FOCUSED CARE AT BEECHNUT

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to care for residents in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 5 residents (Resident #20, Resident #33, and Resident # 54), reviewed for resident rights.<BR/>-CNA K was standing while feeding Resident #54 his breakfast on 06/25/24. <BR/>-LVN B did not provide privacy when administering insulin to Resident #33 on 06/25/2024. <BR/>-RN A did not provide privacy when administering Resident # 20 G-tube medications on 06/25/2024.<BR/>This failure placed residents at risk for feeling embarrased, disrespected and diminished quality of life.<BR/>The findings were:<BR/>Record review of Resident #54's face sheet dated 06/25/24 revealed a [AGE] year-old male admitted to the NF on 05/08/2017. Resident diagnoses included the following: Parkinson's Disease (disorder that affects movement, often including tremors) without dyskinesia (unwanted or involuntary movement), muscle weakness, dysphagia (difficulty swallowing), major depression, age related physical debility, and attention-deficit hyperactivity disorder (not being able to focus).<BR/>Record review of Resident #54's quarterly MDS dated [DATE] revealed that resident had a BIMS score of 3 indicating that resident cognition was severely impaired. Further review of the MDS section G reflected that resident was totally dependent and required full staff performance. <BR/>Record review of Resident #54's Physician Order Summary Report reflected the following order:<BR/>-Dated 05/11/2024 Carb Controlled diet pureed texture, regular consistency.<BR/>Record review of Resident #54's Comprehensive Care Plan dated 10/03/2019 and revised on 11/20/2023 reflected that resident was being care planned for requiring assistance with all ADL's self-care performance deficit r/t disease processes. The interventions included eating: resident being totally dependent on skilled nurses for nutritional intake. <BR/>Observation on 06/25/24 at 9:30AM revealed during breakfast on Station A, CNA K standing on Resident #54's right side feeding resident his breakfast. <BR/>In an interview on 06/25/24 at 10:00AM CNA K said she had been working at the NF for approximately 2 months. CNA K said the reason she was standing while feeding Resident #54 was because she did not have a chair to sit on. CNA K said she was taught in CNA school to sit whenever feeding a resident but had forgotten the reason why she should be sitting instead of standing when feeding a resident. <BR/>In an interview on 06/25/24 at 11:55AM LVN B (on Station A) said she worked the 6AM-6PM shift. LVN B said when a resident was being fed, the staff should be sitting while feeding the resident. LVN B said this was done to provide the resident with dignity.<BR/>In an interview on 06/25/24 at 11:05AM the DON said she had been working at the NF for 5 weeks. The DON said whenever she had to assist with feeding a resident, she would sit to feed the resident. The DON said she would have to review the NF policy because it depended on the resident if they wanted the staff to sit while feeding them.<BR/>Resident # 33<BR/>Record review of Resident #33's face sheet revealed a 63-year- old male admitted to the NF on 05/03/2023 with diagnoses that included the following: hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis (paralysis that affects only one side of the body) following cerebrovascular (decrease in blood flow to the brain) disease affecting the right dominant side, and type two diabetes mellitus (too much sugar in blood).<BR/>Record review of Resident #33's quarterly MDS dated [DATE] revealed that resident had a BIMS score of 2 indicating that resident cognition was severely impaired. <BR/>Record review of Resident #33's Comprehensive Care Plan revised 11/15/2023 revealed that resident was care planned for diabetes mellitus with intervention that included to administer insulin as ordered. <BR/>Record review of Resident #33's Physician Order Summary Report reflected the following order:<BR/>-Dated 05/23/2024 Humalog (fast acting insulin to treat diabetes) subcutaneous inject 10 units before meals for dm (diabetes mellitus), if blood sugar was below 150 do not give insulin.<BR/>Observation on 06/25/24 at 11:49AM revealed LVN B entering Resident #33's room to take the residents blood sugar. LVN B did not close Resident #33's door or pull the resident privacy curtain. LVN B continued to care for the resident by taking resident's blood sugar. Resident blood sugar was 272 requiring 10 units of Humalog subcutaneously. LVN B administered 10 units of Humalog subq to resident's left lower abdomen (belly or stomach region).<BR/>In an interview on 06/25/24 at 12:00PM with LVN B she said she forgot to close Resident #33's door and pull the resident privacy curtain when administering the insulin. <BR/>Resident #20<BR/>Record review of Resident #20's face sheet revealed a 51-year- old male admitted to the NF on 03/19/2023 with diagnoses that included the following: cerebral infarction (decrease blood flow to the brain), dysphagia (difficulty swallowing), gastrostomy (surgical procedure that creates an opening in the stomach to deliver food), aphasia (language disorder that affects a person's ability to communicate), and hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis (paralysis that affects only one side of the body) following cerebral infarction. <BR/>Record review of Resident # 20's MDS annual assessment 04/29/2024 reflected that resident had a BIMS score of 1 indicating that resident cognition was severely impaired.<BR/>Record review of Resident #20's Physician Orders reflected the following:<BR/>-Dated 04/26/2023 flush with 30ml (water) before and after medication pass with 5 ml between each medication.<BR/>Record review of Resident #20's Comprehensive Care Plan dated 10/28/2023 and revised 04/29/2024 reflected the following:<BR/>-Resident #20 required tube feeding r/t dysphagia with an intervention that included resident was dependent with tube feeding and water flushes. <BR/>Observation on 06/25/24 at 4:10PM of medication administration for Resident #20 via gastrostomy tube by RN A. When RN A entered resident's room to administer resident medications, she did not close the door, nor did she pull Resident 20's privacy curtain. Resident #20 was sitting up in his specialized wheelchair watching a movie on his laptop. Resident #20 had a G-tube with a dressing at the site. RN A proceeded to check the resident's G-tube placement by raising the resident's shirt to auscultate (listen) resident's abdomen (stomach). When RN A was done, she continued with checking the G-tube for any residual. RN A proceeded to administer the resident's medication via G-tube by gravity. <BR/>In an interview on 06/25/24 at 4:30PM RN A said whenever providing care for a resident, she was supposed to provide the resident with privacy by closing the door or pulling the curtain. RN A said she became nervous and forgot to provide privacy for Resident #20.<BR/>In an interview on 06/25/24 at 12:07PM the DON said whenever the staff provide care for the resident's they were supposed to provide privacy for the residents. <BR/>Record review of the NF policy on Meal Service dated 04/2022 revealed in part:<BR/> .The dining experience will enhance the resident's quality of life .The staff member does not stand, when feeding or assisting the resident with eating. Staff converse with the residents during mealtime . <BR/>Record review of the NF policy on Resident Rights revised December 2016 revealed in part:<BR/> .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence, be treated with respect, kindness, and dignity .privacy and confidentiality . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of (Residents #41, #26, #16, #46) of 14 residents reviewed for care plans. <BR/>- <BR/>The facility failed to ensure Resident #41 was care planned for hospice care <BR/>- <BR/>The facility failed to ensure Resident #16 and #46 were care planned for ADL's.<BR/>- <BR/>The facility failed to ensure Resident #26 was care planned for behaviors.<BR/>These failure could place residents at risk of not receiving care and services related to their identified needs.<BR/>Findings included: <BR/>Resident #41<BR/>1. Record review of Resident # 41's admission records face sheet dated 2/23/22 revealed he was [AGE] year-old male admitted to the facility 10/12/20 His diagnoses included Epilepsy, benign tumor (soft tissue tumors). Muscle wasting, urinary tract infection and age-related physical conditions. <BR/>Review of Resident #41's Physician Orders dated 05/07/21 revealed -admission to local Hospice <BR/>Record review of Resident #41's MDS assessment dated [DATE] revealed section O on specialized treatment, procedure and program was checked for hospice care.<BR/>Record review of Resident #41's care plan dated 05/04/21 revealed no care plan for hospice care. <BR/>During an interview with the facility DON on 02/24/22 at 2:00PM she said the MDS coordinators are responsible for ensuring that the MDS accurately reflect Resident's condition. <BR/> During an interview with MDS Nurse A on 02/24/22 at 3:30pm, he acknowledged that the care plan for Resident # 41 was not accurate. He said Resident # 41's care plan would be corrected to reflect their condition. He said he was responsible for ensuring that all MDS assessments reflect Resident's condition.<BR/>Resident #26<BR/>2. Record review of Resident #26's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, hypertension, and multiple sclerosis.<BR/>Record review of Resident #26's MDS, dated [DATE] revealed the resident's BIMS assessment was unable to be completed due to resident being never or rarely understood. The resident was not assessed to have any psychiatric disorders.<BR/>Record review of Resident #26's physician's orders, dated as of 02/22/2022 revealed the resident was taking clonazepam and buspirone for anxiety starting 12/17/2021, trazadone for sleep/depression starting 12/17/2021, Seroquel for bipolar disorder starting 02/17/2021.<BR/>Record review of Resident #26's care plan, as of 02/22/2022, revealed the only note made about resident's behavior was, . The resident has a behavior problem in which she sits on the floors and other objects despite encouragement not to do so. There were no other notes regarding resident behavior or psychiatric-related diagnoses.<BR/>Record review of Resident #95's face sheet revealed an [AGE] year-old male who was admitted on [DATE] and was diagnosed with cognitive communication deficit, psychosis and dementia. <BR/>Observations of Resident #26 and #95 on 02/22/22 at 10:30AM revealed Resident #26 sitting in a wheelchair while yelling at and cursing out surveyor after surveyor asked for CMA J and LVN R for location of a room number. Resident #26 was then observed passing nearby Resident #95 as he slept in the hallway on a Geri-chair. Resident #26 yelled wake-up while swiftly brushing Resident #95's cheek with her hand. CMA J was observed to quickly remove Resident #26 from Resident #95. Resident #26 was later observed to cry out loud while asking for her son.<BR/>In an interview with CMA J on 02/24/22 at 1:05 PM, she stated Resident #26 was aggressive, gets upset and calls her sons' name. She said the resident gets up to fight with staff as if she is preparing to defend her son. She went up towards Resident #95 on 02/22/22 and brushed his face she believed with the intention to get his attention so he could move out of the way. She usually does not fight other residents. <BR/>In an interview with LVN R on 02/24/22 at 1:50PM, she stated Resident #26's behaviors included shouting and looking for her children and when hearing a random person's voice, she thinks its her son talking. She does not harm residents but she touches residents sometimes with the intention of going where she wants to go or probably due to vision problems. She stated this type of behavior should be documented and care planned. <BR/>In an interview with the Administrator on 02/25/22 at 10:31AM he stated has never seen Resident #26 hit a resident before but he knows the resident has her outbursts due to her behaviors. He stated he expects behavior monitoring to be care planned for her psychiatric diagnoses as well as psychotropic medication usage.<BR/>In an interview with the DON on 02/25/22 PM, she stated Resident #26's only behavior that she had noticed was screaming and yelling. She stated she is on medications that have been adjusted by her psych provider. She said this type of behavior should be care planned. She stated they usually have care meetings on Friday with nurse department team and they make updates to resident care plans then. She said her care plan was likely missed because they did not talk about her behaviors during a meeting yet. She stated the implication of not care planning behaviors is not having care and needs followed up on with interventions and goals to manage behaviors in place<BR/>In an interview with MDS Nurse A and MDS Nurse B on 02/25/22 at 11:44AM, MDS Nurse A stated Resident #26 was initially in the secured unit and shows aggressive behavior and curses people out and therefore had to leave the secured unit. He said she admitted back into the facility's general community after getting her medications adjusted during her discharge. He stated behaviors settled down but slowly came back. MDS Nurse B said these behaviors should have been care planned and if the resident is on psych meds it should have been triggered in the care plan as well. <BR/>Resident #16<BR/>3. Record review of the face sheet for Resident # 16 revealed a [AGE] year-old female with initial admission date of 6/7/21, and re-admission date 2/15/22. Diagnoses included Schizophrenia, Bipolar disorder, anxiety disorder, dementia without behavioral disturbance, Epileptic seizures, hypertension, and Multiple Sclerosis. <BR/>Record review of the quarterly MDS dated [DATE] revealed Resident # 16 had unclear speech and sometimes understood and sometimes understands others. Resident # 16's BIMS score was 3 indicating severely impaired cognitive skills for daily decision making and required total staff assistance for bed mobility, transfer, dressing, hygiene, toileting, and bathing. <BR/>Record review of Resident# 16's care plan, undated, revealed there was no care plan developed for ADL's, including interventions for ADL assistance. <BR/>Observation and attempted interview with Resident # 16 on 2/22/22 at 9:40 am revealed she was in bed, awake and alert. Resident had clean linens, catheter bag at bedside draining clear urine, and an IV pole with medications being infused for UTI. Resident # 16 stated I'm tired and closed her eyes when an interview was attempted. <BR/>Observation and attempted interview with Resident # 16 on 2/23/22 at 9:15 am revealed she was in bed, awake and alert. Resident # 16 stated Who are you? Bye and closed her eyes when an interview was attempted.<BR/>Resident #46<BR/>4. Record review of the face sheet for Resident #46 revealed a [AGE] year-old male with admission date of 1/06/21. Diagnoses included Parkinson's disease, need for assistance with personal care, dementia without behavioral disturbance, Diabetes, hypertension, Schizophrenia, Benign Prostatic Hyperplasia (enlarged prostate), and paralysis following cerebral infarction (stroke). <BR/>Record review of the Annual MDS dated [DATE] revealed Resident # 46's cognitive skills for daily decision making were moderately impaired, and he required extensive assistance from staff for bed mobility, transfer, dressing, hygiene, toileting, and bathing. Record review of the Care Area Assessment (CAA) Summary revealed ADL/Functional/Rehabilitation Potential was not triggered. <BR/>Record review of Resident #46's care plan, undated, revealed there was no care plan developed for ADL assistance, including appropriate interventions for ADL care. <BR/>In an interview with MDS Nurse A on 2/24/22 at 10:10 am revealed ADLs were not triggered in the Care Area Assessment for Resident's # 16 and #46, so the care plan for ADL's was not developed. MDS Nurse A stated the care plans were developed from the comprehensive assessment for each resident, and if the CAA's are triggered for a particular area, a care plan would be done for that care area. <BR/>Record review of the facility policy Care Planning - Interdisciplinary Team, dated September 2013, revealed, in part: .the care plan is based on the resident's comprehensive assessment and is developed by the Care Planning/Interdisciplinary Team .<BR/>Record review of facility's provided care plans policy dated 2001 revised September 2013 read in part . our facility 's care planning/interdisciplinary team is the responsibility for the development of an individualized comprehensive care plan for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accidents and hazards as is possible for 22 of 22 residents reviewed for accidents and hazards. <BR/>1. <BR/>CNA B and CNA C engaged in a verbal and physical altercation in the presence of at least two residents, Resident #2, and Resident #3 on 1/18/24 at approximately 6:00 a.m.<BR/>2. <BR/>CNA C left a loaded firearm unattended inside her personal bag in an unsecured cabinet under the nurse's station desk located directly across from a resident TV area for an undetermined amount of days/time. <BR/>3. <BR/>CNA C pointed a loaded firearm at CNA B and discharged the gun outside in the air approximately one yard from resident-occupied rooms on 1/18/24.<BR/>An Immediate Jeopardy (IJ) was identified on 02/07/2024 at 9:40 a.m. The IJ template was provided to the facility on [DATE] at 9:40 a.m. While the IJ was removed on 02/08/2024 , the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures placed all residents at risk possibly being seriously harmed/injured or killed by an unsecured firearm or stray bullet. <BR/>Findings included:<BR/>Observation of the nurse's station on the 100 Hall on 01/22/2024 at 11:00 a.m. revealed the entrance to the nurse's station was directly across from a resident television area. There were open areas underneath the desk with shelves. There were bags, purses, and jackets on the shelves. No staff were observed at the nurse's station at that time. There were three residents in wheelchairs sitting in the television area. <BR/>In an interview with the DON on 01/22/2024 at 9:30 a.m., she stated on 01/18/2024, LVN V called her and said two staff members (CNA B and CNA C) were having an altercation. She could not recall what time LVN V called her, but it was at the start of the 6:00 a.m. - 2:00 p.m. shift. The DON said she told LVN V to get replacement staff and send CNA B and CNA C home. The DON said LVN called her again that morning and said there were gun shots fired outside. The DON said the MDS Nurse called the police after she heard gunshots. The DON said there had not been any prior altercations between the two staff that she knew of. She said CNA C was just hired in December 2023. She said CNA C had not complained about any prior incidents with any other staff. She said their corporate staff were involved in the investigation. She said CNA D tried to separate the two staff when they were fighting. She said all three staff were suspended pending the investigation, but CNA D returned to work on Sunday, 01/21/2024. She said the MDS Nurse was currently in the hospital having emergency surgery. She said the nurses did 12-hour shifts from 6:00 a.m. - 6:00 p.m. and 6:00 p.m. - 6:00 a.m. She said RN A was the night shift nurse and she also witnessed the altercation. <BR/>In an interview with the Administrator on 01/22/2024 at 10:22 a.m., he stated on 01/18/2024, he received a call from a nurse at about 7:15 a.m. He said he could not recall what nurse called him, but the nurse said the Medical Records Coordinator said CNA C had a gun and fired shots in the air. The Administrator said CNA C texted him at 8:11 a.m. after the incident and said the other staff jumped her. He said he sent her a text saying she brought a weapon into the facility when signs were posted everywhere saying it was a felony and then discharged it unsafely. He said CNA C texted back saying she figured he would say that and that it was not a felony to protect herself The Administrator said the police came and did an investigation, but as of Friday, 01/19/2024, they had not found CNA C or arrested her. He said CNA C texted that she rode the bus to work, and the gun was in her bag. The Administrator said he did not know where CNA C's bag was stored inside the facility. He said CNA C told him she brought the gun for safety reasons because she rode the bus at night. He said this was the first time he heard about any incident between CNA B and CNA C. The Administrator said CNA C never told him what the argument was about, but he heard during the investigation that the argument was about an unsafe transfer. He said CNA C transferred Resident #2, who was a two-person transfer, alone and CNA B told her how to do it the right way. The Administrator said Resident #2 told him CNA B was very calm when she approached CNA C and told her how to transfer him the right way. The Administrator said that was when things escalated, and CNA D tried to stop CNA C from going outside to mess with CNA B, who was outside smoking. He said RN A, MDS Nurse, and CNA D all tried to stop CNA C from bothering CNA B outside. He said CNA C went outside and that was when everybody heard guns shots. The Administrator said nobody went outside with CNA C. He said from his understanding, there was a short amount of time when CNA C went outside and when gunshots were heard. He said from his understanding, there was not a physical altercation inside the building because some people said it was physical, and some said it was not. He said CNA C told the VP of Operations she was being bullied, but there were no reports of that to him. He said CNA C never reported being bullied before this incident. He said he always did in-services about staff getting along and workplace violence as part of their ongoing training. He said there were no prior issues with staff having altercations that he knew of. He said staff had lockers available to them outside in the courtyard and in the staff breakroom. He said staff could bring their own locks to secure their personal belongings. He said he did not know if CNA C had a locker or not. The Administrator said he implemented a new rule that staff could only bring clear bags into the facility. He said he also contracted to have security in the building 24-hours daily and in-serviced staff. He said there were always signs posted at every entrance and exit about not bringing guns into the building, but he posted more signs. <BR/>In a telephone interview with CNA C on 01/22/2024 at 10:45 a.m., she stated she took responsibility for what she did because they (the Administrator and VP of Operations) told her having weapon on the premises was a felony. She said she only had the gun because she rode the bus at night to and from school. She stated she worked the 6:00 a.m. - 2:00 p.m. shift, but on 01/18/2024, she arrived early and clocked in at 5:45 a.m. She said she got Resident #2 up because he wanted to get up. She said she gave him a bed bath and transferred him safely with a Hoyer Lift to his wheelchair. She said RN A went to Resident #2's room because he was rambling and going on (she did not say what Resident #2 was rambling about). She said RN A said, Oh, you got him up, it was not time to get him up and you were not supposed to get him up by yourself. She said she was still in Resident #2's room and was leaving out right at 6:00 a.m. when CNA B approached her and was very aggressive about it. She said CNA B told her, I don't know what you think you are doing, but this is a two-person assist and you are going to get yourself fired. CNA C said she did not know what CNA B's problem was because she came down the hallway with her hands up like she was going to hit her. CNA C said CNA B swung at her and she backed up and asked CNA B not to do that. She said CNA B told her RN A asked her to come talk to her. She said she asked CNA B why she was so mad, and CNA B said she was done talking and was about to burst her upside her head. CNA C said she previously observed CNA B get Resident #2 up unassisted and CNA B said, I don't care what you thought you saw. CNA C said CNA B kept pushing and chest butting her. CNA C said she was walking away when CNA D grabbed her hand and said, Don't run up behind CNA B like that. CNA C said she told the rest of the staff she was leaving and showed them her bus pass. She said while CNA D held her, CNA B punched her on left side of her face. She said nobody let her leave. She said CNA B said, You about to go outside and get your ass whooped. CNA C said there were 3 - 4 people standing outside with CNA B and they were bullying her, so she pulled her gun out and shot into the air. She said she did not know the names of the other staff who were outside with CNA B. She said she called the Administrator and the VP of Operations after the incident. She said her car was broken, so she had to ride the bus. She said she went to class from 5:00 p.m. - 9:00 p.m. and she stored her bag behind the nurse's station, under the cabinet where there was an open area. She said that was where all the staff kept their things. She said she left her bag with the gun inside on the bottom shelf, next to the computer and chair on hall 100. She said her weapon was not exposed. She said RN A was there when CNA B hit her in the face. She said CNA B and another staff were already outside when she tried to leave the building and CNA D held her back and would not let her leave. She said she did not know if CNA D made it outside before her, but she saw some people at the door yapping their mouth (yelling at her and bullying her). She said she went out the side door of the building and was in the middle of the parking lot when she fired the shot in the air. She said she did not aim the gun at anybody, and she did not try to hurt anybody. She said the other staff were nowhere near her when she fired the shot. She said the other staff were more than 200 - 300 ft. away from her. She said the Medical Records Coordinator heard her telling the other staff to get off her. She said she told the Medical Records Coordinator and another CNA that she was being bullied by CNA B. She said during the week prior to the incident, she was mistreated by some African staff and CNA B defended her, so she did not understand why CNA B hit her in the face. She said she never reported to the Administrator or other management staff that she was being bullied. She said 01/18/2024 was the first day she brought her gun inside the building. She said she had never gone inside the building with a bag before because she previously had her car. She said her car broke down a couple of weeks before the incident. She said she never noticed or paid attention to the posted signs that said she could not bring a gun inside the building. She said she did not know she could not have the gun to protect herself. She said none of the residents had access to it because it was behind nurse station under the open cabinet.