility Policy for Wandering and Elopement documented that the facility would identify residents who were at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The Policy stated that if the resident was identified as at risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety. The policy further stated that if a resident was missing, the facility should initiate the elopement/missing resident emergency procedure: a. Determine if the resident was out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident was not located, notify the ADM, DON, the resident's legal representative, the physician, law enforcement, and as necessary volunteer agencies. The policy was last revised in March 2019. On 4/5/22 at 9:25 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the last time she saw resident 40 was at approximately 11:10 AM on 4/4/22. RN 1 confirmed that she worked 6:00 AM to 6:00 PM on 4/4/22. RN 1 stated that she received report from the night nurse at approximately 6:00 AM on 4/5/22 that the resident still had not returned. RN 1 stated that as of the time of the interview, she still had not seen resident 40 in the building. On 4/5/22 at 10:12 AM, a review of the resident Leave of Absence (LOA) book was reviewed. A review of the LOA book at the nurse's station nearest resident 40's room revealed a sheet for resident 40. The sheet was blank with no entries noted. Instructions located on the inside of the booklet stated: Effective immediately for all residents leaving the facility without a staff member; 1. The release of responsibility form must be completed. 2. Nurse must notify the family contact and document in the nurse's notes. 3. If medication is to accompany the resident, medication teaching is to be done and documented. It should be noted that no documentation could be found in the nursing progress notes of resident 40 going on LOA. On 4/5/22 at 10:23 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that when she had arrived to work on 4/4/22 at 10:00 AM, she was told by a facility nurse that resident 40 had left. CNA 1 stated that she did not know where resident 40 had gone. CNA 1 stated that she left work on 4/4/22 at 10:00 PM, and the resident still had not returned to the facility. CNA 1 stated that when she left the facility at 10:00 PM, she informed the nurse on shift that resident 40 still had not returned to the facility, but the nurse already knew about it. CNA 1 stated that she was not sure if she was supposed to do anything differently if residents left the facility. On 4/5/22 at 11:07 AM, a follow-up interview was conducted with RN 1. RN 1 stated that resident 40 usually goes out every day and refused to sign the LOA book. RN 1 stated that sometimes resident 40 did not make staff aware that he was leaving the facility. RN 1 stated usually when he goes then I come back he is here. RN 1 stated that residents often left the building via the first floor because when you push the door for a long time it will open. RN 1 stated that she should have notified the Administrator (ADM) already, because now it is out of the ordinary. He is alert and oriented times 3. RN 1 stated that she was not documenting when resident 40 left the facility. RN 1 stated that resident 40 had reported depression especially after chemotherapy. RN 1 stated that she had no way of contacting the resident, and that he had never been gone this long. RN 1 stated that resident 40 had left overnight once before, sometime during the winter, but she was not sure when. RN 1 stated that resident 40 knew the door code to be able to exit the building. RN 1 stated that she was not sure if resident 40's absence had been reported to the police. RN 1 stated that when resident 40 left the building on prior occasions he would say it won't be long. RN 1 stated that she should report now because it had been 24 hours and resident 40 had not had his morning medication. On 4/5/22 at 11:24 AM, an interview was conducted with CNA 2. CNA 2 stated that he had last seen resident 40 on 4/4/22 at 7:30 AM. CNA 2 stated that to not see him back by lunch is not normal and especially to be gone overnight. CNA 2 stated he was not aware that resident 40 had been gone from the facility overnight. CNA 2 stated that he spoke to the nurse on shift on 4/4/22 and let her know that resident 40 had not yet returned to the facility. CNA 2 stated that resident 40 did not frequently go out on LOA. On 4/5/22 at 11:29 AM, an interview was again conducted with RN 1. RN 1 stated that she had notified the ADM, and the ADM had stated to document that he was an adult and does not have any issues with his conditions. On 4/5/22 at 11:43 AM, an interview was conducted with the ADM. The ADM stated that she was under the impression that resident 40 had left the faciity on 4/5/22, not 4/4/22. The ADM stated that no one had notified her that resident 40 had left the facility and not returned on 4/4/22. The ADM stated that resident 40 was cognitively intact. The ADM stated that resident 40 could make his own decisions, but that she would call the police and it sounds like he is leaving AMA (Against Medical Advice). On 4/5/22 at 12:53 PM, a follow-up interview was conducted with the ADM. The ADM confirmed that resident 40 had left the facility yesterday. The ADM stated that she had searched the building and confirmed that the resident was not currently in the building. The ADM also stated that she searched resident 40's room, and it appeared that resident 40 had taken his belongings out of his room. The ADM stated that she had called the police. The ADM stated that if a resident left the building, they