<BR/>In an interview with the Medical Records Coordinator on 01/22/2024 at 11:15 a.m., she stated days before the incident on 01/1/2024, CNA C told her some other staff were messing with her and the nurses were always hostile to her. She said she told CNA C file a grievance because the Administrator had an open-door policy. She said CNA C told her that on Saturday, 01/13/2024, some nurses got her into the medication room and got in her face. She said CNA C told her that on the day of the incidents, CNA C came and told her she could not get Resident #2 up or change him by herself even though she previously observed CNA C transfer him alone. The Medical Records Coordinator said RN A told CNA B to go and tell CNA C she could not transfer Resident #2 alone. She said the two staff had a verbal and physical altercation in the residents' room. She said Resident #2 told her CNA C hit CNA B first. She said CNA C told her CNA B hit her first. She said CNA C and CNA B never had any disagreements. She said CNA D told her (Medical Records Coordinator) that CNA C said she had a gun and she had 'something for them' if this (when the nurses cornered her in the medication room and got into her face) happened again. She said CNA C told CNA D she had a gun possibly days before the shooting incident. She said CNA B was a smoker and usually went out to the patio in the courtyard to smoke, but on 01/18/2024, CNA B called CNA out and said, Come outside if you got something for me. The Medical Records Coordinator said she was at the table in the front of the building and saw people running. She said she heard staff saying, No! Let my purse go, let me go! and She got a gun! She said by the time she got to the side of the building: CNA C was already gone. She said she did not hear the gun shot. She said the incident occurred around 6:00 a.m., so of course residents were up at that time and roaming around the building. She said none of the residents were outside. She said CNA D was outside when CNA C shot the gun. She said CNA D tried to keep CNA C from leaving with her purse because she knew the gun was in there. She said CNA C's bag was probably behind the nurse station, but staff were supposed to keep their belongings in the lockers. <BR/>In a telephone interview with CNA B on 01/22/2024 at 11:35 a.m., she stated she worked the 6:00 a.m. - 2:00 p.m. shift and there had not been any other incidents or animosity between her and CNA C. She said the two of them usually got along. She said on 01/18/2024, she had just gotten to work when RN A asked her to talk to CNA C because she got Resident #2 up way too early and she transferred him alone. She said RN A told her CNA C would not listen to her. She said she and CNA D went to the room and saw CNA C in there. She said she asked CNA C to come to the door and then told her RN A asked her to go and talk to her because Resident #2 was a two-person transfer. She said CNA C got mad and clapped her hands saying she was tired of people telling her what to do. CNA B said she told CNA C she was just trying to keep her from getting in trouble. CNA B said she walked away and told RN A it was too early for this. CNA B said the altercation was only verbal and never got physical. CNA B said they went to the nurse's station and continued arguing back and forth. She said RN A and CNA D were there trying to separate them. She said she tried to go outside and smoke to diffuse the situation, but it was brought up that CNA C had a gun. CNA B said CNA D knew CNA C had a gun. She said CNA D said, Don't let her get her purse! CNA B said at that time, CNA C was going for her purse behind the nurse's station desk. She said CNA D said, Don't let her get it because she got a gun! and CNA C said, And Do (meaning she did have a gun). CNA B said she was getting her stuff to go smoke and CNA B walked up on her back (walked closely behind her). She said as she walked down the hall to go smoke, the other staff were still in the building. She said once she got outside, she could see CNA C walking towards her thru the glass door. She said she saw CNA C's bag under left arm and her right hand was inside the bag. She said when CNA C walked outside, she was talking and pointed the gun at her as soon as she got outside. She said she heard CNA C ranting and raving that she was tired of people telling her what to do. She said when CNA C pointed the gun at her, she (CNA C) was about one or two feet away from the building and about three feet away from her. She said CNA C stood right by residents' windows. She said the police found the bullet shell next to building where she shot the gun. She said after CNA C pointed the gun at her, she backed up and pointed it in the air and fired. She said she did not know CNA C had a gun in building before the incident. She said she previously heard CNA C say they would not catch her like that again. She said CNA C was referring to an incident with some other nurses who attacked her. She said CNA C never reported that incident, but other staff knew because she was upset about it. She said CNA C told her the nurses were in her face and talking loudly because she gave a resident the wrong food tray. <BR/>In an interview with LVN V on 01/22/2024 at 12:20 p.m., she stated on 01/18/2024, she had the on-call phone and RN A called her to say there were two staff at the nurse's station fighting. She said she asked RN A what the situation was, and RN A said she and other staff pulled them apart and they walked out of the building. She said she called the DON, and the DON said the staff had to write a statement and leave the building. She said when she called CNA B and told her she needed to leave, CNA B went off on her (got very angry). She said CNA B told her she would not give her a statement. <BR/>In a telephone interview with the VP of Operations on 01/22/2024 at 12:40 p.m., she stated she was first notified of the incident the morning of 01/18/2024, when the Administrator called her. She said she told the Administrator to interview staff who witnessed the incident and call the police. She said when she arrived at the facility on 01/18/2024, they started safe survey interviews with all residents on the 100 hall, where the staff fought and on the 200 hall, where the staff was when she shot the gun. She said they talked to all staff who worked that day and sent a mass email to each resident's RP and family about the incident. She said they held a resident council meeting and staff meeting where they offered counseling to anybody who needed it. She said they contracted to have security in building because they were not aware if the shooter was arrested. She said CNA C called her when she was on her way to the building and she and CNA B did not have any incidents before that morning. She said CNA C told her that she and CNA B were cool because there was a previous incident where some nurses were trying to discipline her, and CNA B took up for her. CNA C said the incident started when she transferred a resident. She said CNA C told her CNA B said she did it incorrectly, but she previously observed CNA B transfer the resident that same way. She said CNA C told her CNA B said she never saw her do it that way, then they got into it (had a verbal altercation). She said CNA C told her CNA D was in between them and pulled her back while CNA B landed a lick (hit her) and RN A jumped in to get them apart. She said CNA C told her CNA B left, saying she did not have time for that while CNA D and RN A held her back. She said CNA C told her she told RN A and CNA D she was getting her bag and bus pass so she could leave for the day, and they eventually let her go. She said CNA C told her she proceeded out of the building thru the same door CNA B left from so she could walk towards the bus stop. She said CNA C told her she had the gun for her protection. She said she told CNA C it was a felony to go into a skilled nursing facility with a gun and the corporate office called the police. She said CNA C told her she had also called the police herself because they were trying to jump her. She said CNA C said there was a lot of staff outside, but after speaking to staff, they found that nobody else said they were outside. She said the other staff were inside trying to keep CNA C from going outside and nobody was outside trying to jump her. She said CNA D went outside after CNA C. She said the police had already gone to building by the time she arrived, and the shell was found in the parking lot. She said they completed staff education and counselors were going to talk to those who expressed uneasiness about the incident. She said none of the residents stated they were disturbed. She said Resident #2 and Resident #3, who were in the room where the incident started, did not have concerns. She said they had psych (psychiatric) services see both residents to make sure. She said they in-serviced all staff that if you see something, say something. She said they also educated staff on anger management, reporting, abuse/neglect, and having a gun in the facility. <BR/>Observation and interview with Resident #2 on 01/22/2024 beginning at 1:30 p.m., revealed he was a larger male who self-ambulated in an electric wheelchair by using his chin to maneuver the controls. Resident #2 could not move his limbs. He stated CNA C was in his room getting him dressed the day of the incident. He said he usually got up at 7:00 a.m., but it was 6:00 a.m. when CNA C got him up. He said CNA C got frustrated and he got frustrated. He said when CNA B came, she was really calm. He said he heard CNA B say, I don't know how you did things where you came from, but around here, this is how we do it. He said the staff were arguing in the hallway but then things got physical when CNA C hit CNA B first. He said CNA C's arm went from down low and then down on CNA B's shoulder, like a windmill. He said the staff went down to the nurse's station, so he could not see anything after that, and he did not know how it ended. He said CNA D came up and stood beside them and did not get involved at all. Resident #2 said he was already in his chair during the incident, but the chair was not on. He said he was upset because CNA C said she was going to go get other residents up, and he told her she could not abandon him like that. He stated he felt safe at the facility, and he did not have any concerns because it was two girls fighting. <BR/>In an interview with CNA D on 01/22/2024 at 1:40 p.m., she stated she worked the 6:00 a.m. - 2:00 p.m. shift. She stated there were no prior incidents between CNA B and CNA C that she knew of. She said CNA C told her she had an issue with some of the nurses because she got into it (had verbal altercations) with them the weekend before the gun incident about a wrong food tray. She said CNA C told her that she and the nurses argued, it got heated, and they went into the MDS office where they yelled in her face. She said CNA C received a verbal warning, but she felt she should not have gotten anything. She said CNA C said they were going to stop playing with her (stop harassing her), but she never said she was bringing a gun to the facility. She said she heard CNA B and CNA C arguing down the hall. She said the argument was about getting a resident up because CNA C said she saw other staff do it that way and she was tired of people telling her how to do her job. She said CNA C said she had gotten Resident #2 up safely so what did it matter. She said she saw both of their hands going up in each other's face and they were fanning each other's hands down. She said she told them to stop because they would lose their jobs. She said CNA C said, You stole me (hit me), oh no bitch, you stole me! She said she and RN A got between them, but they were going around them. She said CNA C said, I got something for you. She said CNA B had already gone outside and invited CNA C to go meet her outside. She said CNA C got her stuff, but they tried to keep her inside. She said CNA C said, I got something for this bitch. She said CNA C's bag was in the open area under the desk at the nurse's station. She said she and the MDS Nurse were standing at the door trying to calm CNA C down. She said the MDS Nurse said she would call the police if they fought. She said they tried to keep CNA C from going outside, but once she went outside, she instantly started digging in her purse and she came out of the purse with something. She said she and the MDS Nurse were right at the door with CNA C. She said she heard CNA B say, Oh you gone point the gun at me! She said CNA C then raised the gun and shot in the air. She said CNA C was on the sidewalk, near resident rooms when she shot the gun. She said CNA C was about a yard from the building and she was about a yard from CNA B. She said CNA C said, Ya'll bitches gone stop playing with me. She said CNA C said she quit and the MDS Nurse said, We already knew that. She said CNA C could have gone out the front door to catch the bus instead of going out the side door. She said the residents were getting up at that time. <BR/>In an interview with Resident #3 on 01/22/2024 at 2:17 p.m., he stated the incident started in his room and then went to the nurse's station. He said he did not know how it started, but he saw one hit the other. He said one staff swung her hand back, but he did not know if she meant to hit the other staff, or if she just landed one accidentally. He said after that, he went outside and saw two police officers at the facility. Her stated he still felt safe in the facility. <BR/>In a telephone interview with RN A on 01/23/2024 at 12:52 p.m., she stated she was waiting for her relief on 01/18/2024 when she CNA C went and got her because she was having issues with Resident #2's wheelchair. She said when she went to the room, she told CNA C she was not sure how to work the wheelchair, but she would get someone who knew. She said she noticed Resident #2 was already in his chair, so she asked CNA C how she got him in there. She said CNA C said she transferred him by herself. She said she told CNA C it was not safe for her to do that, but she said she could do it that way. She said she told CNA C she needed to get someone else to help her with Resident #2. She said she went to find someone to help control Resident #2's wheelchair and saw CNA B with CNA D in front of the nurse's station. She said she told CNA B that CNA C had already gotten the resident up by herself and that she needed help with the controller on Resident #2's wheelchair. She said CNA B went to the room and then she heard some sounds coming from down the hall. She said she heard someone say, Stop fighting. She said the staff were very close together and one hit the other, but she did not know who hit who first. She said CNA B left the building because she was upset, and they tried to calm CNA C down and told her she could not go outside because CNA B was still out there. She said CNA C kept yelling that she had to get out. She said CNA C took her backpack and left the building. She said by that time, she went out of the building and heard the gunshot. She said she did not go to the door with the other staff. She said she did not hear anybody say anything about a gun while they were inside the building. <BR/>In a follow-up interview with the Medical Records Coordinator on 01/24/2024 at 10:15 a.m., she stated after CNA C got into an altercation with the nurses when they were all in her face, CNA D said she (CNA C) told her, I am not gone worry about it because I got something for them. She said after the shooting incident, CNA C called her and said of course she had a gun because she went to school at night on the bus. She said when she went outside after the shooting incident, she heard CNA B tell CNA D, You been knew she had a gun? Why didn't you tell me? The Medical Records Coordinator said CNA D said she already knew CNA C had a gun in the building. <BR/>Record review of the facility's 'Workplace Violence policy, revised 01/2022 revealed, The facility seeks to provide a safe workplace for all team members and has Zero Tolerance toward any type of workplace violence committed by or against team members. Team members are prohibited from making threats or engaging in violent activities. This list of behaviors, while not inclusive, provides examples of conduct that is prohibited. Causing physical injury to another person; Making threatening remarks; Aggressive or hostile behavior that creates a reasonable fear of injury to another person or subjects another individual to emotional distress; . Possession of a weapon while on facility property or while on facility business; . Any potentially dangerous situations must be reported immediately to a supervisor . Threats, threatening conduct, or any other acts of aggression or violence in the workplace will not be tolerated. Any team members determined to have committed such acts will be subject to disciplinary action, up to and including termination .<BR/>Record review of the facility's policy on Firearms and Other Weapons revised 01/2022 revealed, All applicants, associates, contractors, subcontractors, or any other persons are prohibited from using or possessing (whether concealed or not) any weapons while on company premises, engaged in company business, or at company-related activities. The company follows state and federal laws regarding concealed weapons, and to the extent this policy conflicts with any such law, the applicable law governs.<BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by the DON on safe transfers, including Hoyer Lifts and two-person transfers. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by RN A on reviewing each resident's Kardex (a quick reference for nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) on the plan of care and requesting assistance before providing care. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by the physical therapy department regarding Resident #2's motorized wheelchair, including operation, drive mode, tilting, chin joystick, and recharging. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated by the SW regarding workplace violence and reporting incidents of bullying, harassment, and retaliation and possession of a weapon. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated by the SW regarding Abuse and Neglect. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 02/07/2024 at 9:40 a.m. The DON was notified. The DON was provided with the IJ template on 02/07/2024 at 9:40 a.m. A Plan of Removal was requested at that time. <BR/>The following Plan of Removal submitted by the facility was accepted on 02/08/2024 at 11:52 a.m. :<BR/>The facility failed to ensure that resident environment remained free of accidents and hazards.<BR/>1. <BR/>Immediate Action Taken<BR/>* <BR/>Identified staff were immediately suspended on 1/18/24 and police notified on 1/18/24. The residents that were located near were assessed by the Social Worker and Licensed Nurse to be offered the opportunity to have grief counseling by Psych Services to monitor for Post Traumatic Stress completed on 1/18/2024.<BR/>* <BR/>On 2/7/24 the social worker and Director of Nurses (DON), started education with all staff on the company policy for workplace violence, Use of clear bag policy at the community, and abuse and neglect, completed on 2/7/24. Employees that missed the in-service will not be allowed to work until this education has been completed. <BR/>* <BR/>The company will purchase clear bags for all employees to carry personal belongings into the facility in-service initiated on 1/19/24 and completed on 1/22/24. Clear bag policy was posted all over the community on 2/7/24. <BR/>* <BR/>The social worker and Director of Nursing initiated in- serviced to all staff on handguns prohibition policy, this will be completed on 2/8/24, all staff not available for the in-service will not be allowed to work until the in-service is completed with them. <BR/>* <BR/>An In-service by the Social Worker and corporate HR was started on 1/18/2024 to also provide grief counseling information from the employee through the employee's insurance company. This counseling was an immediate offer and is still available. There is no completion date because it is ongoing. Completed 1/18/2024 and ongoing. <BR/>2. <BR/>Identification of Residents Affected or Likely to be Affected: <BR/>* <BR/>On 1/18/2024 the DON and Social Worker completed the audit for any resident who was near and wanted therapy. We identified no residents that wanted therap[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>1. The facility failed to ensure the commercial oven, stove and wall were not soiled with any gummy/greasy substances. <BR/>2. The facility failed to ensure the deep fryer was not full of odiferous grease. <BR/>3. The facility failed to ensure 7 full-size sheet pans did not have baked-on brown substances.<BR/>These deficient practices could place residents at-risk by contributing to foodborne illness, poor intake, and/or weight loss.<BR/>Finding include: <BR/>Observation on 04/18/23 at 8:35 a.m. revealed the deep fryer was full of odiferous grease and had floating crumbs and debris on the surface. The commercial stove and oven were soiled with crumbs and dust on top and the wall behind it was soiled with a gummy substance. <BR/>Observation on 04/19/23 at 2:39 p.m. revealed the deep fryer was full of odiferous grease and had floating crumbs and debris on the surface. The commercial stove and oven were soiled with crumbs and dust on top and the wall behind it was soiled with a gummy substance. Further observation revealed a clean rack of dishes had 7 full-size sheet pan with baked-on brown substances. <BR/>Observation and interview on 04/19/23 3:01p.m., the Dietary Manager stated the commercial stove and oven were soiled with crumbs and dust was on top and the wall behind it was soiled with a gummy substance. She stated the deep fryer contained oil that was murky and soiled with crumbs and debris. When asked who was responsible for ensuring the walls were cleaned and who was responsible for changing the oil in the [NAME]. Why was it important for these items to be cleaned. How could the residents be affected by this failure. The Dietary Manager said frying oil was replaced by the cooks with fresh oil every Sunday because the facility served fish fry every Fridays. She said there were 3 cooks who worked at the kitchen. She said the AM cook made and served breakfast and made lunch. The PM cook served the lunch and made dinner. She said each cook was supposed to clean the stove after each meal. She said, this looks weeks worth of mess not just todays. She said there were some burn stains, but grease could easily be cleaned. She said, the could not get the baking tray to scrub and the would need new ones. The Dietary Manager stated she told the Administrator the kitchen needed new pans. She said she told the Administrator when she started working in the facility 3 and half months ago.<BR/>Observation and interview on 04/19/23 at 3:30 p.m. with the Dietary Manager and [NAME] A. when asked how often they cleaned. Why were these items not cleaned. Why was there build up. [NAME] A said each cook needed to clean the stove after cooking the meal because build up could catch on fire. <BR/>In an interview on 4/20/2023 at 10:20 a.m. with [NAME] B, she said she was the AM cook and stayed until 1:30 p.m. She said, sometimes they needed help because they had so many things and it's easy to fall behind and everything was on the line to be served and had to go out to the residents. She said the cook who came for lunch and dinner was supposed to wash their own dishes, everybody was responsible for cleaning the stove. [NAME] B stated Sometimes we are just too busy to clean the stove and it is all of our responsibility. <BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-602.13 Nonfood-Contact Surfaces, Nonfood-Contact Surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. <BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean.<BR/>Record review of the facility's Food Safety policy (effective date: 01/2018) read in part: .Policy: All food purchased will be wholesome, manufactured, processed, and prepared in compliance with all State, Federal, and local laws and regulations. Food will be handled in a safe and sanitary method to prevent contamination and food-borne illness .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the physician and notify the resident representative when the resident experienced a change in condition for 1 of 22 residents (CR #1) reviewed for a change of condition:<BR/>-The facility failed to immediately inform CR#1's physician after a change in condition. <BR/>-The facility failed to notify the Physician when CR #1 had a choking episode on 04/22/24 and experienced a change in condition.<BR/>-The facility failed to notify CR #1's RP when she experienced a change in condition <BR/>- CR #1 passed away on 04/27/202418 at the hospital.<BR/>An IJ was identified on 04/29/24. The IJ template was provided to the facility on [DATE] at 12:54 PM. While the IJ was removed on 05/03/2024 at 12:24PM, the facility remained out of compliance at a scope of isolated and a severity of harm with potential for more than the minimal harm that is not an immediate jeopardy because all staff had been trained on to notify the physician when a resident experience a change in condition. <BR/>These failures could affect residents in delay of appropriate medical treatment leading to death.<BR/>Findings included:<BR/> Record review of CR #1's face sheet dated 04/25/2024 revealed an 83year old female admitted to the NF originally on 07/22/2022 and again on 09/17/2023 with diagnoses that included the following: Alzheimer's Disease (disease that destroys memory) with late onset, dysphagia (difficulty swallowing) diagnosed 11/09/2022, heart disease, and cerebral infarction (disrupted blood flow to the brain). <BR/>Record review of CR #1's MDS dated [DATE] reflected BIMS score 00 indicating resident cognition was severely impaired. Further review of section K (swallowing/Nutrition Status) reflected that CR #1 had no s/s of possible swallowing disorder. Further review of the MDS section GG reflected that CR #1 required setup or clean-up assistance. <BR/>Record review of CR #1's Physician Order Summary Report for the month of April 2024 included the following orders:<BR/>-Dated 10/10/23 carb controlled no added salt mechanical soft texture, regular consistency.<BR/>-Dated 07/20/23 may crush meds/open capsule every 12 hours for safety.<BR/>-Dated 04/23/2024 SLP evaluation.<BR/>-Dated 04/25/2024 Comprehensive swallow consult including MBSS to assess aspiration risk, r/o silent aspiration, determine least restrictive diet texture, assess esophageal function and physician consult for dysphagia include appropriate nutritional status.<BR/>Record review of the Screening Tool done by the NF Rehab Director on 04/24/24 reflected in part:<BR/> .DON referred PT for ST services for dysphagia management. No s/s of swallow impairment noted at this time however ST to complete eval and schedule MBSS to r/o silent aspiration .<BR/>Record review of CR #1's Speech Therapy note dated 04/25/2024 recommended thin liquids and mechanical soft/ground textures, puree (creamy paste) consistencies.<BR/>Record review of CR #1's Care Plan updated 12/10/2023 did not reflect that CR #1 was being care planned for dysphagia.<BR/>Record review of CR #1's Nursing Progress Notes dated 04/25/2024 documented by RN B at 19:55 (8:55PM) reflected in part:<BR/> .CR #1 was wheeled from the dining room to the nurse station by CNA at about 5:30PM with no sign of distress or discomfort. At about 5:45PM, CNA call out that resident was unresponsive on the wheelchair by the nursing station. Code blue activated, CPR done, oxygen connected, AED used, 911called. 911 arrived and took over the resident resuscitation. 911 later transferred the resident to hospital for further management, family member was notified of resident condition. NP also notified . <BR/>Record review of CR #1's INTERACT Change in Condition dated 04/25/2024at 19:17 (7:17PM) reflected in part:<BR/> NO pulse, no respirations2.This condition, symptom or sign has occurred before: H 1. Yes 2. No 3. Unknown3.Other relevant information: HResident was noticed by a CNA/Nurse in the Hallway drooling by mouth, and choking on food. Quickly, resident was assisted to the floor, a sweep of the mouth, the Heimlich maneuver given, nausea and vomiting small amount of food.4.Summarize your observations, evaluation and recommendations: HPt lost consciousness, with no pulse and no respiration. Signaled to call 911 and CPR began, oral suctioning required and AED utilized although no shock required. 1845 EMT arrived assisting with CODE. ET Tube placed with moderate suctioning and IV NS started in right arm. Pt regained pulse but Medic continued to give breaths per Ambu bag. Pt transported to Hospital. MD, DON, Administrator and daughter notified.5.Have you reviewed and acknowledged <BR/>Interview on 04/26/24 at 2:00PM, the DON said the incident happened on 04/22/2024 around 6:00PM or a little after could not remember the exact time. The DON said CNA A was standing in the hallway calling for help. The DON said when she arrived at the scene, she observed CR #1 had been placed on the floor by staff members. The DON said the nurses had already initiated CPR and that she began to assist with the CODE ensuring that 911 services had been called. The DON said CR #1 had a weak pulse and was not breathing. The DON said CR #1 was not choking and believed that CR #1 had experienced a mini stroke. <BR/>Interview on 04/26/24 at 2:11PM, the Administrator said the NF had called the hospital where CR #1 was transferred to and that the hospital informed that CR #1 had to be intubated and placed on a ventilator. <BR/>Interview on 04/26/2024 at 2:16PM, the RP said he was not notified by the NF that CR #1 had choking episode on 04/22/2024. Further interview with the RP said he was not notified on 04/25/2024 when CR #1 experienced a change in condition.<BR/>Interview on 04/26/24 at 3:06PM, with CNA A said she worked at the NF full time on the 2PM-10PM shift. CNA A said the time was around 5:30PM-6:00PM on 04/25/2024 when CR #1 was being wheeled from the Dining Room by another CNA who's name, she could not recall. CNA A said CR #1 was placed across facing the nurse station. CNA A said CR #1 did not have any front teeth and therefore was unable to chew food well and could not swallow good. CNA A said at one time, CR #1 was on a puree diet, was later upgraded to a mech soft diet. CNA A said on 04/22/24 CR #1 choked off her food while feeding her in bed during dinner time. CNA A said CR #1 was eating potato soup. CNA A said she tried to help CR #1 when she started choking but was unsuccessful and therefore called LVN W who never came to CR #1's room. CNA A said the oncoming nurse LVN B came to the room and just looked at CR #1. CNA A said it was CNA I that helped by pulling CR #1 forward in bed and began to give hand thrust to CR #1's back. CNA A said the food came up which was some potatoes and other undigested food. CNA A said CR #1 appeared to be okay after that incident. CNA A said she told LVN W and LVN B that CR #1's diet needed to be changed. CNA A said she also told the DON as well that CR #1 had experienced choking on 04/22/2024. CNA A said she had informed the DON on 04/22/23 at 7:30PM and that the DON was preparing to leave the NF to go home. CNA A said RN E told her that it was a chain of commands for CR #1 to be assessed by the Speech Therapist which was to inform the ADON. CNA A said she also informed the Speech Therapist who said that he would need an order to assess CR #1. CNA A said RN E told her that she would notify the ADON. CNA A said she went to the Speech Therapist on 04/23/24 in the evening and told him about CR #1's choking episode on 04/22/24. CNA A said the Speech Therapist told her that he would need an order. CNA A said she had informed the Administrator verbally on 04/23/24 and the Administrator told her to write a statement. CNA A said she wrote a statement at 11:34AM on 04/23/24 and send it to the Administrator via e-mail regarding CR #1's choking incident on 04/22/24. CNA A said she did not want the surveyor to say anything to the Administrator because she did not want to lose her job. CNA A said she went to the kitchen on 04/25/24 and told them what food to give CR #1. CNA A did not elaborate on the exact food she told them to give CR #1 but told them to give CR #1 soft texture foods that did not require CR #1 to chew a lot. CNA A said the kitchen gave CR #1 a mechanical soft diet. CNA A said on 04/25/24 at 5:30PM or 6:00PM at the nurse station saw CR #1 leaning to her side drooling at the mouth with food in her mouth. CNA A said nurse LVN C was trying to get the food out of CR #1's mouth. CNA A said LVN C began to hit CR #1 in the back, but CR #1 was not responding. CNA A said herself and LVN C transferred CR #1 on the floor and at this time CR #1 was completely unresponsive. CNA A said she started screaming for help and 911 was called. CNA A said after that she did not know what took place next because she went to see if 911 had arrived so she could direct them to the hall CR #1 was residing on. <BR/>Interview on 04/26/24 at 3:45PM CNA I said she worked the first shift 6AM-2PM mainly but did work over sometimes on the evening shift. CNA I said the first time she observed CR #1 choking was on 04/22/24 after 5:50PM. CNA I said she believed that it was CNA A that called her to come and assist with CR #1's choking episode on 04/22/2024. CNA I said CNA A was standing in the hallway calling for help. CNA I said there was a new nurse caring for CR #1 who's name she could not recall. CNA I said CR #1 was choking when she entered her room. CNA I said she immediately pulled CR #1 forward in bed trying to relieve the choking. CNA I said the food did come up and that the new nurse was just standing on the side of CR #1's bed looking. CNA I said they continued to let CR #1 sit up in bed and they continued to monitor CR #1 for any further choking. CNA I said CNA A said she was going to report the incident. CNA I said CR #1 appeared to be okay for the remainder of the shift. CNA I said the next morning when she returned to work, she told RN E that CR #1 needed to be gotten out of bed for her meals due to the choking episode on 04/22/2024 and RN E agreed.<BR/>Interview on 04/26/24 at 5:19PM via phone LVN B said she worked the 6PM-6AM shift PRN. LVN B said the last time she worked at the NF was on 04/22/24 and 04/23/24. LVN B said CR #1 did not have any issues with chocking. LVN B said CNA A was feeding CR #1 in bed on 04/22/24. LVN B said CR #1 was being fed soup along with some type of salad with chunks of chicken chopped up in it. LVN B said CR #1 was not choking, but just not tolerating the texture of the food. LVN B said CR #1 had tea or apple juice as a beverage. LVN B said she heard CNA A calling for help and when she arrived to CR #1's room, CR #1 was able to follow commands and did spit the food out. LVN B said CNA A was in a complete uproar and got overly excited. LVN B said the incident was mentioned to the DON who came on the unit. LVN B said the DON said she would take care of the matter. LVN B said she did not call the physician because the DON said she would take care of it. <BR/>Interview on 04/26/24 at 5:52PM, the DON said it was CNA A that came to her on 04/22/24 around 8:00PM telling her that CR #1 was having difficulty swallowing. The DON said she put an order in on 04/23/24 for CR #1 to be evaluated by the Speech Therapist but did not call the NP or the physician. The DON said she told the NP when she was at the facility on 04/25/24 and the NP said that was good. The DON said she had not in-serviced the Nursing staff on silent aspiration/choking. The DON said the s/s of silent aspiration were pocketing food, difficulty in breathing, increase heart rate, and change in skin color. Further interview with the DON said the reason she did not call the physician when told that resident had choked on her diet was because she got ahead of herself and just wrote the order. The DON said the physician should have been notified first before she put an order in for CR #1 to be evaluated by Speech Therapist because that was the normal process. <BR/>Interview on 04/27/24 at 12:25PM with LVN C, said she worked the 6p-6a shift. LVN C said on 04/25/24 the incident happened before her shift started. LVN C said the staff were bringing the residents back from the dining Room after eating dinner. LVN C said CNA A asked if CR #1 was choking. LVN C said the time was around 5:30PM. LVN C said she observed CR #1 choking and not breathing. LVN C said her and a CNA (name she could not remember) transferred resident to the floor after removing food from resident mouth and performing the Heimlich maneuver which was unsuccessful. LVN C said CPR was initiated. LVN C said during this time she told a staff member to call 911. <BR/>Record review of the NF's policy on Change in a Resident's Condition or Status revised May 2017 revealed in part:<BR/> .Our facility shall promptly notify the resident, his or her attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition .<BR/>The facility Administrator and DON were notified on 04/27/2024 at 3:16PM that an IJ situation had been identified due to the above failures. The IJ templated was provided to the Administrator on 04/27/2024. <BR/>Interview on 04/28/24 at 11:45AM RN E said she worked the 6:00AM-6PM and that she was not aware of CR #1 choking on her food. <BR/>Interview on 04/29/24 at 9:46AM, the NP said she was at the NF and saw CR #1 but could not remember the exact date. The NP said CR #1 was fine. The NP said the NF never informed her that CR #1 experienced a choking incident on 04/22/24. The NP said she later received a text from RN E on 04/25/24 informing that CR #1 was unresponsive and 911 had to be called. The NP said the DON's mistake was putting an order in without consulting her first. The NP said had she informed her when the incident happened, she would have put interventions in place such as changing the resident's diet and given further orders to assess resident swallowing to prevent resident from aspirating. <BR/>Further interview on 04/29/24 at 11:58AM, with the DON she said when a resident experiences a change in condition the staff were supposed to notify the physician immediately. The DON said she told the primary care nurse LVN B to notify the physician on 04/22/2024. The DON said if the nurse was unable to get in contact with CR #1's physician, the next step would be to notify the Medical Director.<BR/>Attempted interview via phone on 04/29/24 at 12:19PM with the NF Medical Director was unsuccessful. The Medical Director was left a voicemail with a call back number.<BR/>Interview on 04/29/24 at 2:30PM with the ADON said she had been working at the facility for a little over a month. The ADON said none of the nurses or CNA's had informed her that CR #1 choked on her food. The ADON said if they had, she would have called the doctor or NP to get an order for a swallow evaluation and notified the family. <BR/>Interview on 04/30/24 at 1:13PM, CNA N said she had taken care of CR #1 in the past and had observed CR #1 pocketing her food in her mouth at times. CNA N said she did report these happenings to RN E. <BR/>Interview on 04/30/24 at 1:34PM with CR #1's primary care doctor via phone said the NF never notified her that CR #1 had a choking episode on 04/22/24. The Doctor said CR #1 was on a mechanical soft diet and was high risk for choking. The Dr. said if the facility had notified her of resident choking episode on 04/22/24, she could have given prophylactic orders that consisted of the following: place CR #1 on NPO or liquid diet until a barium swallow test was done, placed CR #1 on antibiotics, and started breathing treatments. The doctor said CR #1 may have aspirated on 04/22/24 and that these would have been the measures she would have considered because aspiration could lead to pneumonia.<BR/>Interview on 05/01/24 at 3:22PM via phone CNA D said she worked at the NF PRN. CNA D said CR #1 had a choking episode on a Sunday prior to the incident on 04/22/24. CNA D said the nurse on duty was RN E. CNA D said she notified RN E but did not know what she had done about it. <BR/>Interview on 05/02/24 at 2:30PM LVN W said no one ever told her that CR #1 was choking on her food. <BR/>Further interview on 05/03/24 at 12:12PM the DON said she believed the reason the NF received an IJ was because of the facility failing to follow-up with the physician immediately when CR#1 experienced a choking episode on 04/22/24. <BR/>The following plan of removal was accepted on 04/30/2024 at 7:22PM.<BR/>PLAN OF REMOVAL<BR/>Date: 04/30/2024<BR/>The facility failed to immediately inform CR #1's physician after a change in condition.<BR/>The facility failed to notify the Physician when resident had a choking episode on 04/22/24. <BR/>What corrective actions have been implemented for the identified residents? <BR/>On 4/22/2024 resident CR#1 involved in failed practice was discharged to the hospital per MD orders on 4/25/2024.<BR/>On 4/27/2024 at 4:00pm the Facility Administrator notified the Medical Director, and the attending physician of failed practice. <BR/>Change of condition policy/ Procedure was reviewed by IDT, no changes were made: Completed 4/27/24<BR/>The DCO completed audit of all residents with change of condition in the last 30 days, the physicians were notified of all changes: Completed 4/27/24<BR/>In-services provided to DCO.<BR/>On 4/27/2024 the following in-service was provided to the Director of Clinical Services (DCO) by the Regional Director of Clinical services (RDCO)<BR/>1. <BR/>Notifying the Physician Immediately of Change of Condition Occurs and Obtaining Orders from the Physician before treating the Resident.<BR/>2. <BR/>On notifying resident's responsible party on changes of condition and new intervention that was put in place, completion date 4/27/2024.<BR/>In-services provided to Licensed Nurses<BR/>On 4/27/2024 the DCO initiated in-services for facility charge Nurses on the following:<BR/>I. <BR/>Change of condition in relation to swallowing/aspiration difficulties or choking episode, and to notify resident's attending physician of these changes immediately completion date 4/28/2024. <BR/>II. <BR/>1:1 in-service conducted with LVN B by the DCS regarding physician notification completion date 4/28/2024<BR/>CNA education provided are below.<BR/>C N A 's in-service on notifying License Nurses concerning change in conditions and documentation in POC documentation. completion date 4/28/2024<BR/>Nursing staff will be in-service on the plan before the start of their shift.<BR/> Validation/Monitoring<BR/>The DCS/Designee reviewed residents' last SLP referrals no corrections as of 4/28/2024.<BR/>Facility IDT reviewed policy/procedure of aspiration, swallowing precautions, therapy referrals, no revisions needed. Completion date 4/28/2024.<BR/>What does the facility need to change immediately to keep residents safe and ensure it does not happen again.<BR/>A. <BR/>The DCN/Designees will review all changes in condition and therapy referral in daily clinical meetings and ensure follow is completed timely, staff monitoring is in place, the RP/MD is notified of changes and new recommendation if followed. Completed 4/28/24.<BR/>B. <BR/>The Director of Clinical Services will ensure Licensed Nurses notify the Physician Immediately of Change of Condition Occurs and Obtaining Orders from the Physician before Treating the Resident completed: 4/28/2024.<BR/>C. <BR/>Newly hired nurses will be in-serviced by the Director of Nursing or designee on immediately notifying the attending physician of residents change of conditions, obtaining orders for therapy screening and evaluations as needed. <BR/>Quality Assurance<BR/>An Ad Hoc Quality Assurance and Performance Improvement review of the plan of removal was completed on 4/27/2024 with the Medical Director. The Medical Director has reviewed and agrees with this plan.<BR/>________________________________________________________________________________________________<BR/>The surveyors confirmed the plan of removal had been implemented sufficiently to remove IJ by the following:<BR/>Note: Due to initial IJ being called on 04/27/2024 at 3:16PM, the NF had begun the process in in-servicing staff on notification of change in a resident condition by 04/30/2024, therefore the surveyors began the monitoring process as follow: <BR/> Interview on 04/30/24 at 11:25AM with RN E said she worked on Station B 6AM-6PM. RN E said she had just received in-service on notify the physician as well as the RP when a resident experience a change in condition.<BR/>Observation on 04/30/24 at 11:35AM of Station B across from the nurse station revealed residents sitting in their w/c's dressed in street clothing with no concerns identified.<BR/>Interview on 04/30/24 at 11:42AM with CNA F on Station B said that she worked the morning shift 6AM-2PM. CNA F said she had received in-service on what to do if a resident began to choke while eating. The CNA said she would call for help and would begin to try and clear the resident airway by providing the Heimlich maneuver. The CNA said some s/s/ of silent aspiration was resident having difficulty breathing, change in their facial appearance and skin color. The CNA said if she observed a resident having difficulty swallowing their food or pocketing their food, she would notify the nurse right away so that the resident could be assessed. The CNA said she was in-serviced to notify the nurse whenever she noticed a change in resident condition.<BR/>Interview on 04/30/24 at 11:50AM with CNA Y said she worked the 6AM-2PM full time. CNA Y said she had been in-serviced on notifying the nurse when residents had a change in condition, s/s of silent aspiration were discoloration in the face, change in facial expression, and difficulty breathing. CNA Y said if the resident was choking, she would give them the Heimlich maneuver to try and help the resident clear the air way. CNA Y said she had been in-serviced to review the resident POC in the computer.<BR/>Interview on 04/30/24 at 11:58AM with the Wound Care Nurse said she worked at the NF Monday through Friday and did assist with monitoring the residents during mealtimes. The Wound Care Nurse said she had been in-serviced on choking and how to apply the Heimlich maneuver. The Wound Care Nurse said if the resident became unresponsive, CPR had to be initiated immediately and call 911. The Wound Care Nurse said s/s of silent aspiration were drooling at the mouth, skin discoloration of the face, difficulty breathing, and perspiring. The Wound Care Nurse said the physician and the RP had to be notified immediately when a resident experiences a change in condition and the care plan had to be updated. <BR/>Interview on 04/30/24 at 12:07PM with CMA K said she worked the Memory Care Unit and worked the morning and evening shift. CMA K said she had been in-serviced on choking and silent aspiration. CMA K said s/s of silent aspiration was drooling at the mouth, perspiring, difficulty breathing, and change in skin color. CMA K said if a resident was choking, she would call for the nurse and apply several back blows, if that was unsuccessful, she would do the Heimlich maneuver. CMA K said the incident must be reported to the nurse immediately as any change in condition. CMA K said when feeding a resident, she had to feed them slowly being careful to offer them fluids in between eating.<BR/>Interview on 04/30/34 at 12:14PM with CNA L said she worked the Memory Care Unit 6AM-2PM and been in-serviced reviewing the resident plan of care in POC, monitoring the residents for choking or s/s of silent aspiration and that all changes in condition were to be reported to the nurse. CNA L said resident had to observed closely during mealtimes and if notice a resident choking call the nurse immediately and do the Heimlich maneuver to held dislodge what was blocking the resident airway. CNA L said s/s of silent aspiration was drool at the mouth, difficulty breathing, bulging of the eyes, change in skin color, and grabbing their neck. CNA L said the incident had to be reported to the nurse so that the nurse could call the doctor as well as the family. <BR/>Interview on 04/30/24 at 12:20PM with RN M said she worked the 6AM-6PM shift and had been in-serviced on notifying the physician whenever a resident experience a change in condition. RN M said she had been in-serviced on the s/s of silent aspiration (drooling at the mouth, difficulty breathing, change in the color of resident skin) and choking. RN M said if a resident experienced this, the doctor had to be notified right away to get an order for a swallow evaluation and possible diet change. RN M said the resident care plan also had to be updated and the RP notified. <BR/>Observation on 04/30/24 at 12:32PM in the Dining Room revealed lunch being provided to the residents with over 6 staff members being present, one being the Wound Care Nurse. There were no concerns identified. <BR/>Observation on 04/30/24 at 1:05Pm in the MCU revealed the residents eating their lunch with staff members being present. There were no concerns identified. <BR/>Interview on 04/30/24 at 1:13PM with CNA N said she normally worked the morning shift. CNA N said she had been in-serviced on when a resident was choking to give the Heimlich maneuver. CNA N said s/s of silent aspiration was difficulty breathing, watering of the eyes, drooling at the mouth, and possible reaching for their throat. CNA N said she would try and clear resident airway by giving thrust in the back and then proceed with the Heimlich maneuver. CNA N said she would notify the nurse on all changes in a resident condition. CNA N said she was in-serviced to review the resident care plan. <BR/>Interview on 04/30/24 at 2:38PM with LVN O said he was in orientation and was hired to be a Unit Manager. LVN O said he had received in-service on checking the crash cart, that if the resident was choking to perform the Heimlich maneuver. LVN O said if the resident lost consciousness, he would have someone call 911 and he would start CPR right away. LVN O said some s/s of silent aspiration were the following: short of breath, wheezing, eyes bulging, perspiring, trying to clear their throat, drooling at the mouth, pocketing food. LVN O said the doctor had to notified in both incidents as well as the RP. LVN O said resident care also had to be updated regarding the incident.<BR/>Interview on 04/30/24 at 2:47PM with CNA I said she worked the morning and evening shifts and had been in-serviced on how to do the Heimlich maneuver, chest thrust if a resident was choking. CNA I said the nurse had to be notified of all changes in a resident condition. CNA I said she was in-serviced on recognizing some s/s of silent aspiration (change in a resident facial expression, drooling at the mouth, wheezing or difficulty breathing). CNA I said she was in-serviced that when having to feed a resident, to take her time and feed them slowing being aware to provide resident their beverage between feeding during meal service. CNA I said she was also in-serviced to review resident care plan in POC.<BR/>Interview on 04/30/24 at 8:00PM with CNA P via phone said he worked the night shift 10PM-6AM. CNA P said he had been in-serviced in the following: POC regarding the resident plan of care, choking and how to apply the Heimlich maneuver, back blows and chest thrust, and reporting change in condition. CNA P said the nurse had to be notified if he witnessed a resident choking. CNA P said he was also in-serviced on silent aspiration.<BR/>Interview on 04/30/24 at 8:08PM with CNA J said she worked the night shift 10PM-6AM. CNA J said she received in-service on silent aspiration and choking, checking resident care plan in POC, and when feeding the resident to feed slowly observing for signs of choking and reporting to the nurse immediately all changes in a resident condition. CNA J said she had received in-service on resident plan of care that could be found in the computer.<BR/>Interview on 05/01/24 at 5:00AM with LVN S said she worked the 6:00PM to 6:00AM shift. LVN S said she had been in-serviced on choking and silent aspiration, the importance of notifying the physician when a resident experience a change in condition and making sure resident care plan was updated. <BR/>Interview on 05/01/24 at 9:14PM with LVN R said they worked the night shift 6PM-6AM. LVN R said they had been in-serviced on s/s of silent aspiration, choking and to notify the doctor and the RP. LVN R said they were also in-serviced on making sure that the resident care plan was updated whenever a resident experience a change in condition and checking the crash cart.<BR/>Interview on 05/02/24 at 10:30AM with LVN Q said he worked the 6AM-6PM shift and received in-service making sure a resident care plan was updated when there was a change in condition, notifying the doctor and the RP if the resident experience a change in condition, how to intervene if a resident experience choking, if the resident lose consciousness call for help and began CPR, the s/s of silent aspirations, and checking the crash cart each shift. <BR/>Interview on 05/02/24 at 11:25AM with CNA T said she worked the 6am to 2pm shift on the MCU. CNA T said she had been in-serviced on choking, performing the Heimlich maneuver, abuse and neglect, s/s of silent aspiration, reporting to the nurse when she observed a change in resident, and reviewing the resident plan of care in POC.<BR/>05/02/24 at 11:32AM Interview with the ADON said she was in-serviced on choking/silent aspiration, notifying the doctor and RP when there was a change in resident condition, updating the care plan right away when a resident have a change in condition.<BR/>Interview on 05/02/24 at 2:11PM with the MDS Nurse said she was in-serviced on care planning on how and what to care plan to ensure that each resident care plan was individualized and personalized. The MDS Nurse said she was also in-serviced on care planning for dysphagia, updating the resident care plan when a change in condition has occurred, notifying the physician of the change, s/s of silent aspiration.<BR/>Interview on 05/02/24 at 2:18PM CNA U said they worked 6AM-2PM received in-service on different techniques to open a resident airway when choking which were back and chest thrust, and Heimlich maneuver, s/s of silent aspiration and to report to the nurse all changes in a resident condition.<BR/>Interview on 05/02/24 at 2:30PM with LVN W said she worked the 6AM-6PM shift. LVN W said she had been in-serviced on abuse and neglect, choking, checking the crash cart each shift, notifying the physician if a resident experience a change in condition, and updating the care plan when there was a change in resident condition.<BR/>Interview on 05/02/24 at 4:28PM with CNA V said she worked the 2PM-10PM shift. CNA V said the NF had in serviced her on choking and s/s of silent aspiration (discoloration of the face, difficulty in breathing, and drooling of the mouth). CNA V said if a resident was choking, she would perform the Heimlich or thrust resident on the back. CNA V said she was in-serviced to let the nurse know if she witnesses this and to always look in POC for resident plan of care, and when feeding resident to feeding resident slowing making sure resident was not choking. CNA V said she was also informed to use any recommended utensil when feeding a resident that was high risk for choking.<BR/>Interview on 05/02/24 at 4:38PM with RN X said he worked the 6AM-6PM shift full time on Station C. RN X said he had received in-service on the following: s/s of silent aspiration (resident unable to speak, eyes watering, discoloration of skin to the face, drooling from the mouth, difficulty breathing). RN X said he would apply the Heimlich maneuver if a resident was choking and if the resident loss consciousness, he would have[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 4 residents (Resident #72 and #54) reviewed for quality of care. <BR/>1. <BR/>The facility failed to assess, follow-up with treatment, update the care-plan, obtain new order due to a change in resident # 72's skin condition of the groin and resident's report of pain, at which time the penis split measured 8 cm length by 1 cm width by .4 cm depth and appeared red and raw, and failed to ensure that Resident #72's indwelling catheter (drains urine from your bladder into a bag outside your body) had a securement device to anchor catheter.<BR/>2. The facility failed to ensure that CNA B changed her gloves and perform hand hygiene while providing indwelling catheter and incontinent care to Resident #72.<BR/>On 6/28/24 at 5:44PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 6/30/2024 at 12:27 pm, the facility remained out of compliance at a scope of isolated and a severity of harm with potential for more than the minimal harm that was not an immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>3. <BR/>The facility failed to ensure CNA G and CNA H did not place foley bag on Resident #54's bed during foley and incontinent care.<BR/>These failures could affect residents in delay of appropriate medical treatment leading to pain, discomfort, and death.<BR/>Findings included:<BR/>Resident #72<BR/> Record review of a facility face sheet dated 6/26/2024 indicated Resident # 72 was a [AGE] year-old male and admitted on [DATE] and was re-admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one?sided weakness, but without complete paralysis), obstructive and reflux uropathy (the urine backs <BR/>up into the kidney and cannot drain through the urinary tract), chronic kidney disease, major depressive disorder, neurogenic bladder (nerves that communicate between the bladder and spinal cord and brain malfunction and cause symptoms such as dribbling urine, loss of feeling the bladder is full and being unable to control urine), muscle wasting and atrophy (wasting away of tissue or organ). <BR/>Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #72 had a BIMS score of 09 indicating moderately impaired cognition, and he required an indwelling catheter. <BR/>Record review of a comprehensive care plan dated 09/05/23 indicated Resident #72 was at risk for complications related to Foley catheter and goal will be/remain free from catheter-related trauma through review date. Interventions: Catheter changed PRN (size 18 FR), check Foley catheter placement, ensure Foley was secured via Velcro to provide catheter care every shift.<BR/>Record review of Resident #72's care plan with dated 09/05/2023: Focus: Resident #72 had indwelling catheter and is at risk for increased Urinary Tract Infections diagnosis: Neurogenic bladder: Goal: Resident will be/remain free from catheter related trauma through review date, will show no sign/symptom of Urinary Infection through review date: Interventions: Catheter changed PRN change (Size 18FR), check Foley catheter placement, ensure Foley was secured via Velcro strap to reduce friction/pulling q shift, and monitor/record/report to MD for sign/symptom UTI, pain, burning blood-tinged urine, cloudiness, no output, deepening of urine color, increase pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns.<BR/>Record review of the weekly skin assessment from April 2024 to June 13, 2024, revealed no documentation for slit on penis.<BR/>Record review of Resident # 72's physician orders for March revealed that he had orders for a Urology Consult on 3/14/2024 and 3/30/2024.<BR/>Record review Physician's order dated 04/29/2022 reflected Foley Catheter 18 FR 15 cc bulb to continuous drainage related to diagnosis and on 5/13/20220 reflected another physician's order for Foley catheter 18 FR 15cc bulb to continuous drainage related to (diagnosis renal disease with Hematuria).<BR/>Record review of Resident # 72's physician orders for March revealed that he had orders for a Urology Consult on 3/14/2024 and 3/30/2024.<BR/>Record review of Resident # 72 doctor's progress notes on 3/30/2024 revealed Please schedule urology consult SPT placement to avoid Foley related hematuria on 3/14/24 and UROLOGY CONSULT TO RULE OUT HEMATURIA. <BR/>Record review of Resident #72's skin assessment sheets from February 2024 to June 2024 revealed there were no skin assessments identifying the split in the penile area.<BR/>Record review of nurse's progress notes dated 4/14/2024 revealed Resident #72 was documented to have blood in his urine. A progress note dated 4/30/2024 revealed Resident #72 was observed to have opening in the penile area due to prolonged Foley catheter use. NP notified, awaiting response. Treatment nurse provided care, notified family member. There was no assessment and measurement to opening in the penile area.<BR/>Record review of nurse's progress note revealed on 5/2/24: MD (medical doctor in facility rounding on Resident #72. Documented Nurse follow-up with resident penile area opening with the MD. Resident MD said urologist consult will further evaluate. Resident #72 have urology consult appointment 5/23/24. Further review revealed there were no other NP notes addressing the issue with Resident #72's penis after 05/02/24 and the only physician visit noted was on 05/02/24. <BR/>Record review of Resident #72's physician order included: start date of 4/30/2024 for a wound care consult, one time only for penal wound for 2 days; start date of 5/2/2024 revealed an order for every day and every night shift, monitor for open penial area and notify MD and NP of any change.<BR/>Record review of Resident #72's TAR (Treatment Administration Record) for May 2024 through June 2024 revealed orders to monitor every shift open penile area and notified MD/NP of any changes. were performed. Monitored area on every shift for skin integrity except on 5/13/2024 and 5/14/2024 on night shifts and 5/17/2024 during the day shift. Record review also revealed treatment to monitor every shift the foley insertion site for redness, irritation every day and night shift for skin integrity, and monitor Foley Cath, stripe placement for redness, irritation every shift was was provided on 6/28/2024, night shift and through 7/30/2024.<BR/>Record review revealed Resident # 72 did not see the Urologist until 6/20/24 due to the Urologist office relocating and the facility was not aware. <BR/>Record review of Resident 72's Urology consult dated 6/20/2024 revealed diagnosis that includedwere Neurogenic Bladder (t,he name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem), gross hematuria (when you can see the blood in your urine) and Hyperplasia of prostate (a noncancerous enlargement of the prostate gland) with lower urinary tract symptoms, .managed with Foley catheter but has caused and urethral breakdown now has a penoscrotal hypospadias (in perineal hypospadias, the scrotum is abnormally divided and the urethral opening is located along the center of the divided sac).