were supposed to sign an LOA. The ADM stated that if the resident did not want to sign an LOA form, then the nurse should document the date and time on the LOA form and also document a progress note. The ADM stated that the nurse should also document when the resident returned, as well as notify the ADM, Director of Nursing, Assistant Director of Nursing (ADON), family and physician. The ADM stated she did not know of any other instances when resident 40 had left the facility overnight. The ADM stated she had not notified resident 40's physician that he had left the facility overnight. When asked what prompted her investigation into resident 40 leaving the building, the ADM stated that it was because the State Survey Agency (SSA) representatives had been asking questions. On 4/05/22 at 1:10 PM, a follow-up interview was conducted with CNA 2. CNA 2 stated that the last time he saw resident 40 he was wearing blue jeans, black shoes, and a black leather jacket. CNA 2 stated that resident 40 was independent for all cares, mobility, and transfers. On 4/05/22 at 1:13 PM, RN 1 was interviewed again. RN 1 stated that at the time resident 40 left the facility he had stated that he was going to a local grocery store to get food and he did not say when he would be returning. RN 1 stated she asked resident 40 to sign the LOA book, but resident 40 ignored her request. RN 1 stated that at the time of his departure resident 40's mood was normal per his baseline, but prior to leaving he was upset about the facility and did not want to be there anymore. RN 1 stated that resident 40 took his backpack with him when he departed, but that he always carried it with him. RN 1 stated that she was fearful that the ADM would retaliate against her for disclosing information to the SSA representatives. RN 1 stated that she had informed the ADM initially that resident 40 had been gone since 4/4/22 and the ADM had replied, He's old, he can go out, he doesn't have any medical condition that is concerning. RN 1 stated that the ADM asked again when resident 40 had left the facility after the SSA representative had questioned the ADM about the timing of notification. RN 1 stated that she told the ADM, I told you it was yesterday. RN 1 stated that the ADM acted like she did not know that resident 40 had left the faciity on 4/4/22. RN 1 stated that she had told the ADM the complete story, and now she acted like she was not informed. That's fishy. On 4/7/22 at 8:28 AM, a follow-up interview was conducted with the ADM. The ADM stated that resident 40 was re-admitted last night around 7 PM. The ADM stated that the plan for resident 40 was to have the resident on 1:1 with a staff member, and they called a Social Service Worker (SSW) consultant to have them come talk to the resident. The ADM stated that 1:1 was a lot of coordinating, but that they would continue with it until resident 40 cleared and did not have any more behaviors. The ADM stated that the emergency room (ER) stated that resident 40 was ready to come back to the facility and he was deemed not a threat to himself or others. The ADM stated they would have a SSW come in today and evaluate him. Review of resident 40's hospital ER summary dated 4/5/22 documented the reason for the visit was a Crisis Evaluation for Suicidal Ideation. The note stated that resident 40 arrived to the ER endorsing severe pain and suicidal ideation with a plan to end his life either with a gun or with a knife. Patient presents alert and oriented x 4 [person, place, time, and situation], fidgety and restless and moves around (standing to sitting and pacing somewhat) while meeting with Crisis Worker. Patient reports feeling 'frustrated' about the amount of pain he is in as well as the state of his physical health and states his body is wearing down and he does not have energy to keep going He reports he has not seen a therapist since December 2021 due to lack of energy and apathy to follow-up. Patient has a history of cutting and stating he has only dealt with emotions as 'tied up or angry' and cuts to release his emotions. Patient reports he does not own a gun currently but states if he did, 'I would not be here right now.' Patient is unable to safety plan and has a knife in his belongings here in the hospital. He reports he attempted suicide in 2006 when he jumped from a second story bridge in [name of state] into the [name of river] River. After this attempt, patient reports he was hospitalized at a county hospital, a private psychiatric hospital, and then a state hospital. The patient history further documented that resident 40 reported that since his radiation treatment had begun, he had worsening depression and that the Sertraline was no longer working for him. Resident 40 also reported that while living in the skilled nursing facility he had no one to talk to. Resident 40 was screened as a Moderate risk for suicide/self-harm. Resident 40 met the criteria for a voluntary admission and was evaluated as unable to remain safe in a less restrictive environment at this time. 2. Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE] diagnoses that included cerebral palsy, suicidal ideations, major depressive disorder, anxiety disorder, chronic pain syndrome, opioid use, and neuromuscular dysfunction of the bladder. Resident medical record was reviewed between 3/23/22 and 4/13/22. On 3/2/21, facility staff completed an Evaluation for Community Access for resident 49 in which they determined that the resident had a history of being unsafe in the community and had a physical impairment which rendered the resident unsafe in the community. The resident met the criteria determining that resident should not be in community alone. A PASRR level II was completed for resident 49 on 3/22/21. The PASRR documented that resident 49 has a history of treatment for depression and anxiety, along with multiple maladaptive personality traits; all of these have caused pt (patient) significant functional impairment for many years. He also endorsed symptoms of PTSD (Post Traumatic Stress Disorder) that he reports are causing him significant disruption at this time. The PASRR indicated that resident 49 had a history of suicidal ideations and suicide attempts, beginning in his teens. The PASRR indicated that in September 2020, resident 49 was residing at a long term care facility and tried to strangle himself, which led to an inpatient psychiatric hospitalization. The PASRR continues He has also experienced excessive anxiety and worry, difficulty managing feelings of worry, restlessness/fatigue d/t (due to) excessive worry, irritability, tension, and trouble sleeping d/t anxiety. He has been diagnosed with bipolar in the past, but it appears that his symptoms are more consistent with borderline traits vs (versus) true manic sxs (signs and symptoms). he described very rapid mood swings but struggled to identify manic sxs. He has experienced and reported chronic fears of abandonment, a long standing pattern of dysfunctional interpersonal relationships and devaluation/elevations of others in relationships, impulsivity in multiple areas in his life . recurring and often impulsive suicidal gestures or threats (he purchased a knife on the Internet and had it delivered to his prior SNF (skilled nursing facility) in a suicidal gesture and later tried to strangle himself), anger/irritability w/o (without) provocation, and affective instability/emotional reactivity vs true mania (he describes going from depressed to angery (sic) very rapidly . ). He has also been diagnosed with antisocial personality disorder given his history of disregard for the rules (smoking marijuana in the SNF setting), being disrespectful to police w/o provocation, irritability and verbal aggression with staff, and reckless disregard for his own safety with his impulsivity and failure to plan ahead. He has taken flights impulsively to various places in the United States where he has no support, unable to provide for himself or without funds to pay for food and shelter. He has left multiple nursing homes AMA (against medical advice) without adequate planning for his needs, resulting in poor outcomes. He has often been deceptive/overreported symptoms in medication seeking behaviors (pain meds (medications) or benzos (benzodiazepenes)). He has also snuck friends into the SNF or has snuck out of SNF's in the past, violating COVID-19 protocols. He has feigned helplessness to get help or sympathy from staff. He has been physically assaulted on multiple occasions, including once being beaten up and left for dead in an abandoned house. Due to this incident among his other altercations he reports sxs of PTSD including recurring nightmares/intrusive memories (The nightmares don't stop and they haunt me), avoidant behaviors, feelings of distrust of others/detachment from others, persistent negative emotions, irritability/anger out of the blue (I don't know why I just get pissed and I want to fight or punch a wall or something), reckless/self-destructive behaviors, and difficulty sleeping d/t his nightmares. The PASRR also stated that Pt stated that he is willing to get a referral for mental health but that it can be difficult to re-establish rapport and trust with new mental health providers. Pt did state that he wants to have someone who can help him in his decision making, such as a guardian or POA (power of attorney) . He recognized that he needs help in his decision making, and stated I have walked away from too many places over nothing, and it is getting to the point where people are going to start saying we can't have him come here. I'm going to be in a lot worse place than where I'm at now If I don't get help. The SNF Resident Advocate was made aware of pt's wishes. Pt is on multiple psychotropic medications and he has been compliant in taking them. He reported that he has been depressed ever since leaving his prior SNF and that he hit bottom when he left there. He did not endorse SI (suicidal ideations) at this time; however given his history of impulsivity and multiple suicide attempts (and hospitalization d/t a suicide attempt in 2020) he should be closely monitored for any lethal means/means for self-harm that would be accessible to him. Given his online purchase of a knife in 2020 every package that might come to pt should be opened with staff present to ensure pt's safety. The PASRR listed the following recommendations for mental health treatment: He should be monitored closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. He should be referred for outpatient mental health treatment as well to him him learn better coping skills. He was getting treatment from [name of mental health provider] at his prior SNF. On 3/26/21, facility staff documented that Reported to administrator that resident confided in another resident that he was contemplating suicide. Nursing to monitor resident for behaviors/self harm and/or suicidal verbalizations. On 4/7/21, approximately 12 days later, the facility Licensed Clinical Social Worker (LCSW) Consultant documented the following in resident 49's progress notes: .Monitor resident closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. On 5/6/21, the Resi[TRUNCATED]