<BR/>During an interview on 6/25/24 at 9:55 am, CNA B said that when care was provided to a resident with a catheter, she made sure the catheter was not pulled but did not check for a securement device. She said the nurses were responsible for placing the securement device. She said a catheter that was not secure could come out or cause pain.<BR/>During an interview on 6/25/24 at 1:11 pm, LVN A said she had been at the facility for 4 years. She said that residents with an indwelling catheter should be checked every shift and a securement device should be in place to prevent discomfort and dislodgment. She said she had received competency training on indwelling catheters and care. <BR/>During an observation and interview on 06/26/24 at 9:45 am, Resident # 72 was observed with an indwelling catheter with no securement device for the catheter. Resident # 27 said there was a pulling feeling in his private area at times. <BR/>During an interview on 6/26/24 at 10:43 am, the DON said the charge nurses were responsible for checking residents with catheters each shift and each resident with a catheter should have a securement device. She said she was responsible for all nursing oversight and training and nurses had been trained on catheter assessment and ensuring a securement device was in place. She said if a catheter was not secure it could cause abrasions and become dislodged. <BR/>During an interview with the DON regarding Resident #72 on 6/27/24 at 4:10 PM the DON was not sure why Resident #72 did not see a Urologist on 3/14/24, 3/30/24, and 5/2/24. She stated she would check on chart and call the Urologist's office.<BR/>During an observation of indwelling catheter care on 6/27/24 at 10:22 AM, Resident #72 was transferred from the wheelchair to the bed by C.NA B and MA D assisting. Resident #72 had Velcro strap on, that did not secure the catheter, the strap was on the resident mid-thigh. Incontinent care done by C.NA B. She did not wash her hands before donning clean gloves. C.NA B used wet wipes to clean the Foley catheter twice. Resident #72's penis head was slit from the base to the scrotum and was red and raw. C.NA B did not change gloves when they repositioned Resident #72 to the left side. The resident had a moderate amount of bowel movement. C.NA B picked up a clean brief and placed it on the bed. C.NA picked up wet wipes and cleaned the BM, folding the wipes in half twice, once after each wipe. Using the same gloves, C.NA B picked up the clean brief and placed it on the resident, pulled up the pant without securing the indwelling catheter. <BR/>Observation of Resident #72 on 6/28/2024 at 3:15pm, the Velcro was at the knee of the resident and not securing the in-dwelling catheter. Measurement of the slit length was 8 centimeters, the width was 1 centimeter, and the depth was 0.4 centimeter. The area was pinkish.<BR/>During an interview on 06/27/24 at 10:43 AM, Resident #72 was observed with an indwelling catheter with securement device (Velcro) not securing the catheter. Resident # 72 said the foley catheter has always been rubbing and pulling on him and his slit grew over time. He said it was very painful.<BR/>During an interview on 06/27/24 at 10:50 AM, CNA B said that when care was provided to a resident with a catheter, she made sure the catheter was not pulled but did not check for a securement device. She said the nurses were responsible for placing the securement device. She said a catheter that was not secure could come out or cause pain. She said she forgot to wash her hands and change gloves. She said she has been working with the facility for 1 year and did have the skills check off done. She said that the resident had not complained of pain before and she knew to report to the charge nurse when any resident complained of pain. <BR/>During an interview on 6/27/24 at 11:00 AM, LVN A said she had been at the facility for 1 year. She said that residents with an indwelling catheter should be checked every shift and a securement device should be in place to prevent discomfort and dislodgment. She said she had received competency training on indwelling catheters and care.<BR/>During an interview on 6/27/24 at 11:43 AM, the DON said the charge nurses were responsible for checking residents with catheters each shift and each resident with a catheter should have a securement device. She said she was responsible for all nursing oversight and training and nurses had been trained on catheter assessment and ensuring a securement device was in place. She said if a catheter was not secure it could cause abrasions and become dislodged.<BR/>On 6/28/24 at 7:45AM, the DON said she had sent the facility marketing director to the urologist office to pick up the results. <BR/>In an interview on 6/28/2024 at 8:39 am with the MDS Nurse, she said that Resident # 72 went to his urology appointment on May 25th, 2024, but for some reason it was rescheduled, so they did not see him that day. She said that they received the documentation from his urology appointment from 6/20/24 this morning and provided a copy.<BR/>In an interview on 6/28/24 at 11:37 AM RN A said the nurses changed catheters monthly or as needed when there was a leak. She said she was aware of the slit to Resident #72's penis when she changed the catheter a month or 2 months ago. She stated the resident had a urologist appointment on 5/23/24 and she thought the treatment nurse did the slit measurement. She cannot remember the length and width of the slit to the penis. RN A said the nurses secured the Velcro to the catheter to avoid it pulling and trauma.<BR/>In an interview on 6/28/2024 at 2:32pm with the treatment nurse, she said she identified the split during a skin assessment around March or April 2024. She informed the DON, the MDS Nurse, the family representative, and the doctor. The doctor wrote an order for the resident to see a urologist and wait for their recommendations. The nurse said the resident's penis had a little opening, but no redness and the resident told her he was not in pain then. Resident #72 has never told the nurse he felt pain from the slit. The treatment nurse said she always made sure that Resident #72 had the catheter strap. She said since she noticed the slit it has remained that way, although she has not measured the slit length. The nurse said she knew that there was a urology appointment scheduled but she did not know if Resident #72 made it to that appointment. She never noticed blood in the urine and the resident never mentioned blood in the urine.<BR/>In an interview on 6/28/2024 at 3:20pm with the treatment nurse, after measuring she stated she did not know the slit was that long.<BR/>In an interview with the DON on 6/28/24 at 3:30 PM, regarding resident urologist consult from 3/14/24 3/30/24 for hematuria, consult for slit on penis on 4/30/24 and 5/2/24. DON said she would check for the results because there no result on the PCC. At 4:30 PM on 6/27/24, DON said she would be calling the urologist office for the result. DON said she did not get any respond from the doctor's order and the results were not documented in the progress notes and she just found out Resident #72 visited the urologist on 6/20/24 and there was no result om the chart.<BR/>In an interview with the DON on 06/28/2024 at 4:30 PM, the DON stated he was made aware by the CNA involved about the infection control issue during incontinent care. The DON said every staff should wash their hands before and after every care. He said gloves should be changed and the hands should be sanitized after cleaning the resident's buttocks or the resident's front part before touching the any clean items. He said not washing the hands, not changing the gloves, and not sanitizing the hands in between changing of gloves could result to cross contamination and infection. The DON also added if the brief had fallen to the floor, it should not be used anymore for a simple reason that it was already dirty. The DON said the expectation was for the staff to remember to wash their hands and change their gloves when transitioning from a dirty area to a clean area, sanitize their hand when changing their gloves, and not to use items that had fallen to the floor. The DON said he already did a one-on-one in-service with CNA D but would do an infection control in-service for all the staff. He concluded that he would continually remind the staff to be attentive to the procedures for infection control and that he would personally monitor infection control.<BR/>On 7/1/24 at 3:04PM called the MD left message on answering service.<BR/>Interview with the MD (Medical Director) on 07/01/2024 at 3:22pm, he said he knew the resident and he is on dialysis. MD has seen him at the facility. The facility called him about the blood in resident's urine and he does not remember how long ago it was. He said he remembered the call and that the resident was supposed to see a urologist. He doesn't know how long the resident was supposed to see the urologist. The MD said someone told him about the slit in the penis. He doesn't know if it was evaluated, but that the resident had a foley catheter and was referred to the urologist to get it repaired. The MD said all communications between the resident's NP, the physician regarding the resident should be in PCC in the notes. He was informed of the resident's delayed urology consult last week and knew the resident was waiting to know but unsure if the appointment was delayed or cancelled. The MD knows the resident had gone to a urology appointment before and that a follow-up was scheduled. All the appointment information should be in the nursing notes. The MD said he has a group practice, and an NP also sees the MD's patients. Changes in conditions are reported to a resident's PCP and the MD gets notified about his residents. The MD is also notified of significant changes in condition for other residents since he is also the Medical Director of this facility. At QA/QAPI meetings, the MD and the facility will discuss patient care at that time about all patients. The MD does not know how long the slit is, he did not see bleeding from the area last time he saw the resident. When asked if he knew how long the resident had the slit, the MD replied, If you have to put words in my mouth it would be three weeks, but he could not say for sure. The MD said he has seen the resident twice and that the NP has seen this patient as well.<BR/>The result from the urologist dated 6/20/24 presented to the state surveyor on 6/28/24 at 8:20 AM.<BR/>Consult 6/20/24: Reason for visit: Blood in urine, Progress Notes: Assessment/Plan, Problem List Items Addressed This Visit: Visit Diagnoses: Neurogenic bladder-Primary, gross hematuria, hyperplasia of prostate with lower urinary tract symptoms (LUTS).<BR/>1. Neurogenic bladder/urinary retention<BR/>- from CVA but still makes urine<BR/>- managed with Foley catheter but has caused urethral breakdown now has a penoscrotal hypospadias.<BR/>-Discussed risks and benefits of changing to a suprapubic tube and he wants to proceed<BR/>2. Penoscrotal hypospadias<BR/>- due to urethral<BR/>3. Hematuria<BR/>- resolved, obtain Cysto <BR/>Observation on 6/28/24 at 3:10 PM revealed Resident #72 was back from dialysis and was sitting on the wheelchair. She was propelled by staff to resident #72's room for a skin assessment. CNA A and CNA B transferred Resident #72 to bed and the Velcro was on the resident's knee, not securing the catheter. The treatment Nurse undid the brief then picked up the penis measuring the slit. The length was 8 cm by 1cm width by 0.4cm depth, red and raw. The treatment nurse stated while measuring the slit that she did not know it was that bad and it was her first time measuring it. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 6/28/24 at 5:45PM. The Administrator and the DON were notified The Administrator was provided with the IJ template via email on 6/28/2024 at 5:56PM.<BR/>The following plan of removal was submitted by the facility and was accepted on 6/29/2024 at 10:14AM.<BR/>Immediate Jeopardy (the facility)<BR/>On 6/28/2024 an incident survey was initiated at. On 6/28/2024 the state surveyor provided an Immediate Jeopardy (IJ) Template notification that the regulatory services had determined that the condition at the facility constituted an immediate jeopardy to resident health and safety. <BR/>The facility failed to assess, follow-up with treatment, update the care-plan, and obtain new order due to a change in resident # 72's skin condition of the groin to the physician.<BR/>F690 Plan of Removal<BR/>Immediate Action: <BR/>o <BR/>Resident #72 head to toe assessment was completed by Treatment Nurse and ADCO on 6/28/24. The weekly skin assessment was updated to show the measurements and description of the slit.<BR/>o <BR/> Resident #72 was assessed for pain by the ADCO on 6/28/24 which he denied having pain.<BR/>o <BR/>Resident #72's Physician was updated on the slit by the DCO on 6/28/24, and no new order received. Current monitoring orders were already in place and completed every shift.<BR/>o <BR/>Resident #72's care plan was updated on 6/28/24 to reflect the skin changes in the penis and intervention. <BR/>o <BR/>All residents with foley catheters were assessed to ensure no slit in the penis, there was a leg strap to anchor their Foley tubing on 6/28/24 by the ADCO. No concern was identified.<BR/>o <BR/>The care plan of all resident's with foley catheters was reviewed by the MDS Nurse on 6/28/24 to ensure the care plan was updated with no concerns noted.<BR/> Facilities Plan to ensure compliance quickly:<BR/>o <BR/>The treatment Nurse was provided with 1:1 training on proper skin assessment including weekly measurement of the wound, documentation on weekly skin assessment, updating the Physician on changes in the skin, and updating care plan by the Director of Nursing and was completed on 6/28/24. The monitoring will be placed in the treatment sheet and reviewed during daily clinical meetings by the DCO/Designee.<BR/>o <BR/>The Director of Nursing/Designee initiated an in-service for all Nursing staff to ensure foley catheters were secured with the strap to resident's thigh. Report any trauma or irritation to the meatus to the charge Nurse and attending physician/NP when found. Inservice will be completed on 6/29/24. All staff members will be provided with in-service prior to the beginning of their shift.<BR/>o <BR/>Skin assessment competency was completed on the Treatment Nurse by the DCO on 6/28.<BR/>o <BR/>Daily focused rounds will be completed by Nurse management daily on all residents with foley catheter to ensure they have leg strap on, and to identify any irritation and trauma to the penis. If there was any to ensure Physician notification was completed and new order received.<BR/>o <BR/>The Medical Director was notified of the Immediate Jeopardy on 6/28/2024.<BR/>o <BR/>The current policies reviewed on Skin management by the Medical Director on 06-28-2024: Prevention and treatment of wounds, and catheter insertion, and maintenance with no changes to the current policy completed on 6/28/24. This practice will be reviewed monthly with the QA committee to ensure compliance in place. <BR/>o <BR/>The Social worker/Designee will be educated by the Administrator on 6/29/24 to make future urology appointments and discuss with the IDT if they were having any difficulty in getting timely appointment for further direction.<BR/>The surveyors confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following:<BR/>Observation and interview on 6/30/2024 at 11:00 am with Resident #72 was sitting in wheelchair eating a snack. He was well-groomed with no odors. Resident #72 said he is feeling okay but wondered why it took the facility so long to address his catheter. He said he was now afraid of an infection from his stoma to g-tube. Resident #72 raised his shirt at that time and a small pea-sized area was observed in what appeared to be a white cream. Resident #72 consented for the DON to come assess him with another staff member. He was then transported back to his room. The DON later came and said that the white substance was not an infection but a cream that they used to treat the stoma called theravox, which was confirmed by viewing the container and conducting a record review of Resident #72's physician orders.<BR/>In an interview on 6/29/2024 at 10: 20 AM RN A said she had been working with the facility for 8 months 6:00 AM to 6:00 PM shift. She had in-services on incontinent care, indwelling catheter care, securing catheter, hanging foley bag below the bladder, and reporting any abnormalities to the charge nurse like skin irritation. If there were any changes in the site notify the NP and check indwelling catheter every shift. They were assessing catheter before daily but now every shift and for any slit to the penis they should document in the progress note.<BR/>In an interview on 6/29/2024 at 10: 49 AM LVN A said she had been working with the facility for 1 year on the 6:00 AM to 2:00 PM shift. She had in-services on incontinent care, indwelling catheter placement, securing the catheter, and reporting any abnormalities to the doctor like skin irritation and document.<BR/>In an interview on 6/29/2024 at 10: 56 AM RN B, (Weekend Supervisor) said she had been working with the facility for 2 years on the 9:00 AM to 6:00 PM shift. She had in-services on pain, skin assessment, indwelling catheter care, securing the catheter, reporting any abnormalities to the doctor, and SBAR like skin irritation and slit measure daily and document.<BR/>In an interview on 6/29/2024 at 11: 26 AM RA A (Restorative Aide) said she had been working with the facility for 8 years, on the 6:00 AM to 2:00 PM shift. She had in-services on incontinent care, indwelling catheter care, securing the catheter, and reporting any abnormalities to the charge nurse like skin irritation.<BR/>In an interview on 6/29/2024 at 11: 14 AM C.NA A said she had been working with the facility for 1 year on the, 6:00 AM to 2:00 PM shift. She had in-services on incontinent care, indwelling catheter care, securing the catheter, free of kinking, and reporting any abnormalities to the charge nurse like skin irritation.<BR/>In an interview on 6/29/2024 at 11:18 AM MA C said she had been working with the facility for 7 years on the 7:00 AM to 8:30 PM shift (Friday, Saturday, & Sunday). She had in-services on incontinent care, indwelling catheter care, securing the catheter, and reporting any abnormalities to the charge nurse like skin irritation and document.<BR/>In an interview on 6/29/2024 at 11: 26 AM C.NA B said she had been working with the facility for 1 year on the, 6:00 AM to 2:00 PM shift. She, had in-services on incontinent care, indwelling catheter care, securing the catheter, and reporting any abnormalities to the charge nurse like skin irritation.<BR/>In an interview on 6/29/2024 at 8:20 PM LVN C said she had been working with the facility on the 6:00 PM to 10 PM shift. She had in-services on skin assessment, indwelling catheter care, securing the catheter, and reporting any abnormalities to the ADON, the DON, and the M.D.<BR/>In an interview on 6/29/2024 at 8:27 PM, C.NA D said she had been working with the facility for 2 years on the 2:00 PM to 10 PM shift. She had in-services on incontinent care, indwelling catheter care, securing the catheter, and reporting any abnormalities to the charge nurse.<BR/>In an interview with the Administrator and the DON on 06/30/2024 at 9:38AM, the DON said that Resident #74's doctor told the nurses he will send his paperwork, but he did not return from his 06/20/2024 appointment with it. The Administrator and the DON said they were not aware of this situation regarding the facility not following up after the Urologist appointment. The Administrator started on 06/03/2024 and the DON started 05/16/2024 and that they were not aware the follow-up doctor's visit system was broken. They believed the SW was assigned to run the system. The DON said if a resident missed an appointment, it could have caused a delay in care. She also found out that nurses were calling the Urologist's office but not documenting it. Now the facility will send the resident with an envelope to their visit, make sure the doctor's office returns documents, and items needing follow-up back with the resident. If not, the charge nurse will contact the office. The monitoring system will include the DON, the ADON, the Unit Managers, and the SW. <BR/>In an interview with the SW on 06/30/2024 at 10:33AM, he said that he used to make specialist appointments, and now nursing will assist him with paperwork and documentation. He said that appointments were to be documented in the electronic medical records. The nursing staff will be in charge of managing the communication and will follow-up with the doctor's office. The appointments and changes in condition would be discussed at the morning meetings, and if there were any issues or concerns, he would let the DON and the ADON know.<BR/>In an interview with CNA J on 06/30/2024 at 10:49AM, she said she worked the 6:00AM to 2:00PM shift. She had in-services on incontinent care, catheter care, pain management, and notifying the charge nurse of changes in condition with catheter and pain.<BR/>In an interview with LVN K on 06/30/2024 at 10:58AM, she said she worked when she was called and had in-services on catheter care, documentation, documenting for changes in condition, and reporting them to the DON and MD. <BR/>In an interview with CMA A on 06/30/2024 at 11:06am, she stated she worked the 7:00AM to 8:30PM shift. She had in-services on catheter care and reporting changes in condition to the charge nurse, ADON, DON and MD.<BR/>In an interview with CMA B on 06/30/2024 at 11:12AM, she stated she worked when she was called. She had in-services on foley catheter, assessing pain, and reporting changes in condition to the nurse, ADON and DON. <BR/>In an interview with LVN G on 06/30/2024 at 11:21AM, she stated was a Unit Manager from 8:00AM to 5:00PM. She was in-serviced on pain assessment, catheter care, and reporting changes in condition to the MD.<BR/>In an interview with the ADON on 06/30/2024 at 11:30AM, she stated her shift was from 8:00AM to 5:00PM. She was in-serviced on pain management and reporting changes in condition to the DON and MD, and catheter care.<BR/>In an interview with LVN H on 06/30/2024 at 11:37am, she was in-serviced on foley catheter, pain, appointments, and reporting changes in condition. She also was trained on scheduling and monitoring appointments. <BR/>Interview with RN A on 07/02/2024 at 12:09PM, she said that she was in-serviced on reporting changes in condition to the DON and MD. <BR/>Interview with LVN M on 07/02/2024 at 1:51PM, she was in-serviced on foley catheter care, pain management and scheduling and documenting appointments for residents.<BR/>Interview with CNA M on 07/02/2024 at 1:51pm, she said she was in-service on foley catheter for residents.<BR/>The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 06/30/2024 at 12:27PM. The facility remained out of compliance at a severity level of 2 and a scope of E due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.<BR/>Resident #54<BR/>Record review of Resident #54's face sheet dated 06/27/24 revealed he was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #54 had diagnoses which included: diabetes mellitus (body do not produce enough insulin or cannot use it properly), hypertension (high or raised blood pressure), urinary tract infection (an illness in any part of the urinary tract), and neuromuscular dysfunction of the bladder (the nerves and muscles do not work together very well).<BR/>Record review of Resident #54's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 of 15 indicated moderate impaired cognition. Further review revealed the resident had indwelling Foley. <BR/>Record review of Resident #5[TRUNCATED]

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control process designed to provide safe and sanitary environment and to help prevent the development and transmission of diseases and infections for four (Residents #33, #37, #40 and #106) out of five Residents observed for infection control during medication administration: in handling of laundry and in wearing of face mask, in that:<BR/> - <BR/>LVN D and CMA E failed to sanitize blood pressure machine used for multiple residents during medication administration for residents #33, #37, #40 and #106.<BR/>- <BR/>The facility failed to ensure Laundry Provider D was transporting clean resident clothes down the 200 Hall with laundry cart covered. <BR/>- <BR/>The facility failed to ensure CNA A, and CNA B wore N95 masks properly. <BR/>These failures could place residents at risk of cross contamination and contracting of infectious diseases.<BR/>Findings included:<BR/>Transmission-Based Precautions<BR/>Observation on 02/22/22 at 12:04 PM revealed CNA A, and CNA B were not wearing N95 masks properly. The backstrap of the N95 was hanging underneath their chins. <BR/>During an interview on 02/22/22 at 12:09 PM, CNA A said he was not wearing his mask properly because he could hardly breath.<BR/>During a follow-up interview on 02/23/22 12:28 PM with CNA A, he said he was trained on infection control a couple of weeks ago. He said the training covered wearing masks appropriately, proper hand hygiene, donning and doffing PPE. <BR/>During an interview on 02/22/22 at 12:12 PM, CNA B said she was not wearing her mask properly because she could hardly breath and she forgot to put it on properly.<BR/>Observation on 02/22/22 at 12:15 PM revealed the Speech Therapist making contact with residents. She did not wash her hands or use hand sanitizer while cutting food for a resident during lunch service. <BR/>During an interview on 02/22/22 at 1:34 PM with the Speech Therapist, she said she was supposed to wash her hands in between residents during dining. She said there was not that many sanitizing stations in the area, so it was just easier to help the resident in need rather than to walk over to the sanitizing station. She said she normally used hand sanitizer at her building because there were sanitation stations on every wall which was not the case in this facility.<BR/>Observation and interview on 02/22/22 at 1:50 PM revealed the Activity Director passing out snacks. She said her role was to clean up her cart and pass out coffee, snacks, and other items. She said she also passed out juice, yogurt, and water. She said staff was supposed wash their hands and wear gloves and wash again between residents. She said she did not wear gloves today because it was a bad habit. She said she would do better. She said the facility could benefit from adding more sanitizing stations.<BR/>Universal Precautions<BR/>During observation on 2/23/2022 at 7:53 AM LVN D on the 200 Hall was using a blood pressure machine to check Resident #106 blood pressure but failed to sanitize the blood pressure machine after using it.<BR/>During observation on 2/23/2022 at 8:31AM LVN D went to Resident #40 to check his blood pressure using the same blood pressure machine she used on Resident #106 - again, LVN D failed to sanitize blood pressure machine before using it on Resident #40 and failed to sanitize the blood pressure machine after using it on the Resident #40. <BR/>During interview on 2/23/2022 at 9:49 AM LVN D agreed that failure to sanitize the equipment used for multiple residents was a compromise of infection control which could affect the residents.<BR/>During an observation on 2/23/2022 at 8:53 AM CMA E was took the blood pressure of Resident #37 but failed to sanitize the blood pressure machine after using it for the resident.<BR/>During an observation on 2/23/2022 at 9:15 AM, CMA E checked Resident #33's blood pressure using the same blood pressure machine she used on Resident #37 - again, CMA E failed to sanitize blood pressure machine before using it on Resident #33 she also failed to sanitize the blood pressure machine after using it on Resident #33. <BR/>During an interview on 2/23/2022 at 9:42 AM CMA E stated that she forgot. She stated that she had proper infection control training and was aware this could place residents at risk for infection. <BR/>Laundry<BR/>During an observation and interview on 2/23/22 at 9:00 am revealed Laundry Provider D was transporting clean resident clothes down the 200 Hall in an uncovered laundry cart. Laundry Provider D did not know if the clothing should have been covered while transporting it down the hallway. <BR/>Interview on 2/24/22 at 2:30 pm, the Director of Laundry Services revealed the laundry cart was always covered with a plastic tarp unless it was being loaded with clean clothing and should always be covered when it was transported down the hallways for infection control purposes. She stated it was important to make sure the clean clothing was not contaminated by anything it might contact while it was being moved down the hallways. <BR/>During an interview on 2/24/22 at 8:57 AM with the DON and the ADON, the DON stated they always trained their staff during hiring process and they provided ongoing training for them. The ADON stated they also had an online training portal where all employees were being assigned training on a regular basis. Both the DON and the ADON agreed staff were required to sanitize equipment used for multiple residents, as failure to sanitize equipment posed infection risk to residents, because they could pass any disease or virus from one patient to another.<BR/>During an interview on 2/24/22 at 8:57 AM with the DON, she said staff were supposed to wash or sanitize their hands when feeding the residents. She said after feeding one resident, staff should wash or sanitize before feeding another resident. She said all staff members were required to wear face mask to always cover mouth and nose. She said alteration of facemasks was not acceptable. She said staff were not required to wear gloves when passing out food, but they were required to wash or sanitize their hands.<BR/>During an interview on 2/24/22 at 10:00 AM surveyor requested a facility policy on infection control regarding equipment used for multiple residents, the DON stated they did not have any specific policy regarding equipment such as blood pressure machine used for multiple residents. However, DON stated it was required of employees to sanitize equipment such as stethoscope, blood pressure machine, Oxygen saturation machine, thermometer, etc. used for multiple residents. <BR/>Interview with the DON on 2/24/22 at 3:40 pm revealed the clean laundry cart should be covered with a plastic tarp or similar cover while it was being used to transport clean laundry down the hallways, to make sure it did not become contaminated with dust or anything it might touch. <BR/>Record review of facility's policy Departmental (Environmental Services) - Laundry and Linen, revised January 2014, revealed, in part: clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean carts .<BR/>Record review of the website https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html#g revealed, in part: .transport and store clean textiles and fabrics by methods that will ensure their cleanliness and protect them from dust and soil during interfacility loading, transport, and unloading .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accidents and hazards as is possible for 22 of 22 residents reviewed for accidents and hazards. <BR/>1. <BR/>CNA B and CNA C engaged in a verbal and physical altercation in the presence of at least two residents, Resident #2, and Resident #3 on 1/18/24 at approximately 6:00 a.m.<BR/>2. <BR/>CNA C left a loaded firearm unattended inside her personal bag in an unsecured cabinet under the nurse's station desk located directly across from a resident TV area for an undetermined amount of days/time. <BR/>3. <BR/>CNA C pointed a loaded firearm at CNA B and discharged the gun outside in the air approximately one yard from resident-occupied rooms on 1/18/24.<BR/>An Immediate Jeopardy (IJ) was identified on 02/07/2024 at 9:40 a.m. The IJ template was provided to the facility on [DATE] at 9:40 a.m. While the IJ was removed on 02/08/2024 , the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures placed all residents at risk possibly being seriously harmed/injured or killed by an unsecured firearm or stray bullet. <BR/>Findings included:<BR/>Observation of the nurse's station on the 100 Hall on 01/22/2024 at 11:00 a.m. revealed the entrance to the nurse's station was directly across from a resident television area. There were open areas underneath the desk with shelves. There were bags, purses, and jackets on the shelves. No staff were observed at the nurse's station at that time. There were three residents in wheelchairs sitting in the television area. <BR/>In an interview with the DON on 01/22/2024 at 9:30 a.m., she stated on 01/18/2024, LVN V called her and said two staff members (CNA B and CNA C) were having an altercation. She could not recall what time LVN V called her, but it was at the start of the 6:00 a.m. - 2:00 p.m. shift. The DON said she told LVN V to get replacement staff and send CNA B and CNA C home. The DON said LVN called her again that morning and said there were gun shots fired outside. The DON said the MDS Nurse called the police after she heard gunshots. The DON said there had not been any prior altercations between the two staff that she knew of. She said CNA C was just hired in December 2023. She said CNA C had not complained about any prior incidents with any other staff. She said their corporate staff were involved in the investigation. She said CNA D tried to separate the two staff when they were fighting. She said all three staff were suspended pending the investigation, but CNA D returned to work on Sunday, 01/21/2024. She said the MDS Nurse was currently in the hospital having emergency surgery. She said the nurses did 12-hour shifts from 6:00 a.m. - 6:00 p.m. and 6:00 p.m. - 6:00 a.m. She said RN A was the night shift nurse and she also witnessed the altercation. <BR/>In an interview with the Administrator on 01/22/2024 at 10:22 a.m., he stated on 01/18/2024, he received a call from a nurse at about 7:15 a.m. He said he could not recall what nurse called him, but the nurse said the Medical Records Coordinator said CNA C had a gun and fired shots in the air. The Administrator said CNA C texted him at 8:11 a.m. after the incident and said the other staff jumped her. He said he sent her a text saying she brought a weapon into the facility when signs were posted everywhere saying it was a felony and then discharged it unsafely. He said CNA C texted back saying she figured he would say that and that it was not a felony to protect herself The Administrator said the police came and did an investigation, but as of Friday, 01/19/2024, they had not found CNA C or arrested her. He said CNA C texted that she rode the bus to work, and the gun was in her bag. The Administrator said he did not know where CNA C's bag was stored inside the facility. He said CNA C told him she brought the gun for safety reasons because she rode the bus at night. He said this was the first time he heard about any incident between CNA B and CNA C. The Administrator said CNA C never told him what the argument was about, but he heard during the investigation that the argument was about an unsafe transfer. He said CNA C transferred Resident #2, who was a two-person transfer, alone and CNA B told her how to do it the right way. The Administrator said Resident #2 told him CNA B was very calm when she approached CNA C and told her how to transfer him the right way. The Administrator said that was when things escalated, and CNA D tried to stop CNA C from going outside to mess with CNA B, who was outside smoking. He said RN A, MDS Nurse, and CNA D all tried to stop CNA C from bothering CNA B outside. He said CNA C went outside and that was when everybody heard guns shots. The Administrator said nobody went outside with CNA C. He said from his understanding, there was a short amount of time when CNA C went outside and when gunshots were heard. He said from his understanding, there was not a physical altercation inside the building because some people said it was physical, and some said it was not. He said CNA C told the VP of Operations she was being bullied, but there were no reports of that to him. He said CNA C never reported being bullied before this incident. He said he always did in-services about staff getting along and workplace violence as part of their ongoing training. He said there were no prior issues with staff having altercations that he knew of. He said staff had lockers available to them outside in the courtyard and in the staff breakroom. He said staff could bring their own locks to secure their personal belongings. He said he did not know if CNA C had a locker or not. The Administrator said he implemented a new rule that staff could only bring clear bags into the facility. He said he also contracted to have security in the building 24-hours daily and in-serviced staff. He said there were always signs posted at every entrance and exit about not bringing guns into the building, but he posted more signs. <BR/>In a telephone interview with CNA C on 01/22/2024 at 10:45 a.m., she stated she took responsibility for what she did because they (the Administrator and VP of Operations) told her having weapon on the premises was a felony. She said she only had the gun because she rode the bus at night to and from school. She stated she worked the 6:00 a.m. - 2:00 p.m. shift, but on 01/18/2024, she arrived early and clocked in at 5:45 a.m. She said she got Resident #2 up because he wanted to get up. She said she gave him a bed bath and transferred him safely with a Hoyer Lift to his wheelchair. She said RN A went to Resident #2's room because he was rambling and going on (she did not say what Resident #2 was rambling about). She said RN A said, Oh, you got him up, it was not time to get him up and you were not supposed to get him up by yourself. She said she was still in Resident #2's room and was leaving out right at 6:00 a.m. when CNA B approached her and was very aggressive about it. She said CNA B told her, I don't know what you think you are doing, but this is a two-person assist and you are going to get yourself fired. CNA C said she did not know what CNA B's problem was because she came down the hallway with her hands up like she was going to hit her. CNA C said CNA B swung at her and she backed up and asked CNA B not to do that. She said CNA B told her RN A asked her to come talk to her. She said she asked CNA B why she was so mad, and CNA B said she was done talking and was about to burst her upside her head. CNA C said she previously observed CNA B get Resident #2 up unassisted and CNA B said, I don't care what you thought you saw. CNA C said CNA B kept pushing and chest butting her. CNA C said she was walking away when CNA D grabbed her hand and said, Don't run up behind CNA B like that. CNA C said she told the rest of the staff she was leaving and showed them her bus pass. She said while CNA D held her, CNA B punched her on left side of her face. She said nobody let her leave. She said CNA B said, You about to go outside and get your ass whooped. CNA C said there were 3 - 4 people standing outside with CNA B and they were bullying her, so she pulled her gun out and shot into the air. She said she did not know the names of the other staff who were outside with CNA B. She said she called the Administrator and the VP of Operations after the incident. She said her car was broken, so she had to ride the bus. She said she went to class from 5:00 p.m. - 9:00 p.m. and she stored her bag behind the nurse's station, under the cabinet where there was an open area. She said that was where all the staff kept their things. She said she left her bag with the gun inside on the bottom shelf, next to the computer and chair on hall 100. She said her weapon was not exposed. She said RN A was there when CNA B hit her in the face. She said CNA B and another staff were already outside when she tried to leave the building and CNA D held her back and would not let her leave. She said she did not know if CNA D made it outside before her, but she saw some people at the door yapping their mouth (yelling at her and bullying her). She said she went out the side door of the building and was in the middle of the parking lot when she fired the shot in the air. She said she did not aim the gun at anybody, and she did not try to hurt anybody. She said the other staff were nowhere near her when she fired the shot. She said the other staff were more than 200 - 300 ft. away from her. She said the Medical Records Coordinator heard her telling the other staff to get off her. She said she told the Medical Records Coordinator and another CNA that she was being bullied by CNA B. She said during the week prior to the incident, she was mistreated by some African staff and CNA B defended her, so she did not understand why CNA B hit her in the face. She said she never reported to the Administrator or other management staff that she was being bullied. She said 01/18/2024 was the first day she brought her gun inside the building. She said she had never gone inside the building with a bag before because she previously had her car. She said her car broke down a couple of weeks before the incident. She said she never noticed or paid attention to the posted signs that said she could not bring a gun inside the building. She said she did not know she could not have the gun to protect herself. She said none of the residents had access to it because it was behind nurse station under the open cabinet.<BR/>In an interview with the Medical Records Coordinator on 01/22/2024 at 11:15 a.m., she stated days before the incident on 01/1/2024, CNA C told her some other staff were messing with her and the nurses were always hostile to her. She said she told CNA C file a grievance because the Administrator had an open-door policy. She said CNA C told her that on Saturday, 01/13/2024, some nurses got her into the medication room and got in her face. She said CNA C told her that on the day of the incidents, CNA C came and told her she could not get Resident #2 up or change him by herself even though she previously observed CNA C transfer him alone. The Medical Records Coordinator said RN A told CNA B to go and tell CNA C she could not transfer Resident #2 alone. She said the two staff had a verbal and physical altercation in the residents' room. She said Resident #2 told her CNA C hit CNA B first. She said CNA C told her CNA B hit her first. She said CNA C and CNA B never had any disagreements. She said CNA D told her (Medical Records Coordinator) that CNA C said she had a gun and she had 'something for them' if this (when the nurses cornered her in the medication room and got into her face) happened again. She said CNA C told CNA D she had a gun possibly days before the shooting incident. She said CNA B was a smoker and usually went out to the patio in the courtyard to smoke, but on 01/18/2024, CNA B called CNA out and said, Come outside if you got something for me. The Medical Records Coordinator said she was at the table in the front of the building and saw people running. She said she heard staff saying, No! Let my purse go, let me go! and She got a gun! She said by the time she got to the side of the building: CNA C was already gone. She said she did not hear the gun shot. She said the incident occurred around 6:00 a.m., so of course residents were up at that time and roaming around the building. She said none of the residents were outside. She said CNA D was outside when CNA C shot the gun. She said CNA D tried to keep CNA C from leaving with her purse because she knew the gun was in there. She said CNA C's bag was probably behind the nurse station, but staff were supposed to keep their belongings in the lockers. <BR/>In a telephone interview with CNA B on 01/22/2024 at 11:35 a.m., she stated she worked the 6:00 a.m. - 2:00 p.m. shift and there had not been any other incidents or animosity between her and CNA C. She said the two of them usually got along. She said on 01/18/2024, she had just gotten to work when RN A asked her to talk to CNA C because she got Resident #2 up way too early and she transferred him alone. She said RN A told her CNA C would not listen to her. She said she and CNA D went to the room and saw CNA C in there. She said she asked CNA C to come to the door and then told her RN A asked her to go and talk to her because Resident #2 was a two-person transfer. She said CNA C got mad and clapped her hands saying she was tired of people telling her what to do. CNA B said she told CNA C she was just trying to keep her from getting in trouble. CNA B said she walked away and told RN A it was too early for this. CNA B said the altercation was only verbal and never got physical. CNA B said they went to the nurse's station and continued arguing back and forth. She said RN A and CNA D were there trying to separate them. She said she tried to go outside and smoke to diffuse the situation, but it was brought up that CNA C had a gun. CNA B said CNA D knew CNA C had a gun. She said CNA D said, Don't let her get her purse! CNA B said at that time, CNA C was going for her purse behind the nurse's station desk. She said CNA D said, Don't let her get it because she got a gun! and CNA C said, And Do (meaning she did have a gun). CNA B said she was getting her stuff to go smoke and CNA B walked up on her back (walked closely behind her). She said as she walked down the hall to go smoke, the other staff were still in the building. She said once she got outside, she could see CNA C walking towards her thru the glass door. She said she saw CNA C's bag under left arm and her right hand was inside the bag. She said when CNA C walked outside, she was talking and pointed the gun at her as soon as she got outside. She said she heard CNA C ranting and raving that she was tired of people telling her what to do. She said when CNA C pointed the gun at her, she (CNA C) was about one or two feet away from the building and about three feet away from her. She said CNA C stood right by residents' windows. She said the police found the bullet shell next to building where she shot the gun. She said after CNA C pointed the gun at her, she backed up and pointed it in the air and fired. She said she did not know CNA C had a gun in building before the incident. She said she previously heard CNA C say they would not catch her like that again. She said CNA C was referring to an incident with some other nurses who attacked her. She said CNA C never reported that incident, but other staff knew because she was upset about it. She said CNA C told her the nurses were in her face and talking loudly because she gave a resident the wrong food tray. <BR/>In an interview with LVN V on 01/22/2024 at 12:20 p.m., she stated on 01/18/2024, she had the on-call phone and RN A called her to say there were two staff at the nurse's station fighting. She said she asked RN A what the situation was, and RN A said she and other staff pulled them apart and they walked out of the building. She said she called the DON, and the DON said the staff had to write a statement and leave the building. She said when she called CNA B and told her she needed to leave, CNA B went off on her (got very angry). She said CNA B told her she would not give her a statement. <BR/>In a telephone interview with the VP of Operations on 01/22/2024 at 12:40 p.m., she stated she was first notified of the incident the morning of 01/18/2024, when the Administrator called her. She said she told the Administrator to interview staff who witnessed the incident and call the police. She said when she arrived at the facility on 01/18/2024, they started safe survey interviews with all residents on the 100 hall, where the staff fought and on the 200 hall, where the staff was when she shot the gun. She said they talked to all staff who worked that day and sent a mass email to each resident's RP and family about the incident. She said they held a resident council meeting and staff meeting where they offered counseling to anybody who needed it. She said they contracted to have security in building because they were not aware if the shooter was arrested. She said CNA C called her when she was on her way to the building and she and CNA B did not have any incidents before that morning. She said CNA C told her that she and CNA B were cool because there was a previous incident where some nurses were trying to discipline her, and CNA B took up for her. CNA C said the incident started when she transferred a resident. She said CNA C told her CNA B said she did it incorrectly, but she previously observed CNA B transfer the resident that same way. She said CNA C told her CNA B said she never saw her do it that way, then they got into it (had a verbal altercation). She said CNA C told her CNA D was in between them and pulled her back while CNA B landed a lick (hit her) and RN A jumped in to get them apart. She said CNA C told her CNA B left, saying she did not have time for that while CNA D and RN A held her back. She said CNA C told her she told RN A and CNA D she was getting her bag and bus pass so she could leave for the day, and they eventually let her go. She said CNA C told her she proceeded out of the building thru the same door CNA B left from so she could walk towards the bus stop. She said CNA C told her she had the gun for her protection. She said she told CNA C it was a felony to go into a skilled nursing facility with a gun and the corporate office called the police. She said CNA C told her she had also called the police herself because they were trying to jump her. She said CNA C said there was a lot of staff outside, but after speaking to staff, they found that nobody else said they were outside. She said the other staff were inside trying to keep CNA C from going outside and nobody was outside trying to jump her. She said CNA D went outside after CNA C. She said the police had already gone to building by the time she arrived, and the shell was found in the parking lot. She said they completed staff education and counselors were going to talk to those who expressed uneasiness about the incident. She said none of the residents stated they were disturbed. She said Resident #2 and Resident #3, who were in the room where the incident started, did not have concerns. She said they had psych (psychiatric) services see both residents to make sure. She said they in-serviced all staff that if you see something, say something. She said they also educated staff on anger management, reporting, abuse/neglect, and having a gun in the facility. <BR/>Observation and interview with Resident #2 on 01/22/2024 beginning at 1:30 p.m., revealed he was a larger male who self-ambulated in an electric wheelchair by using his chin to maneuver the controls. Resident #2 could not move his limbs. He stated CNA C was in his room getting him dressed the day of the incident. He said he usually got up at 7:00 a.m., but it was 6:00 a.m. when CNA C got him up. He said CNA C got frustrated and he got frustrated. He said when CNA B came, she was really calm. He said he heard CNA B say, I don't know how you did things where you came from, but around here, this is how we do it. He said the staff were arguing in the hallway but then things got physical when CNA C hit CNA B first. He said CNA C's arm went from down low and then down on CNA B's shoulder, like a windmill. He said the staff went down to the nurse's station, so he could not see anything after that, and he did not know how it ended. He said CNA D came up and stood beside them and did not get involved at all. Resident #2 said he was already in his chair during the incident, but the chair was not on. He said he was upset because CNA C said she was going to go get other residents up, and he told her she could not abandon him like that. He stated he felt safe at the facility, and he did not have any concerns because it was two girls fighting. <BR/>In an interview with CNA D on 01/22/2024 at 1:40 p.m., she stated she worked the 6:00 a.m. - 2:00 p.m. shift. She stated there were no prior incidents between CNA B and CNA C that she knew of. She said CNA C told her she had an issue with some of the nurses because she got into it (had verbal altercations) with them the weekend before the gun incident about a wrong food tray. She said CNA C told her that she and the nurses argued, it got heated, and they went into the MDS office where they yelled in her face. She said CNA C received a verbal warning, but she felt she should not have gotten anything. She said CNA C said they were going to stop playing with her (stop harassing her), but she never said she was bringing a gun to the facility. She said she heard CNA B and CNA C arguing down the hall. She said the argument was about getting a resident up because CNA C said she saw other staff do it that way and she was tired of people telling her how to do her job. She said CNA C said she had gotten Resident #2 up safely so what did it matter. She said she saw both of their hands going up in each other's face and they were fanning each other's hands down. She said she told them to stop because they would lose their jobs. She said CNA C said, You stole me (hit me), oh no bitch, you stole me! She said she and RN A got between them, but they were going around them. She said CNA C said, I got something for you. She said CNA B had already gone outside and invited CNA C to go meet her outside. She said CNA C got her stuff, but they tried to keep her inside. She said CNA C said, I got something for this bitch. She said CNA C's bag was in the open area under the desk at the nurse's station. She said she and the MDS Nurse were standing at the door trying to calm CNA C down. She said the MDS Nurse said she would call the police if they fought. She said they tried to keep CNA C from going outside, but once she went outside, she instantly started digging in her purse and she came out of the purse with something. She said she and the MDS Nurse were right at the door with CNA C. She said she heard CNA B say, Oh you gone point the gun at me! She said CNA C then raised the gun and shot in the air. She said CNA C was on the sidewalk, near resident rooms when she shot the gun. She said CNA C was about a yard from the building and she was about a yard from CNA B. She said CNA C said, Ya'll bitches gone stop playing with me. She said CNA C said she quit and the MDS Nurse said, We already knew that. She said CNA C could have gone out the front door to catch the bus instead of going out the side door. She said the residents were getting up at that time. <BR/>In an interview with Resident #3 on 01/22/2024 at 2:17 p.m., he stated the incident started in his room and then went to the nurse's station. He said he did not know how it started, but he saw one hit the other. He said one staff swung her hand back, but he did not know if she meant to hit the other staff, or if she just landed one accidentally. He said after that, he went outside and saw two police officers at the facility. Her stated he still felt safe in the facility. <BR/>In a telephone interview with RN A on 01/23/2024 at 12:52 p.m., she stated she was waiting for her relief on 01/18/2024 when she CNA C went and got her because she was having issues with Resident #2's wheelchair. She said when she went to the room, she told CNA C she was not sure how to work the wheelchair, but she would get someone who knew. She said she noticed Resident #2 was already in his chair, so she asked CNA C how she got him in there. She said CNA C said she transferred him by herself. She said she told CNA C it was not safe for her to do that, but she said she could do it that way. She said she told CNA C she needed to get someone else to help her with Resident #2. She said she went to find someone to help control Resident #2's wheelchair and saw CNA B with CNA D in front of the nurse's station. She said she told CNA B that CNA C had already gotten the resident up by herself and that she needed help with the controller on Resident #2's wheelchair. She said CNA B went to the room and then she heard some sounds coming from down the hall. She said she heard someone say, Stop fighting. She said the staff were very close together and one hit the other, but she did not know who hit who first. She said CNA B left the building because she was upset, and they tried to calm CNA C down and told her she could not go outside because CNA B was still out there. She said CNA C kept yelling that she had to get out. She said CNA C took her backpack and left the building. She said by that time, she went out of the building and heard the gunshot. She said she did not go to the door with the other staff. She said she did not hear anybody say anything about a gun while they were inside the building. <BR/>In a follow-up interview with the Medical Records Coordinator on 01/24/2024 at 10:15 a.m., she stated after CNA C got into an altercation with the nurses when they were all in her face, CNA D said she (CNA C) told her, I am not gone worry about it because I got something for them. She said after the shooting incident, CNA C called her and said of course she had a gun because she went to school at night on the bus. She said when she went outside after the shooting incident, she heard CNA B tell CNA D, You been knew she had a gun? Why didn't you tell me? The Medical Records Coordinator said CNA D said she already knew CNA C had a gun in the building. <BR/>Record review of the facility's 'Workplace Violence policy, revised 01/2022 revealed, The facility seeks to provide a safe workplace for all team members and has Zero Tolerance toward any type of workplace violence committed by or against team members. Team members are prohibited from making threats or engaging in violent activities. This list of behaviors, while not inclusive, provides examples of conduct that is prohibited. Causing physical injury to another person; Making threatening remarks; Aggressive or hostile behavior that creates a reasonable fear of injury to another person or subjects another individual to emotional distress; . Possession of a weapon while on facility property or while on facility business; . Any potentially dangerous situations must be reported immediately to a supervisor . Threats, threatening conduct, or any other acts of aggression or violence in the workplace will not be tolerated. Any team members determined to have committed such acts will be subject to disciplinary action, up to and including termination .<BR/>Record review of the facility's policy on Firearms and Other Weapons revised 01/2022 revealed, All applicants, associates, contractors, subcontractors, or any other persons are prohibited from using or possessing (whether concealed or not) any weapons while on company premises, engaged in company business, or at company-related activities. The company follows state and federal laws regarding concealed weapons, and to the extent this policy conflicts with any such law, the applicable law governs.<BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by the DON on safe transfers, including Hoyer Lifts and two-person transfers. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by RN A on reviewing each resident's Kardex (a quick reference for nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) on the plan of care and requesting assistance before providing care. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by the physical therapy department regarding Resident #2's motorized wheelchair, including operation, drive mode, tilting, chin joystick, and recharging. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated by the SW regarding workplace violence and reporting incidents of bullying, harassment, and retaliation and possession of a weapon. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated by the SW regarding Abuse and Neglect. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 02/07/2024 at 9:40 a.m. The DON was notified. The DON was provided with the IJ template on 02/07/2024 at 9:40 a.m. A Plan of Removal was requested at that time. <BR/>The following Plan of Removal submitted by the facility was accepted on 02/08/2024 at 11:52 a.m. :<BR/>The facility failed to ensure that resident environment remained free of accidents and hazards.<BR/>1. <BR/>Immediate Action Taken<BR/>* <BR/>Identified staff were immediately suspended on 1/18/24 and police notified on 1/18/24. The residents that were located near were assessed by the Social Worker and Licensed Nurse to be offered the opportunity to have grief counseling by Psych Services to monitor for Post Traumatic Stress completed on 1/18/2024.<BR/>* <BR/>On 2/7/24 the social worker and Director of Nurses (DON), started education with all staff on the company policy for workplace violence, Use of clear bag policy at the community, and abuse and neglect, completed on 2/7/24. Employees that missed the in-service will not be allowed to work until this education has been completed. <BR/>* <BR/>The company will purchase clear bags for all employees to carry personal belongings into the facility in-service initiated on 1/19/24 and completed on 1/22/24. Clear bag policy was posted all over the community on 2/7/24. <BR/>* <BR/>The social worker and Director of Nursing initiated in- serviced to all staff on handguns prohibition policy, this will be completed on 2/8/24, all staff not available for the in-service will not be allowed to work until the in-service is completed with them. <BR/>* <BR/>An In-service by the Social Worker and corporate HR was started on 1/18/2024 to also provide grief counseling information from the employee through the employee's insurance company. This counseling was an immediate offer and is still available. There is no completion date because it is ongoing. Completed 1/18/2024 and ongoing. <BR/>2. <BR/>Identification of Residents Affected or Likely to be Affected: <BR/>* <BR/>On 1/18/2024 the DON and Social Worker completed the audit for any resident who was near and wanted therapy. We identified no residents that wanted therap[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the physician and notify the resident representative when the resident experienced a change in condition for 1 of 22 residents (CR #1) reviewed for a change of condition:<BR/>-The facility failed to immediately inform CR#1's physician after a change in condition. <BR/>-The facility failed to notify the Physician when CR #1 had a choking episode on 04/22/24 and experienced a change in condition.<BR/>-The facility failed to notify CR #1's RP when she experienced a change in condition <BR/>- CR #1 passed away on 04/27/202418 at the hospital.<BR/>An IJ was identified on 04/29/24. The IJ template was provided to the facility on [DATE] at 12:54 PM. While the IJ was removed on 05/03/2024 at 12:24PM, the facility remained out of compliance at a scope of isolated and a severity of harm with potential for more than the minimal harm that is not an immediate jeopardy because all staff had been trained on to notify the physician when a resident experience a change in condition. <BR/>These failures could affect residents in delay of appropriate medical treatment leading to death.<BR/>Findings included:<BR/> Record review of CR #1's face sheet dated 04/25/2024 revealed an 83year old female admitted to the NF originally on 07/22/2022 and again on 09/17/2023 with diagnoses that included the following: Alzheimer's Disease (disease that destroys memory) with late onset, dysphagia (difficulty swallowing) diagnosed 11/09/2022, heart disease, and cerebral infarction (disrupted blood flow to the brain). <BR/>Record review of CR #1's MDS dated [DATE] reflected BIMS score 00 indicating resident cognition was severely impaired. Further review of section K (swallowing/Nutrition Status) reflected that CR #1 had no s/s of possible swallowing disorder. Further review of the MDS section GG reflected that CR #1 required setup or clean-up assistance. <BR/>Record review of CR #1's Physician Order Summary Report for the month of April 2024 included the following orders:<BR/>-Dated 10/10/23 carb controlled no added salt mechanical soft texture, regular consistency.<BR/>-Dated 07/20/23 may crush meds/open capsule every 12 hours for safety.<BR/>-Dated 04/23/2024 SLP evaluation.<BR/>-Dated 04/25/2024 Comprehensive swallow consult including MBSS to assess aspiration risk, r/o silent aspiration, determine least restrictive diet texture, assess esophageal function and physician consult for dysphagia include appropriate nutritional status.<BR/>Record review of the Screening Tool done by the NF Rehab Director on 04/24/24 reflected in part:<BR/> .DON referred PT for ST services for dysphagia management. No s/s of swallow impairment noted at this time however ST to complete eval and schedule MBSS to r/o silent aspiration .<BR/>Record review of CR #1's Speech Therapy note dated 04/25/2024 recommended thin liquids and mechanical soft/ground textures, puree (creamy paste) consistencies.<BR/>Record review of CR #1's Care Plan updated 12/10/2023 did not reflect that CR #1 was being care planned for dysphagia.<BR/>Record review of CR #1's Nursing Progress Notes dated 04/25/2024 documented by RN B at 19:55 (8:55PM) reflected in part:<BR/> .CR #1 was wheeled from the dining room to the nurse station by CNA at about 5:30PM with no sign of distress or discomfort. At about 5:45PM, CNA call out that resident was unresponsive on the wheelchair by the nursing station. Code blue activated, CPR done, oxygen connected, AED used, 911called. 911 arrived and took over the resident resuscitation. 911 later transferred the resident to hospital for further management, family member was notified of resident condition. NP also notified . <BR/>Record review of CR #1's INTERACT Change in Condition dated 04/25/2024at 19:17 (7:17PM) reflected in part:<BR/> NO pulse, no respirations2.This condition, symptom or sign has occurred before: H 1. Yes 2. No 3. Unknown3.Other relevant information: HResident was noticed by a CNA/Nurse in the Hallway drooling by mouth, and choking on food. Quickly, resident was assisted to the floor, a sweep of the mouth, the Heimlich maneuver given, nausea and vomiting small amount of food.4.Summarize your observations, evaluation and recommendations: HPt lost consciousness, with no pulse and no respiration. Signaled to call 911 and CPR began, oral suctioning required and AED utilized although no shock required. 1845 EMT arrived assisting with CODE. ET Tube placed with moderate suctioning and IV NS started in right arm. Pt regained pulse but Medic continued to give breaths per Ambu bag. Pt transported to Hospital. MD, DON, Administrator and daughter notified.5.Have you reviewed and acknowledged <BR/>Interview on 04/26/24 at 2:00PM, the DON said the incident happened on 04/22/2024 around 6:00PM or a little after could not remember the exact time. The DON said CNA A was standing in the hallway calling for help. The DON said when she arrived at the scene, she observed CR #1 had been placed on the floor by staff members. The DON said the nurses had already initiated CPR and that she began to assist with the CODE ensuring that 911 services had been called. The DON said CR #1 had a weak pulse and was not breathing. The DON said CR #1 was not choking and believed that CR #1 had experienced a mini stroke. <BR/>Interview on 04/26/24 at 2:11PM, the Administrator said the NF had called the hospital where CR #1 was transferred to and that the hospital informed that CR #1 had to be intubated and placed on a ventilator. <BR/>Interview on 04/26/2024 at 2:16PM, the RP said he was not notified by the NF that CR #1 had choking episode on 04/22/2024. Further interview with the RP said he was not notified on 04/25/2024 when CR #1 experienced a change in condition.<BR/>Interview on 04/26/24 at 3:06PM, with CNA A said she worked at the NF full time on the 2PM-10PM shift. CNA A said the time was around 5:30PM-6:00PM on 04/25/2024 when CR #1 was being wheeled from the Dining Room by another CNA who's name, she could not recall. CNA A said CR #1 was placed across facing the nurse station. CNA A said CR #1 did not have any front teeth and therefore was unable to chew food well and could not swallow good. CNA A said at one time, CR #1 was on a puree diet, was later upgraded to a mech soft diet. CNA A said on 04/22/24 CR #1 choked off her food while feeding her in bed during dinner time. CNA A said CR #1 was eating potato soup. CNA A said she tried to help CR #1 when she started choking but was unsuccessful and therefore called LVN W who never came to CR #1's room. CNA A said the oncoming nurse LVN B came to the room and just looked at CR #1. CNA A said it was CNA I that helped by pulling CR #1 forward in bed and began to give hand thrust to CR #1's back. CNA A said the food came up which was some potatoes and other undigested food. CNA A said CR #1 appeared to be okay after that incident. CNA A said she told LVN W and LVN B that CR #1's diet needed to be changed. CNA A said she also told the DON as well that CR #1 had experienced choking on 04/22/2024. CNA A said she had informed the DON on 04/22/23 at 7:30PM and that the DON was preparing to leave the NF to go home. CNA A said RN E told her that it was a chain of commands for CR #1 to be assessed by the Speech Therapist which was to inform the ADON. CNA A said she also informed the Speech Therapist who said that he would need an order to assess CR #1. CNA A said RN E told her that she would notify the ADON. CNA A said she went to the Speech Therapist on 04/23/24 in the evening and told him about CR #1's choking episode on 04/22/24. CNA A said the Speech Therapist told her that he would need an order. CNA A said she had informed the Administrator verbally on 04/23/24 and the Administrator told her to write a statement. CNA A said she wrote a statement at 11:34AM on 04/23/24 and send it to the Administrator via e-mail regarding CR #1's choking incident on 04/22/24. CNA A said she did not want the surveyor to say anything to the Administrator because she did not want to lose her job. CNA A said she went to the kitchen on 04/25/24 and told them what food to give CR #1. CNA A did not elaborate on the exact food she told them to give CR #1 but told them to give CR #1 soft texture foods that did not require CR #1 to chew a lot. CNA A said the kitchen gave CR #1 a mechanical soft diet. CNA A said on 04/25/24 at 5:30PM or 6:00PM at the nurse station saw CR #1 leaning to her side drooling at the mouth with food in her mouth. CNA A said nurse LVN C was trying to get the food out of CR #1's mouth. CNA A said LVN C began to hit CR #1 in the back, but CR #1 was not responding. CNA A said herself and LVN C transferred CR #1 on the floor and at this time CR #1 was completely unresponsive. CNA A said she started screaming for help and 911 was called. CNA A said after that she did not know what took place next because she went to see if 911 had arrived so she could direct them to the hall CR #1 was residing on. <BR/>Interview on 04/26/24 at 3:45PM CNA I said she worked the first shift 6AM-2PM mainly but did work over sometimes on the evening shift. CNA I said the first time she observed CR #1 choking was on 04/22/24 after 5:50PM. CNA I said she believed that it was CNA A that called her to come and assist with CR #1's choking episode on 04/22/2024. CNA I said CNA A was standing in the hallway calling for help. CNA I said there was a new nurse caring for CR #1 who's name she could not recall. CNA I said CR #1 was choking when she entered her room. CNA I said she immediately pulled CR #1 forward in bed trying to relieve the choking. CNA I said the food did come up and that the new nurse was just standing on the side of CR #1's bed looking. CNA I said they continued to let CR #1 sit up in bed and they continued to monitor CR #1 for any further choking. CNA I said CNA A said she was going to report the incident. CNA I said CR #1 appeared to be okay for the remainder of the shift. CNA I said the next morning when she returned to work, she told RN E that CR #1 needed to be gotten out of bed for her meals due to the choking episode on 04/22/2024 and RN E agreed.<BR/>Interview on 04/26/24 at 5:19PM via phone LVN B said she worked the 6PM-6AM shift PRN. LVN B said the last time she worked at the NF was on 04/22/24 and 04/23/24. LVN B said CR #1 did not have any issues with chocking. LVN B said CNA A was feeding CR #1 in bed on 04/22/24. LVN B said CR #1 was being fed soup along with some type of salad with chunks of chicken chopped up in it. LVN B said CR #1 was not choking, but just not tolerating the texture of the food. LVN B said CR #1 had tea or apple juice as a beverage. LVN B said she heard CNA A calling for help and when she arrived to CR #1's room, CR #1 was able to follow commands and did spit the food out. LVN B said CNA A was in a complete uproar and got overly excited. LVN B said the incident was mentioned to the DON who came on the unit. LVN B said the DON said she would take care of the matter. LVN B said she did not call the physician because the DON said she would take care of it. <BR/>Interview on 04/26/24 at 5:52PM, the DON said it was CNA A that came to her on 04/22/24 around 8:00PM telling her that CR #1 was having difficulty swallowing. The DON said she put an order in on 04/23/24 for CR #1 to be evaluated by the Speech Therapist but did not call the NP or the physician. The DON said she told the NP when she was at the facility on 04/25/24 and the NP said that was good. The DON said she had not in-serviced the Nursing staff on silent aspiration/choking. The DON said the s/s of silent aspiration were pocketing food, difficulty in breathing, increase heart rate, and change in skin color. Further interview with the DON said the reason she did not call the physician when told that resident had choked on her diet was because she got ahead of herself and just wrote the order. The DON said the physician should have been notified first before she put an order in for CR #1 to be evaluated by Speech Therapist because that was the normal process. <BR/>Interview on 04/27/24 at 12:25PM with LVN C, said she worked the 6p-6a shift. LVN C said on 04/25/24 the incident happened before her shift started. LVN C said the staff were bringing the residents back from the dining Room after eating dinner. LVN C said CNA A asked if CR #1 was choking. LVN C said the time was around 5:30PM. LVN C said she observed CR #1 choking and not breathing. LVN C said her and a CNA (name she could not remember) transferred resident to the floor after removing food from resident mouth and performing the Heimlich maneuver which was unsuccessful. LVN C said CPR was initiated. LVN C said during this time she told a staff member to call 911. <BR/>Record review of the NF's policy on Change in a Resident's Condition or Status revised May 2017 revealed in part:<BR/> .Our facility shall promptly notify the resident, his or her attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition .<BR/>The facility Administrator and DON were notified on 04/27/2024 at 3:16PM that an IJ situation had been identified due to the above failures. The IJ templated was provided to the Administrator on 04/27/2024. <BR/>Interview on 04/28/24 at 11:45AM RN E said she worked the 6:00AM-6PM and that she was not aware of CR #1 choking on her food. <BR/>Interview on 04/29/24 at 9:46AM, the NP said she was at the NF and saw CR #1 but could not remember the exact date. The NP said CR #1 was fine. The NP said the NF never informed her that CR #1 experienced a choking incident on 04/22/24. The NP said she later received a text from RN E on 04/25/24 informing that CR #1 was unresponsive and 911 had to be called. The NP said the DON's mistake was putting an order in without consulting her first. The NP said had she informed her when the incident happened, she would have put interventions in place such as changing the resident's diet and given further orders to assess resident swallowing to prevent resident from aspirating. <BR/>Further interview on 04/29/24 at 11:58AM, with the DON she said when a resident experiences a change in condition the staff were supposed to notify the physician immediately. The DON said she told the primary care nurse LVN B to notify the physician on 04/22/2024. The DON said if the nurse was unable to get in contact with CR #1's physician, the next step would be to notify the Medical Director.<BR/>Attempted interview via phone on 04/29/24 at 12:19PM with the NF Medical Director was unsuccessful. The Medical Director was left a voicemail with a call back number.<BR/>Interview on 04/29/24 at 2:30PM with the ADON said she had been working at the facility for a little over a month. The ADON said none of the nurses or CNA's had informed her that CR #1 choked on her food. The ADON said if they had, she would have called the doctor or NP to get an order for a swallow evaluation and notified the family. <BR/>Interview on 04/30/24 at 1:13PM, CNA N said she had taken care of CR #1 in the past and had observed CR #1 pocketing her food in her mouth at times. CNA N said she did report these happenings to RN E. <BR/>Interview on 04/30/24 at 1:34PM with CR #1's primary care doctor via phone said the NF never notified her that CR #1 had a choking episode on 04/22/24. The Doctor said CR #1 was on a mechanical soft diet and was high risk for choking. The Dr. said if the facility had notified her of resident choking episode on 04/22/24, she could have given prophylactic orders that consisted of the following: place CR #1 on NPO or liquid diet until a barium swallow test was done, placed CR #1 on antibiotics, and started breathing treatments. The doctor said CR #1 may have aspirated on 04/22/24 and that these would have been the measures she would have considered because aspiration could lead to pneumonia.<BR/>Interview on 05/01/24 at 3:22PM via phone CNA D said she worked at the NF PRN. CNA D said CR #1 had a choking episode on a Sunday prior to the incident on 04/22/24. CNA D said the nurse on duty was RN E. CNA D said she notified RN E but did not know what she had done about it. <BR/>Interview on 05/02/24 at 2:30PM LVN W said no one ever told her that CR #1 was choking on her food. <BR/>Further interview on 05/03/24 at 12:12PM the DON said she believed the reason the NF received an IJ was because of the facility failing to follow-up with the physician immediately when CR#1 experienced a choking episode on 04/22/24. <BR/>The following plan of removal was accepted on 04/30/2024 at 7:22PM.<BR/>PLAN OF REMOVAL<BR/>Date: 04/30/2024<BR/>The facility failed to immediately inform CR #1's physician after a change in condition.<BR/>The facility failed to notify the Physician when resident had a choking episode on 04/22/24. <BR/>What corrective actions have been implemented for the identified residents? <BR/>On 4/22/2024 resident CR#1 involved in failed practice was discharged to the hospital per MD orders on 4/25/2024.<BR/>On 4/27/2024 at 4:00pm the Facility Administrator notified the Medical Director, and the attending physician of failed practice. <BR/>Change of condition policy/ Procedure was reviewed by IDT, no changes were made: Completed 4/27/24<BR/>The DCO completed audit of all residents with change of condition in the last 30 days, the physicians were notified of all changes: Completed 4/27/24<BR/>In-services provided to DCO.<BR/>On 4/27/2024 the following in-service was provided to the Director of Clinical Services (DCO) by the Regional Director of Clinical services (RDCO)<BR/>1. <BR/>Notifying the Physician Immediately of Change of Condition Occurs and Obtaining Orders from the Physician before treating the Resident.<BR/>2. <BR/>On notifying resident's responsible party on changes of condition and new intervention that was put in place, completion date 4/27/2024.<BR/>In-services provided to Licensed Nurses<BR/>On 4/27/2024 the DCO initiated in-services for facility charge Nurses on the following:<BR/>I. <BR/>Change of condition in relation to swallowing/aspiration difficulties or choking episode, and to notify resident's attending physician of these changes immediately completion date 4/28/2024. <BR/>II. <BR/>1:1 in-service conducted with LVN B by the DCS regarding physician notification completion date 4/28/2024<BR/>CNA education provided are below.<BR/>C N A 's in-service on notifying License Nurses concerning change in conditions and documentation in POC documentation. completion date 4/28/2024<BR/>Nursing staff will be in-service on the plan before the start of their shift.<BR/> Validation/Monitoring<BR/>The DCS/Designee reviewed residents' last SLP referrals no corrections as of 4/28/2024.<BR/>Facility IDT reviewed policy/procedure of aspiration, swallowing precautions, therapy referrals, no revisions needed. Completion date 4/28/2024.<BR/>What does the facility need to change immediately to keep residents safe and ensure it does not happen again.<BR/>A. <BR/>The DCN/Designees will review all changes in condition and therapy referral in daily clinical meetings and ensure follow is completed timely, staff monitoring is in place, the RP/MD is notified of changes and new recommendation if followed. Completed 4/28/24.<BR/>B. <BR/>The Director of Clinical Services will ensure Licensed Nurses notify the Physician Immediately of Change of Condition Occurs and Obtaining Orders from the Physician before Treating the Resident completed: 4/28/2024.<BR/>C. <BR/>Newly hired nurses will be in-serviced by the Director of Nursing or designee on immediately notifying the attending physician of residents change of conditions, obtaining orders for therapy screening and evaluations as needed. <BR/>Quality Assurance<BR/>An Ad Hoc Quality Assurance and Performance Improvement review of the plan of removal was completed on 4/27/2024 with the Medical Director. The Medical Director has reviewed and agrees with this plan.<BR/>________________________________________________________________________________________________<BR/>The surveyors confirmed the plan of removal had been implemented sufficiently to remove IJ by the following:<BR/>Note: Due to initial IJ being called on 04/27/2024 at 3:16PM, the NF had begun the process in in-servicing staff on notification of change in a resident condition by 04/30/2024, therefore the surveyors began the monitoring process as follow: <BR/> Interview on 04/30/24 at 11:25AM with RN E said she worked on Station B 6AM-6PM. RN E said she had just received in-service on notify the physician as well as the RP when a resident experience a change in condition.<BR/>Observation on 04/30/24 at 11:35AM of Station B across from the nurse station revealed residents sitting in their w/c's dressed in street clothing with no concerns identified.<BR/>Interview on 04/30/24 at 11:42AM with CNA F on Station B said that she worked the morning shift 6AM-2PM. CNA F said she had received in-service on what to do if a resident began to choke while eating. The CNA said she would call for help and would begin to try and clear the resident airway by providing the Heimlich maneuver. The CNA said some s/s/ of silent aspiration was resident having difficulty breathing, change in their facial appearance and skin color. The CNA said if she observed a resident having difficulty swallowing their food or pocketing their food, she would notify the nurse right away so that the resident could be assessed. The CNA said she was in-serviced to notify the nurse whenever she noticed a change in resident condition.<BR/>Interview on 04/30/24 at 11:50AM with CNA Y said she worked the 6AM-2PM full time. CNA Y said she had been in-serviced on notifying the nurse when residents had a change in condition, s/s of silent aspiration were discoloration in the face, change in facial expression, and difficulty breathing. CNA Y said if the resident was choking, she would give them the Heimlich maneuver to try and help the resident clear the air way. CNA Y said she had been in-serviced to review the resident POC in the computer.<BR/>Interview on 04/30/24 at 11:58AM with the Wound Care Nurse said she worked at the NF Monday through Friday and did assist with monitoring the residents during mealtimes. The Wound Care Nurse said she had been in-serviced on choking and how to apply the Heimlich maneuver. The Wound Care Nurse said if the resident became unresponsive, CPR had to be initiated immediately and call 911. The Wound Care Nurse said s/s of silent aspiration were drooling at the mouth, skin discoloration of the face, difficulty breathing, and perspiring. The Wound Care Nurse said the physician and the RP had to be notified immediately when a resident experiences a change in condition and the care plan had to be updated. <BR/>Interview on 04/30/24 at 12:07PM with CMA K said she worked the Memory Care Unit and worked the morning and evening shift. CMA K said she had been in-serviced on choking and silent aspiration. CMA K said s/s of silent aspiration was drooling at the mouth, perspiring, difficulty breathing, and change in skin color. CMA K said if a resident was choking, she would call for the nurse and apply several back blows, if that was unsuccessful, she would do the Heimlich maneuver. CMA K said the incident must be reported to the nurse immediately as any change in condition. CMA K said when feeding a resident, she had to feed them slowly being careful to offer them fluids in between eating.<BR/>Interview on 04/30/34 at 12:14PM with CNA L said she worked the Memory Care Unit 6AM-2PM and been in-serviced reviewing the resident plan of care in POC, monitoring the residents for choking or s/s of silent aspiration and that all changes in condition were to be reported to the nurse. CNA L said resident had to observed closely during mealtimes and if notice a resident choking call the nurse immediately and do the Heimlich maneuver to held dislodge what was blocking the resident airway. CNA L said s/s of silent aspiration was drool at the mouth, difficulty breathing, bulging of the eyes, change in skin color, and grabbing their neck. CNA L said the incident had to be reported to the nurse so that the nurse could call the doctor as well as the family. <BR/>Interview on 04/30/24 at 12:20PM with RN M said she worked the 6AM-6PM shift and had been in-serviced on notifying the physician whenever a resident experience a change in condition. RN M said she had been in-serviced on the s/s of silent aspiration (drooling at the mouth, difficulty breathing, change in the color of resident skin) and choking. RN M said if a resident experienced this, the doctor had to be notified right away to get an order for a swallow evaluation and possible diet change. RN M said the resident care plan also had to be updated and the RP notified. <BR/>Observation on 04/30/24 at 12:32PM in the Dining Room revealed lunch being provided to the residents with over 6 staff members being present, one being the Wound Care Nurse. There were no concerns identified. <BR/>Observation on 04/30/24 at 1:05Pm in the MCU revealed the residents eating their lunch with staff members being present. There were no concerns identified. <BR/>Interview on 04/30/24 at 1:13PM with CNA N said she normally worked the morning shift. CNA N said she had been in-serviced on when a resident was choking to give the Heimlich maneuver. CNA N said s/s of silent aspiration was difficulty breathing, watering of the eyes, drooling at the mouth, and possible reaching for their throat. CNA N said she would try and clear resident airway by giving thrust in the back and then proceed with the Heimlich maneuver. CNA N said she would notify the nurse on all changes in a resident condition. CNA N said she was in-serviced to review the resident care plan. <BR/>Interview on 04/30/24 at 2:38PM with LVN O said he was in orientation and was hired to be a Unit Manager. LVN O said he had received in-service on checking the crash cart, that if the resident was choking to perform the Heimlich maneuver. LVN O said if the resident lost consciousness, he would have someone call 911 and he would start CPR right away. LVN O said some s/s of silent aspiration were the following: short of breath, wheezing, eyes bulging, perspiring, trying to clear their throat, drooling at the mouth, pocketing food. LVN O said the doctor had to notified in both incidents as well as the RP. LVN O said resident care also had to be updated regarding the incident.<BR/>Interview on 04/30/24 at 2:47PM with CNA I said she worked the morning and evening shifts and had been in-serviced on how to do the Heimlich maneuver, chest thrust if a resident was choking. CNA I said the nurse had to be notified of all changes in a resident condition. CNA I said she was in-serviced on recognizing some s/s of silent aspiration (change in a resident facial expression, drooling at the mouth, wheezing or difficulty breathing). CNA I said she was in-serviced that when having to feed a resident, to take her time and feed them slowing being aware to provide resident their beverage between feeding during meal service. CNA I said she was also in-serviced to review resident care plan in POC.<BR/>Interview on 04/30/24 at 8:00PM with CNA P via phone said he worked the night shift 10PM-6AM. CNA P said he had been in-serviced in the following: POC regarding the resident plan of care, choking and how to apply the Heimlich maneuver, back blows and chest thrust, and reporting change in condition. CNA P said the nurse had to be notified if he witnessed a resident choking. CNA P said he was also in-serviced on silent aspiration.<BR/>Interview on 04/30/24 at 8:08PM with CNA J said she worked the night shift 10PM-6AM. CNA J said she received in-service on silent aspiration and choking, checking resident care plan in POC, and when feeding the resident to feed slowly observing for signs of choking and reporting to the nurse immediately all changes in a resident condition. CNA J said she had received in-service on resident plan of care that could be found in the computer.<BR/>Interview on 05/01/24 at 5:00AM with LVN S said she worked the 6:00PM to 6:00AM shift. LVN S said she had been in-serviced on choking and silent aspiration, the importance of notifying the physician when a resident experience a change in condition and making sure resident care plan was updated. <BR/>Interview on 05/01/24 at 9:14PM with LVN R said they worked the night shift 6PM-6AM. LVN R said they had been in-serviced on s/s of silent aspiration, choking and to notify the doctor and the RP. LVN R said they were also in-serviced on making sure that the resident care plan was updated whenever a resident experience a change in condition and checking the crash cart.<BR/>Interview on 05/02/24 at 10:30AM with LVN Q said he worked the 6AM-6PM shift and received in-service making sure a resident care plan was updated when there was a change in condition, notifying the doctor and the RP if the resident experience a change in condition, how to intervene if a resident experience choking, if the resident lose consciousness call for help and began CPR, the s/s of silent aspirations, and checking the crash cart each shift. <BR/>Interview on 05/02/24 at 11:25AM with CNA T said she worked the 6am to 2pm shift on the MCU. CNA T said she had been in-serviced on choking, performing the Heimlich maneuver, abuse and neglect, s/s of silent aspiration, reporting to the nurse when she observed a change in resident, and reviewing the resident plan of care in POC.<BR/>05/02/24 at 11:32AM Interview with the ADON said she was in-serviced on choking/silent aspiration, notifying the doctor and RP when there was a change in resident condition, updating the care plan right away when a resident have a change in condition.<BR/>Interview on 05/02/24 at 2:11PM with the MDS Nurse said she was in-serviced on care planning on how and what to care plan to ensure that each resident care plan was individualized and personalized. The MDS Nurse said she was also in-serviced on care planning for dysphagia, updating the resident care plan when a change in condition has occurred, notifying the physician of the change, s/s of silent aspiration.<BR/>Interview on 05/02/24 at 2:18PM CNA U said they worked 6AM-2PM received in-service on different techniques to open a resident airway when choking which were back and chest thrust, and Heimlich maneuver, s/s of silent aspiration and to report to the nurse all changes in a resident condition.<BR/>Interview on 05/02/24 at 2:30PM with LVN W said she worked the 6AM-6PM shift. LVN W said she had been in-serviced on abuse and neglect, choking, checking the crash cart each shift, notifying the physician if a resident experience a change in condition, and updating the care plan when there was a change in resident condition.<BR/>Interview on 05/02/24 at 4:28PM with CNA V said she worked the 2PM-10PM shift. CNA V said the NF had in serviced her on choking and s/s of silent aspiration (discoloration of the face, difficulty in breathing, and drooling of the mouth). CNA V said if a resident was choking, she would perform the Heimlich or thrust resident on the back. CNA V said she was in-serviced to let the nurse know if she witnesses this and to always look in POC for resident plan of care, and when feeding resident to feeding resident slowing making sure resident was not choking. CNA V said she was also informed to use any recommended utensil when feeding a resident that was high risk for choking.<BR/>Interview on 05/02/24 at 4:38PM with RN X said he worked the 6AM-6PM shift full time on Station C. RN X said he had received in-service on the following: s/s of silent aspiration (resident unable to speak, eyes watering, discoloration of skin to the face, drooling from the mouth, difficulty breathing). RN X said he would apply the Heimlich maneuver if a resident was choking and if the resident loss consciousness, he would have[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of (Residents #41, #26, #16, #46) of 14 residents reviewed for care plans. <BR/>- <BR/>The facility failed to ensure Resident #41 was care planned for hospice care <BR/>- <BR/>The facility failed to ensure Resident #16 and #46 were care planned for ADL's.<BR/>- <BR/>The facility failed to ensure Resident #26 was care planned for behaviors.<BR/>These failure could place residents at risk of not receiving care and services related to their identified needs.<BR/>Findings included: <BR/>Resident #41<BR/>1. Record review of Resident # 41's admission records face sheet dated 2/23/22 revealed he was [AGE] year-old male admitted to the facility 10/12/20 His diagnoses included Epilepsy, benign tumor (soft tissue tumors). Muscle wasting, urinary tract infection and age-related physical conditions. <BR/>Review of Resident #41's Physician Orders dated 05/07/21 revealed -admission to local Hospice <BR/>Record review of Resident #41's MDS assessment dated [DATE] revealed section O on specialized treatment, procedure and program was checked for hospice care.<BR/>Record review of Resident #41's care plan dated 05/04/21 revealed no care plan for hospice care. <BR/>During an interview with the facility DON on 02/24/22 at 2:00PM she said the MDS coordinators are responsible for ensuring that the MDS accurately reflect Resident's condition. <BR/> During an interview with MDS Nurse A on 02/24/22 at 3:30pm, he acknowledged that the care plan for Resident # 41 was not accurate. He said Resident # 41's care plan would be corrected to reflect their condition. He said he was responsible for ensuring that all MDS assessments reflect Resident's condition.<BR/>Resident #26<BR/>2. Record review of Resident #26's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, hypertension, and multiple sclerosis.<BR/>Record review of Resident #26's MDS, dated [DATE] revealed the resident's BIMS assessment was unable to be completed due to resident being never or rarely understood. The resident was not assessed to have any psychiatric disorders.<BR/>Record review of Resident #26's physician's orders, dated as of 02/22/2022 revealed the resident was taking clonazepam and buspirone for anxiety starting 12/17/2021, trazadone for sleep/depression starting 12/17/2021, Seroquel for bipolar disorder starting 02/17/2021.<BR/>Record review of Resident #26's care plan, as of 02/22/2022, revealed the only note made about resident's behavior was, . The resident has a behavior problem in which she sits on the floors and other objects despite encouragement not to do so. There were no other notes regarding resident behavior or psychiatric-related diagnoses.<BR/>Record review of Resident #95's face sheet revealed an [AGE] year-old male who was admitted on [DATE] and was diagnosed with cognitive communication deficit, psychosis and dementia. <BR/>Observations of Resident #26 and #95 on 02/22/22 at 10:30AM revealed Resident #26 sitting in a wheelchair while yelling at and cursing out surveyor after surveyor asked for CMA J and LVN R for location of a room number. Resident #26 was then observed passing nearby Resident #95 as he slept in the hallway on a Geri-chair. Resident #26 yelled wake-up while swiftly brushing Resident #95's cheek with her hand. CMA J was observed to quickly remove Resident #26 from Resident #95. Resident #26 was later observed to cry out loud while asking for her son.<BR/>In an interview with CMA J on 02/24/22 at 1:05 PM, she stated Resident #26 was aggressive, gets upset and calls her sons' name. She said the resident gets up to fight with staff as if she is preparing to defend her son. She went up towards Resident #95 on 02/22/22 and brushed his face she believed with the intention to get his attention so he could move out of the way. She usually does not fight other residents. <BR/>In an interview with LVN R on 02/24/22 at 1:50PM, she stated Resident #26's behaviors included shouting and looking for her children and when hearing a random person's voice, she thinks its her son talking. She does not harm residents but she touches residents sometimes with the intention of going where she wants to go or probably due to vision problems. She stated this type of behavior should be documented and care planned. <BR/>In an interview with the Administrator on 02/25/22 at 10:31AM he stated has never seen Resident #26 hit a resident before but he knows the resident has her outbursts due to her behaviors. He stated he expects behavior monitoring to be care planned for her psychiatric diagnoses as well as psychotropic medication usage.<BR/>In an interview with the DON on 02/25/22 PM, she stated Resident #26's only behavior that she had noticed was screaming and yelling. She stated she is on medications that have been adjusted by her psych provider. She said this type of behavior should be care planned. She stated they usually have care meetings on Friday with nurse department team and they make updates to resident care plans then. She said her care plan was likely missed because they did not talk about her behaviors during a meeting yet. She stated the implication of not care planning behaviors is not having care and needs followed up on with interventions and goals to manage behaviors in place<BR/>In an interview with MDS Nurse A and MDS Nurse B on 02/25/22 at 11:44AM, MDS Nurse A stated Resident #26 was initially in the secured unit and shows aggressive behavior and curses people out and therefore had to leave the secured unit. He said she admitted back into the facility's general community after getting her medications adjusted during her discharge. He stated behaviors settled down but slowly came back. MDS Nurse B said these behaviors should have been care planned and if the resident is on psych meds it should have been triggered in the care plan as well. <BR/>Resident #16<BR/>3. Record review of the face sheet for Resident # 16 revealed a [AGE] year-old female with initial admission date of 6/7/21, and re-admission date 2/15/22. Diagnoses included Schizophrenia, Bipolar disorder, anxiety disorder, dementia without behavioral disturbance, Epileptic seizures, hypertension, and Multiple Sclerosis. <BR/>Record review of the quarterly MDS dated [DATE] revealed Resident # 16 had unclear speech and sometimes understood and sometimes understands others. Resident # 16's BIMS score was 3 indicating severely impaired cognitive skills for daily decision making and required total staff assistance for bed mobility, transfer, dressing, hygiene, toileting, and bathing. <BR/>Record review of Resident# 16's care plan, undated, revealed there was no care plan developed for ADL's, including interventions for ADL assistance. <BR/>Observation and attempted interview with Resident # 16 on 2/22/22 at 9:40 am revealed she was in bed, awake and alert. Resident had clean linens, catheter bag at bedside draining clear urine, and an IV pole with medications being infused for UTI. Resident # 16 stated I'm tired and closed her eyes when an interview was attempted. <BR/>Observation and attempted interview with Resident # 16 on 2/23/22 at 9:15 am revealed she was in bed, awake and alert. Resident # 16 stated Who are you? Bye and closed her eyes when an interview was attempted.<BR/>Resident #46<BR/>4. Record review of the face sheet for Resident #46 revealed a [AGE] year-old male with admission date of 1/06/21. Diagnoses included Parkinson's disease, need for assistance with personal care, dementia without behavioral disturbance, Diabetes, hypertension, Schizophrenia, Benign Prostatic Hyperplasia (enlarged prostate), and paralysis following cerebral infarction (stroke). <BR/>Record review of the Annual MDS dated [DATE] revealed Resident # 46's cognitive skills for daily decision making were moderately impaired, and he required extensive assistance from staff for bed mobility, transfer, dressing, hygiene, toileting, and bathing. Record review of the Care Area Assessment (CAA) Summary revealed ADL/Functional/Rehabilitation Potential was not triggered. <BR/>Record review of Resident #46's care plan, undated, revealed there was no care plan developed for ADL assistance, including appropriate interventions for ADL care. <BR/>In an interview with MDS Nurse A on 2/24/22 at 10:10 am revealed ADLs were not triggered in the Care Area Assessment for Resident's # 16 and #46, so the care plan for ADL's was not developed. MDS Nurse A stated the care plans were developed from the comprehensive assessment for each resident, and if the CAA's are triggered for a particular area, a care plan would be done for that care area. <BR/>Record review of the facility policy Care Planning - Interdisciplinary Team, dated September 2013, revealed, in part: .the care plan is based on the resident's comprehensive assessment and is developed by the Care Planning/Interdisciplinary Team .<BR/>Record review of facility's provided care plans policy dated 2001 revised September 2013 read in part . our facility 's care planning/interdisciplinary team is the responsibility for the development of an individualized comprehensive care plan for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accidents and hazards as is possible for 22 of 22 residents reviewed for accidents and hazards. <BR/>1. <BR/>CNA B and CNA C engaged in a verbal and physical altercation in the presence of at least two residents, Resident #2, and Resident #3 on 1/18/24 at approximately 6:00 a.m.<BR/>2. <BR/>CNA C left a loaded firearm unattended inside her personal bag in an unsecured cabinet under the nurse's station desk located directly across from a resident TV area for an undetermined amount of days/time. <BR/>3. <BR/>CNA C pointed a loaded firearm at CNA B and discharged the gun outside in the air approximately one yard from resident-occupied rooms on 1/18/24.<BR/>An Immediate Jeopardy (IJ) was identified on 02/07/2024 at 9:40 a.m. The IJ template was provided to the facility on [DATE] at 9:40 a.m. While the IJ was removed on 02/08/2024 , the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures placed all residents at risk possibly being seriously harmed/injured or killed by an unsecured firearm or stray bullet. <BR/>Findings included:<BR/>Observation of the nurse's station on the 100 Hall on 01/22/2024 at 11:00 a.m. revealed the entrance to the nurse's station was directly across from a resident television area. There were open areas underneath the desk with shelves. There were bags, purses, and jackets on the shelves. No staff were observed at the nurse's station at that time. There were three residents in wheelchairs sitting in the television area. <BR/>In an interview with the DON on 01/22/2024 at 9:30 a.m., she stated on 01/18/2024, LVN V called her and said two staff members (CNA B and CNA C) were having an altercation. She could not recall what time LVN V called her, but it was at the start of the 6:00 a.m. - 2:00 p.m. shift. The DON said she told LVN V to get replacement staff and send CNA B and CNA C home. The DON said LVN called her again that morning and said there were gun shots fired outside. The DON said the MDS Nurse called the police after she heard gunshots. The DON said there had not been any prior altercations between the two staff that she knew of. She said CNA C was just hired in December 2023. She said CNA C had not complained about any prior incidents with any other staff. She said their corporate staff were involved in the investigation. She said CNA D tried to separate the two staff when they were fighting. She said all three staff were suspended pending the investigation, but CNA D returned to work on Sunday, 01/21/2024. She said the MDS Nurse was currently in the hospital having emergency surgery. She said the nurses did 12-hour shifts from 6:00 a.m. - 6:00 p.m. and 6:00 p.m. - 6:00 a.m. She said RN A was the night shift nurse and she also witnessed the altercation. <BR/>In an interview with the Administrator on 01/22/2024 at 10:22 a.m., he stated on 01/18/2024, he received a call from a nurse at about 7:15 a.m. He said he could not recall what nurse called him, but the nurse said the Medical Records Coordinator said CNA C had a gun and fired shots in the air. The Administrator said CNA C texted him at 8:11 a.m. after the incident and said the other staff jumped her. He said he sent her a text saying she brought a weapon into the facility when signs were posted everywhere saying it was a felony and then discharged it unsafely. He said CNA C texted back saying she figured he would say that and that it was not a felony to protect herself The Administrator said the police came and did an investigation, but as of Friday, 01/19/2024, they had not found CNA C or arrested her. He said CNA C texted that she rode the bus to work, and the gun was in her bag. The Administrator said he did not know where CNA C's bag was stored inside the facility. He said CNA C told him she brought the gun for safety reasons because she rode the bus at night. He said this was the first time he heard about any incident between CNA B and CNA C. The Administrator said CNA C never told him what the argument was about, but he heard during the investigation that the argument was about an unsafe transfer. He said CNA C transferred Resident #2, who was a two-person transfer, alone and CNA B told her how to do it the right way. The Administrator said Resident #2 told him CNA B was very calm when she approached CNA C and told her how to transfer him the right way. The Administrator said that was when things escalated, and CNA D tried to stop CNA C from going outside to mess with CNA B, who was outside smoking. He said RN A, MDS Nurse, and CNA D all tried to stop CNA C from bothering CNA B outside. He said CNA C went outside and that was when everybody heard guns shots. The Administrator said nobody went outside with CNA C. He said from his understanding, there was a short amount of time when CNA C went outside and when gunshots were heard. He said from his understanding, there was not a physical altercation inside the building because some people said it was physical, and some said it was not. He said CNA C told the VP of Operations she was being bullied, but there were no reports of that to him. He said CNA C never reported being bullied before this incident. He said he always did in-services about staff getting along and workplace violence as part of their ongoing training. He said there were no prior issues with staff having altercations that he knew of. He said staff had lockers available to them outside in the courtyard and in the staff breakroom. He said staff could bring their own locks to secure their personal belongings. He said he did not know if CNA C had a locker or not. The Administrator said he implemented a new rule that staff could only bring clear bags into the facility. He said he also contracted to have security in the building 24-hours daily and in-serviced staff. He said there were always signs posted at every entrance and exit about not bringing guns into the building, but he posted more signs. <BR/>In a telephone interview with CNA C on 01/22/2024 at 10:45 a.m., she stated she took responsibility for what she did because they (the Administrator and VP of Operations) told her having weapon on the premises was a felony. She said she only had the gun because she rode the bus at night to and from school. She stated she worked the 6:00 a.m. - 2:00 p.m. shift, but on 01/18/2024, she arrived early and clocked in at 5:45 a.m. She said she got Resident #2 up because he wanted to get up. She said she gave him a bed bath and transferred him safely with a Hoyer Lift to his wheelchair. She said RN A went to Resident #2's room because he was rambling and going on (she did not say what Resident #2 was rambling about). She said RN A said, Oh, you got him up, it was not time to get him up and you were not supposed to get him up by yourself. She said she was still in Resident #2's room and was leaving out right at 6:00 a.m. when CNA B approached her and was very aggressive about it. She said CNA B told her, I don't know what you think you are doing, but this is a two-person assist and you are going to get yourself fired. CNA C said she did not know what CNA B's problem was because she came down the hallway with her hands up like she was going to hit her. CNA C said CNA B swung at her and she backed up and asked CNA B not to do that. She said CNA B told her RN A asked her to come talk to her. She said she asked CNA B why she was so mad, and CNA B said she was done talking and was about to burst her upside her head. CNA C said she previously observed CNA B get Resident #2 up unassisted and CNA B said, I don't care what you thought you saw. CNA C said CNA B kept pushing and chest butting her. CNA C said she was walking away when CNA D grabbed her hand and said, Don't run up behind CNA B like that. CNA C said she told the rest of the staff she was leaving and showed them her bus pass. She said while CNA D held her, CNA B punched her on left side of her face. She said nobody let her leave. She said CNA B said, You about to go outside and get your ass whooped. CNA C said there were 3 - 4 people standing outside with CNA B and they were bullying her, so she pulled her gun out and shot into the air. She said she did not know the names of the other staff who were outside with CNA B. She said she called the Administrator and the VP of Operations after the incident. She said her car was broken, so she had to ride the bus. She said she went to class from 5:00 p.m. - 9:00 p.m. and she stored her bag behind the nurse's station, under the cabinet where there was an open area. She said that was where all the staff kept their things. She said she left her bag with the gun inside on the bottom shelf, next to the computer and chair on hall 100. She said her weapon was not exposed. She said RN A was there when CNA B hit her in the face. She said CNA B and another staff were already outside when she tried to leave the building and CNA D held her back and would not let her leave. She said she did not know if CNA D made it outside before her, but she saw some people at the door yapping their mouth (yelling at her and bullying her). She said she went out the side door of the building and was in the middle of the parking lot when she fired the shot in the air. She said she did not aim the gun at anybody, and she did not try to hurt anybody. She said the other staff were nowhere near her when she fired the shot. She said the other staff were more than 200 - 300 ft. away from her. She said the Medical Records Coordinator heard her telling the other staff to get off her. She said she told the Medical Records Coordinator and another CNA that she was being bullied by CNA B. She said during the week prior to the incident, she was mistreated by some African staff and CNA B defended her, so she did not understand why CNA B hit her in the face. She said she never reported to the Administrator or other management staff that she was being bullied. She said 01/18/2024 was the first day she brought her gun inside the building. She said she had never gone inside the building with a bag before because she previously had her car. She said her car broke down a couple of weeks before the incident. She said she never noticed or paid attention to the posted signs that said she could not bring a gun inside the building. She said she did not know she could not have the gun to protect herself. She said none of the residents had access to it because it was behind nurse station under the open cabinet.<BR/>In an interview with the Medical Records Coordinator on 01/22/2024 at 11:15 a.m., she stated days before the incident on 01/1/2024, CNA C told her some other staff were messing with her and the nurses were always hostile to her. She said she told CNA C file a grievance because the Administrator had an open-door policy. She said CNA C told her that on Saturday, 01/13/2024, some nurses got her into the medication room and got in her face. She said CNA C told her that on the day of the incidents, CNA C came and told her she could not get Resident #2 up or change him by herself even though she previously observed CNA C transfer him alone. The Medical Records Coordinator said RN A told CNA B to go and tell CNA C she could not transfer Resident #2 alone. She said the two staff had a verbal and physical altercation in the residents' room. She said Resident #2 told her CNA C hit CNA B first. She said CNA C told her CNA B hit her first. She said CNA C and CNA B never had any disagreements. She said CNA D told her (Medical Records Coordinator) that CNA C said she had a gun and she had 'something for them' if this (when the nurses cornered her in the medication room and got into her face) happened again. She said CNA C told CNA D she had a gun possibly days before the shooting incident. She said CNA B was a smoker and usually went out to the patio in the courtyard to smoke, but on 01/18/2024, CNA B called CNA out and said, Come outside if you got something for me. The Medical Records Coordinator said she was at the table in the front of the building and saw people running. She said she heard staff saying, No! Let my purse go, let me go! and She got a gun! She said by the time she got to the side of the building: CNA C was already gone. She said she did not hear the gun shot. She said the incident occurred around 6:00 a.m., so of course residents were up at that time and roaming around the building. She said none of the residents were outside. She said CNA D was outside when CNA C shot the gun. She said CNA D tried to keep CNA C from leaving with her purse because she knew the gun was in there. She said CNA C's bag was probably behind the nurse station, but staff were supposed to keep their belongings in the lockers. <BR/>In a telephone interview with CNA B on 01/22/2024 at 11:35 a.m., she stated she worked the 6:00 a.m. - 2:00 p.m. shift and there had not been any other incidents or animosity between her and CNA C. She said the two of them usually got along. She said on 01/18/2024, she had just gotten to work when RN A asked her to talk to CNA C because she got Resident #2 up way too early and she transferred him alone. She said RN A told her CNA C would not listen to her. She said she and CNA D went to the room and saw CNA C in there. She said she asked CNA C to come to the door and then told her RN A asked her to go and talk to her because Resident #2 was a two-person transfer. She said CNA C got mad and clapped her hands saying she was tired of people telling her what to do. CNA B said she told CNA C she was just trying to keep her from getting in trouble. CNA B said she walked away and told RN A it was too early for this. CNA B said the altercation was only verbal and never got physical. CNA B said they went to the nurse's station and continued arguing back and forth. She said RN A and CNA D were there trying to separate them. She said she tried to go outside and smoke to diffuse the situation, but it was brought up that CNA C had a gun. CNA B said CNA D knew CNA C had a gun. She said CNA D said, Don't let her get her purse! CNA B said at that time, CNA C was going for her purse behind the nurse's station desk. She said CNA D said, Don't let her get it because she got a gun! and CNA C said, And Do (meaning she did have a gun). CNA B said she was getting her stuff to go smoke and CNA B walked up on her back (walked closely behind her). She said as she walked down the hall to go smoke, the other staff were still in the building. She said once she got outside, she could see CNA C walking towards her thru the glass door. She said she saw CNA C's bag under left arm and her right hand was inside the bag. She said when CNA C walked outside, she was talking and pointed the gun at her as soon as she got outside. She said she heard CNA C ranting and raving that she was tired of people telling her what to do. She said when CNA C pointed the gun at her, she (CNA C) was about one or two feet away from the building and about three feet away from her. She said CNA C stood right by residents' windows. She said the police found the bullet shell next to building where she shot the gun. She said after CNA C pointed the gun at her, she backed up and pointed it in the air and fired. She said she did not know CNA C had a gun in building before the incident. She said she previously heard CNA C say they would not catch her like that again. She said CNA C was referring to an incident with some other nurses who attacked her. She said CNA C never reported that incident, but other staff knew because she was upset about it. She said CNA C told her the nurses were in her face and talking loudly because she gave a resident the wrong food tray. <BR/>In an interview with LVN V on 01/22/2024 at 12:20 p.m., she stated on 01/18/2024, she had the on-call phone and RN A called her to say there were two staff at the nurse's station fighting. She said she asked RN A what the situation was, and RN A said she and other staff pulled them apart and they walked out of the building. She said she called the DON, and the DON said the staff had to write a statement and leave the building. She said when she called CNA B and told her she needed to leave, CNA B went off on her (got very angry). She said CNA B told her she would not give her a statement. <BR/>In a telephone interview with the VP of Operations on 01/22/2024 at 12:40 p.m., she stated she was first notified of the incident the morning of 01/18/2024, when the Administrator called her. She said she told the Administrator to interview staff who witnessed the incident and call the police. She said when she arrived at the facility on 01/18/2024, they started safe survey interviews with all residents on the 100 hall, where the staff fought and on the 200 hall, where the staff was when she shot the gun. She said they talked to all staff who worked that day and sent a mass email to each resident's RP and family about the incident. She said they held a resident council meeting and staff meeting where they offered counseling to anybody who needed it. She said they contracted to have security in building because they were not aware if the shooter was arrested. She said CNA C called her when she was on her way to the building and she and CNA B did not have any incidents before that morning. She said CNA C told her that she and CNA B were cool because there was a previous incident where some nurses were trying to discipline her, and CNA B took up for her. CNA C said the incident started when she transferred a resident. She said CNA C told her CNA B said she did it incorrectly, but she previously observed CNA B transfer the resident that same way. She said CNA C told her CNA B said she never saw her do it that way, then they got into it (had a verbal altercation). She said CNA C told her CNA D was in between them and pulled her back while CNA B landed a lick (hit her) and RN A jumped in to get them apart. She said CNA C told her CNA B left, saying she did not have time for that while CNA D and RN A held her back. She said CNA C told her she told RN A and CNA D she was getting her bag and bus pass so she could leave for the day, and they eventually let her go. She said CNA C told her she proceeded out of the building thru the same door CNA B left from so she could walk towards the bus stop. She said CNA C told her she had the gun for her protection. She said she told CNA C it was a felony to go into a skilled nursing facility with a gun and the corporate office called the police. She said CNA C told her she had also called the police herself because they were trying to jump her. She said CNA C said there was a lot of staff outside, but after speaking to staff, they found that nobody else said they were outside. She said the other staff were inside trying to keep CNA C from going outside and nobody was outside trying to jump her. She said CNA D went outside after CNA C. She said the police had already gone to building by the time she arrived, and the shell was found in the parking lot. She said they completed staff education and counselors were going to talk to those who expressed uneasiness about the incident. She said none of the residents stated they were disturbed. She said Resident #2 and Resident #3, who were in the room where the incident started, did not have concerns. She said they had psych (psychiatric) services see both residents to make sure. She said they in-serviced all staff that if you see something, say something. She said they also educated staff on anger management, reporting, abuse/neglect, and having a gun in the facility. <BR/>Observation and interview with Resident #2 on 01/22/2024 beginning at 1:30 p.m., revealed he was a larger male who self-ambulated in an electric wheelchair by using his chin to maneuver the controls. Resident #2 could not move his limbs. He stated CNA C was in his room getting him dressed the day of the incident. He said he usually got up at 7:00 a.m., but it was 6:00 a.m. when CNA C got him up. He said CNA C got frustrated and he got frustrated. He said when CNA B came, she was really calm. He said he heard CNA B say, I don't know how you did things where you came from, but around here, this is how we do it. He said the staff were arguing in the hallway but then things got physical when CNA C hit CNA B first. He said CNA C's arm went from down low and then down on CNA B's shoulder, like a windmill. He said the staff went down to the nurse's station, so he could not see anything after that, and he did not know how it ended. He said CNA D came up and stood beside them and did not get involved at all. Resident #2 said he was already in his chair during the incident, but the chair was not on. He said he was upset because CNA C said she was going to go get other residents up, and he told her she could not abandon him like that. He stated he felt safe at the facility, and he did not have any concerns because it was two girls fighting. <BR/>In an interview with CNA D on 01/22/2024 at 1:40 p.m., she stated she worked the 6:00 a.m. - 2:00 p.m. shift. She stated there were no prior incidents between CNA B and CNA C that she knew of. She said CNA C told her she had an issue with some of the nurses because she got into it (had verbal altercations) with them the weekend before the gun incident about a wrong food tray. She said CNA C told her that she and the nurses argued, it got heated, and they went into the MDS office where they yelled in her face. She said CNA C received a verbal warning, but she felt she should not have gotten anything. She said CNA C said they were going to stop playing with her (stop harassing her), but she never said she was bringing a gun to the facility. She said she heard CNA B and CNA C arguing down the hall. She said the argument was about getting a resident up because CNA C said she saw other staff do it that way and she was tired of people telling her how to do her job. She said CNA C said she had gotten Resident #2 up safely so what did it matter. She said she saw both of their hands going up in each other's face and they were fanning each other's hands down. She said she told them to stop because they would lose their jobs. She said CNA C said, You stole me (hit me), oh no bitch, you stole me! She said she and RN A got between them, but they were going around them. She said CNA C said, I got something for you. She said CNA B had already gone outside and invited CNA C to go meet her outside. She said CNA C got her stuff, but they tried to keep her inside. She said CNA C said, I got something for this bitch. She said CNA C's bag was in the open area under the desk at the nurse's station. She said she and the MDS Nurse were standing at the door trying to calm CNA C down. She said the MDS Nurse said she would call the police if they fought. She said they tried to keep CNA C from going outside, but once she went outside, she instantly started digging in her purse and she came out of the purse with something. She said she and the MDS Nurse were right at the door with CNA C. She said she heard CNA B say, Oh you gone point the gun at me! She said CNA C then raised the gun and shot in the air. She said CNA C was on the sidewalk, near resident rooms when she shot the gun. She said CNA C was about a yard from the building and she was about a yard from CNA B. She said CNA C said, Ya'll bitches gone stop playing with me. She said CNA C said she quit and the MDS Nurse said, We already knew that. She said CNA C could have gone out the front door to catch the bus instead of going out the side door. She said the residents were getting up at that time. <BR/>In an interview with Resident #3 on 01/22/2024 at 2:17 p.m., he stated the incident started in his room and then went to the nurse's station. He said he did not know how it started, but he saw one hit the other. He said one staff swung her hand back, but he did not know if she meant to hit the other staff, or if she just landed one accidentally. He said after that, he went outside and saw two police officers at the facility. Her stated he still felt safe in the facility. <BR/>In a telephone interview with RN A on 01/23/2024 at 12:52 p.m., she stated she was waiting for her relief on 01/18/2024 when she CNA C went and got her because she was having issues with Resident #2's wheelchair. She said when she went to the room, she told CNA C she was not sure how to work the wheelchair, but she would get someone who knew. She said she noticed Resident #2 was already in his chair, so she asked CNA C how she got him in there. She said CNA C said she transferred him by herself. She said she told CNA C it was not safe for her to do that, but she said she could do it that way. She said she told CNA C she needed to get someone else to help her with Resident #2. She said she went to find someone to help control Resident #2's wheelchair and saw CNA B with CNA D in front of the nurse's station. She said she told CNA B that CNA C had already gotten the resident up by herself and that she needed help with the controller on Resident #2's wheelchair. She said CNA B went to the room and then she heard some sounds coming from down the hall. She said she heard someone say, Stop fighting. She said the staff were very close together and one hit the other, but she did not know who hit who first. She said CNA B left the building because she was upset, and they tried to calm CNA C down and told her she could not go outside because CNA B was still out there. She said CNA C kept yelling that she had to get out. She said CNA C took her backpack and left the building. She said by that time, she went out of the building and heard the gunshot. She said she did not go to the door with the other staff. She said she did not hear anybody say anything about a gun while they were inside the building. <BR/>In a follow-up interview with the Medical Records Coordinator on 01/24/2024 at 10:15 a.m., she stated after CNA C got into an altercation with the nurses when they were all in her face, CNA D said she (CNA C) told her, I am not gone worry about it because I got something for them. She said after the shooting incident, CNA C called her and said of course she had a gun because she went to school at night on the bus. She said when she went outside after the shooting incident, she heard CNA B tell CNA D, You been knew she had a gun? Why didn't you tell me? The Medical Records Coordinator said CNA D said she already knew CNA C had a gun in the building. <BR/>Record review of the facility's 'Workplace Violence policy, revised 01/2022 revealed, The facility seeks to provide a safe workplace for all team members and has Zero Tolerance toward any type of workplace violence committed by or against team members. Team members are prohibited from making threats or engaging in violent activities. This list of behaviors, while not inclusive, provides examples of conduct that is prohibited. Causing physical injury to another person; Making threatening remarks; Aggressive or hostile behavior that creates a reasonable fear of injury to another person or subjects another individual to emotional distress; . Possession of a weapon while on facility property or while on facility business; . Any potentially dangerous situations must be reported immediately to a supervisor . Threats, threatening conduct, or any other acts of aggression or violence in the workplace will not be tolerated. Any team members determined to have committed such acts will be subject to disciplinary action, up to and including termination .<BR/>Record review of the facility's policy on Firearms and Other Weapons revised 01/2022 revealed, All applicants, associates, contractors, subcontractors, or any other persons are prohibited from using or possessing (whether concealed or not) any weapons while on company premises, engaged in company business, or at company-related activities. The company follows state and federal laws regarding concealed weapons, and to the extent this policy conflicts with any such law, the applicable law governs.<BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by the DON on safe transfers, including Hoyer Lifts and two-person transfers. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by RN A on reviewing each resident's Kardex (a quick reference for nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) on the plan of care and requesting assistance before providing care. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by the physical therapy department regarding Resident #2's motorized wheelchair, including operation, drive mode, tilting, chin joystick, and recharging. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated by the SW regarding workplace violence and reporting incidents of bullying, harassment, and retaliation and possession of a weapon. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated by the SW regarding Abuse and Neglect. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 02/07/2024 at 9:40 a.m. The DON was notified. The DON was provided with the IJ template on 02/07/2024 at 9:40 a.m. A Plan of Removal was requested at that time. <BR/>The following Plan of Removal submitted by the facility was accepted on 02/08/2024 at 11:52 a.m. :<BR/>The facility failed to ensure that resident environment remained free of accidents and hazards.<BR/>1. <BR/>Immediate Action Taken<BR/>* <BR/>Identified staff were immediately suspended on 1/18/24 and police notified on 1/18/24. The residents that were located near were assessed by the Social Worker and Licensed Nurse to be offered the opportunity to have grief counseling by Psych Services to monitor for Post Traumatic Stress completed on 1/18/2024.<BR/>* <BR/>On 2/7/24 the social worker and Director of Nurses (DON), started education with all staff on the company policy for workplace violence, Use of clear bag policy at the community, and abuse and neglect, completed on 2/7/24. Employees that missed the in-service will not be allowed to work until this education has been completed. <BR/>* <BR/>The company will purchase clear bags for all employees to carry personal belongings into the facility in-service initiated on 1/19/24 and completed on 1/22/24. Clear bag policy was posted all over the community on 2/7/24. <BR/>* <BR/>The social worker and Director of Nursing initiated in- serviced to all staff on handguns prohibition policy, this will be completed on 2/8/24, all staff not available for the in-service will not be allowed to work until the in-service is completed with them. <BR/>* <BR/>An In-service by the Social Worker and corporate HR was started on 1/18/2024 to also provide grief counseling information from the employee through the employee's insurance company. This counseling was an immediate offer and is still available. There is no completion date because it is ongoing. Completed 1/18/2024 and ongoing. <BR/>2. <BR/>Identification of Residents Affected or Likely to be Affected: <BR/>* <BR/>On 1/18/2024 the DON and Social Worker completed the audit for any resident who was near and wanted therapy. We identified no residents that wanted therap[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accidents and hazards as is possible for 22 of 22 residents reviewed for accidents and hazards. <BR/>1. <BR/>CNA B and CNA C engaged in a verbal and physical altercation in the presence of at least two residents, Resident #2, and Resident #3 on 1/18/24 at approximately 6:00 a.m.<BR/>2. <BR/>CNA C left a loaded firearm unattended inside her personal bag in an unsecured cabinet under the nurse's station desk located directly across from a resident TV area for an undetermined amount of days/time. <BR/>3. <BR/>CNA C pointed a loaded firearm at CNA B and discharged the gun outside in the air approximately one yard from resident-occupied rooms on 1/18/24.<BR/>An Immediate Jeopardy (IJ) was identified on 02/07/2024 at 9:40 a.m. The IJ template was provided to the facility on [DATE] at 9:40 a.m. While the IJ was removed on 02/08/2024 , the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures placed all residents at risk possibly being seriously harmed/injured or killed by an unsecured firearm or stray bullet. <BR/>Findings included:<BR/>Observation of the nurse's station on the 100 Hall on 01/22/2024 at 11:00 a.m. revealed the entrance to the nurse's station was directly across from a resident television area. There were open areas underneath the desk with shelves. There were bags, purses, and jackets on the shelves. No staff were observed at the nurse's station at that time. There were three residents in wheelchairs sitting in the television area. <BR/>In an interview with the DON on 01/22/2024 at 9:30 a.m., she stated on 01/18/2024, LVN V called her and said two staff members (CNA B and CNA C) were having an altercation. She could not recall what time LVN V called her, but it was at the start of the 6:00 a.m. - 2:00 p.m. shift. The DON said she told LVN V to get replacement staff and send CNA B and CNA C home. The DON said LVN called her again that morning and said there were gun shots fired outside. The DON said the MDS Nurse called the police after she heard gunshots. The DON said there had not been any prior altercations between the two staff that she knew of. She said CNA C was just hired in December 2023. She said CNA C had not complained about any prior incidents with any other staff. She said their corporate staff were involved in the investigation. She said CNA D tried to separate the two staff when they were fighting. She said all three staff were suspended pending the investigation, but CNA D returned to work on Sunday, 01/21/2024. She said the MDS Nurse was currently in the hospital having emergency surgery. She said the nurses did 12-hour shifts from 6:00 a.m. - 6:00 p.m. and 6:00 p.m. - 6:00 a.m. She said RN A was the night shift nurse and she also witnessed the altercation. <BR/>In an interview with the Administrator on 01/22/2024 at 10:22 a.m., he stated on 01/18/2024, he received a call from a nurse at about 7:15 a.m. He said he could not recall what nurse called him, but the nurse said the Medical Records Coordinator said CNA C had a gun and fired shots in the air. The Administrator said CNA C texted him at 8:11 a.m. after the incident and said the other staff jumped her. He said he sent her a text saying she brought a weapon into the facility when signs were posted everywhere saying it was a felony and then discharged it unsafely. He said CNA C texted back saying she figured he would say that and that it was not a felony to protect herself The Administrator said the police came and did an investigation, but as of Friday, 01/19/2024, they had not found CNA C or arrested her. He said CNA C texted that she rode the bus to work, and the gun was in her bag. The Administrator said he did not know where CNA C's bag was stored inside the facility. He said CNA C told him she brought the gun for safety reasons because she rode the bus at night. He said this was the first time he heard about any incident between CNA B and CNA C. The Administrator said CNA C never told him what the argument was about, but he heard during the investigation that the argument was about an unsafe transfer. He said CNA C transferred Resident #2, who was a two-person transfer, alone and CNA B told her how to do it the right way. The Administrator said Resident #2 told him CNA B was very calm when she approached CNA C and told her how to transfer him the right way. The Administrator said that was when things escalated, and CNA D tried to stop CNA C from going outside to mess with CNA B, who was outside smoking. He said RN A, MDS Nurse, and CNA D all tried to stop CNA C from bothering CNA B outside. He said CNA C went outside and that was when everybody heard guns shots. The Administrator said nobody went outside with CNA C. He said from his understanding, there was a short amount of time when CNA C went outside and when gunshots were heard. He said from his understanding, there was not a physical altercation inside the building because some people said it was physical, and some said it was not. He said CNA C told the VP of Operations she was being bullied, but there were no reports of that to him. He said CNA C never reported being bullied before this incident. He said he always did in-services about staff getting along and workplace violence as part of their ongoing training. He said there were no prior issues with staff having altercations that he knew of. He said staff had lockers available to them outside in the courtyard and in the staff breakroom. He said staff could bring their own locks to secure their personal belongings. He said he did not know if CNA C had a locker or not. The Administrator said he implemented a new rule that staff could only bring clear bags into the facility. He said he also contracted to have security in the building 24-hours daily and in-serviced staff. He said there were always signs posted at every entrance and exit about not bringing guns into the building, but he posted more signs. <BR/>In a telephone interview with CNA C on 01/22/2024 at 10:45 a.m., she stated she took responsibility for what she did because they (the Administrator and VP of Operations) told her having weapon on the premises was a felony. She said she only had the gun because she rode the bus at night to and from school. She stated she worked the 6:00 a.m. - 2:00 p.m. shift, but on 01/18/2024, she arrived early and clocked in at 5:45 a.m. She said she got Resident #2 up because he wanted to get up. She said she gave him a bed bath and transferred him safely with a Hoyer Lift to his wheelchair. She said RN A went to Resident #2's room because he was rambling and going on (she did not say what Resident #2 was rambling about). She said RN A said, Oh, you got him up, it was not time to get him up and you were not supposed to get him up by yourself. She said she was still in Resident #2's room and was leaving out right at 6:00 a.m. when CNA B approached her and was very aggressive about it. She said CNA B told her, I don't know what you think you are doing, but this is a two-person assist and you are going to get yourself fired. CNA C said she did not know what CNA B's problem was because she came down the hallway with her hands up like she was going to hit her. CNA C said CNA B swung at her and she backed up and asked CNA B not to do that. She said CNA B told her RN A asked her to come talk to her. She said she asked CNA B why she was so mad, and CNA B said she was done talking and was about to burst her upside her head. CNA C said she previously observed CNA B get Resident #2 up unassisted and CNA B said, I don't care what you thought you saw. CNA C said CNA B kept pushing and chest butting her. CNA C said she was walking away when CNA D grabbed her hand and said, Don't run up behind CNA B like that. CNA C said she told the rest of the staff she was leaving and showed them her bus pass. She said while CNA D held her, CNA B punched her on left side of her face. She said nobody let her leave. She said CNA B said, You about to go outside and get your ass whooped. CNA C said there were 3 - 4 people standing outside with CNA B and they were bullying her, so she pulled her gun out and shot into the air. She said she did not know the names of the other staff who were outside with CNA B. She said she called the Administrator and the VP of Operations after the incident. She said her car was broken, so she had to ride the bus. She said she went to class from 5:00 p.m. - 9:00 p.m. and she stored her bag behind the nurse's station, under the cabinet where there was an open area. She said that was where all the staff kept their things. She said she left her bag with the gun inside on the bottom shelf, next to the computer and chair on hall 100. She said her weapon was not exposed. She said RN A was there when CNA B hit her in the face. She said CNA B and another staff were already outside when she tried to leave the building and CNA D held her back and would not let her leave. She said she did not know if CNA D made it outside before her, but she saw some people at the door yapping their mouth (yelling at her and bullying her). She said she went out the side door of the building and was in the middle of the parking lot when she fired the shot in the air. She said she did not aim the gun at anybody, and she did not try to hurt anybody. She said the other staff were nowhere near her when she fired the shot. She said the other staff were more than 200 - 300 ft. away from her. She said the Medical Records Coordinator heard her telling the other staff to get off her. She said she told the Medical Records Coordinator and another CNA that she was being bullied by CNA B. She said during the week prior to the incident, she was mistreated by some African staff and CNA B defended her, so she did not understand why CNA B hit her in the face. She said she never reported to the Administrator or other management staff that she was being bullied. She said 01/18/2024 was the first day she brought her gun inside the building. She said she had never gone inside the building with a bag before because she previously had her car. She said her car broke down a couple of weeks before the incident. She said she never noticed or paid attention to the posted signs that said she could not bring a gun inside the building. She said she did not know she could not have the gun to protect herself. She said none of the residents had access to it because it was behind nurse station under the open cabinet.<BR/>In an interview with the Medical Records Coordinator on 01/22/2024 at 11:15 a.m., she stated days before the incident on 01/1/2024, CNA C told her some other staff were messing with her and the nurses were always hostile to her. She said she told CNA C file a grievance because the Administrator had an open-door policy. She said CNA C told her that on Saturday, 01/13/2024, some nurses got her into the medication room and got in her face. She said CNA C told her that on the day of the incidents, CNA C came and told her she could not get Resident #2 up or change him by herself even though she previously observed CNA C transfer him alone. The Medical Records Coordinator said RN A told CNA B to go and tell CNA C she could not transfer Resident #2 alone. She said the two staff had a verbal and physical altercation in the residents' room. She said Resident #2 told her CNA C hit CNA B first. She said CNA C told her CNA B hit her first. She said CNA C and CNA B never had any disagreements. She said CNA D told her (Medical Records Coordinator) that CNA C said she had a gun and she had 'something for them' if this (when the nurses cornered her in the medication room and got into her face) happened again. She said CNA C told CNA D she had a gun possibly days before the shooting incident. She said CNA B was a smoker and usually went out to the patio in the courtyard to smoke, but on 01/18/2024, CNA B called CNA out and said, Come outside if you got something for me. The Medical Records Coordinator said she was at the table in the front of the building and saw people running. She said she heard staff saying, No! Let my purse go, let me go! and She got a gun! She said by the time she got to the side of the building: CNA C was already gone. She said she did not hear the gun shot. She said the incident occurred around 6:00 a.m., so of course residents were up at that time and roaming around the building. She said none of the residents were outside. She said CNA D was outside when CNA C shot the gun. She said CNA D tried to keep CNA C from leaving with her purse because she knew the gun was in there. She said CNA C's bag was probably behind the nurse station, but staff were supposed to keep their belongings in the lockers. <BR/>In a telephone interview with CNA B on 01/22/2024 at 11:35 a.m., she stated she worked the 6:00 a.m. - 2:00 p.m. shift and there had not been any other incidents or animosity between her and CNA C. She said the two of them usually got along. She said on 01/18/2024, she had just gotten to work when RN A asked her to talk to CNA C because she got Resident #2 up way too early and she transferred him alone. She said RN A told her CNA C would not listen to her. She said she and CNA D went to the room and saw CNA C in there. She said she asked CNA C to come to the door and then told her RN A asked her to go and talk to her because Resident #2 was a two-person transfer. She said CNA C got mad and clapped her hands saying she was tired of people telling her what to do. CNA B said she told CNA C she was just trying to keep her from getting in trouble. CNA B said she walked away and told RN A it was too early for this. CNA B said the altercation was only verbal and never got physical. CNA B said they went to the nurse's station and continued arguing back and forth. She said RN A and CNA D were there trying to separate them. She said she tried to go outside and smoke to diffuse the situation, but it was brought up that CNA C had a gun. CNA B said CNA D knew CNA C had a gun. She said CNA D said, Don't let her get her purse! CNA B said at that time, CNA C was going for her purse behind the nurse's station desk. She said CNA D said, Don't let her get it because she got a gun! and CNA C said, And Do (meaning she did have a gun). CNA B said she was getting her stuff to go smoke and CNA B walked up on her back (walked closely behind her). She said as she walked down the hall to go smoke, the other staff were still in the building. She said once she got outside, she could see CNA C walking towards her thru the glass door. She said she saw CNA C's bag under left arm and her right hand was inside the bag. She said when CNA C walked outside, she was talking and pointed the gun at her as soon as she got outside. She said she heard CNA C ranting and raving that she was tired of people telling her what to do. She said when CNA C pointed the gun at her, she (CNA C) was about one or two feet away from the building and about three feet away from her. She said CNA C stood right by residents' windows. She said the police found the bullet shell next to building where she shot the gun. She said after CNA C pointed the gun at her, she backed up and pointed it in the air and fired. She said she did not know CNA C had a gun in building before the incident. She said she previously heard CNA C say they would not catch her like that again. She said CNA C was referring to an incident with some other nurses who attacked her. She said CNA C never reported that incident, but other staff knew because she was upset about it. She said CNA C told her the nurses were in her face and talking loudly because she gave a resident the wrong food tray. <BR/>In an interview with LVN V on 01/22/2024 at 12:20 p.m., she stated on 01/18/2024, she had the on-call phone and RN A called her to say there were two staff at the nurse's station fighting. She said she asked RN A what the situation was, and RN A said she and other staff pulled them apart and they walked out of the building. She said she called the DON, and the DON said the staff had to write a statement and leave the building. She said when she called CNA B and told her she needed to leave, CNA B went off on her (got very angry). She said CNA B told her she would not give her a statement. <BR/>In a telephone interview with the VP of Operations on 01/22/2024 at 12:40 p.m., she stated she was first notified of the incident the morning of 01/18/2024, when the Administrator called her. She said she told the Administrator to interview staff who witnessed the incident and call the police. She said when she arrived at the facility on 01/18/2024, they started safe survey interviews with all residents on the 100 hall, where the staff fought and on the 200 hall, where the staff was when she shot the gun. She said they talked to all staff who worked that day and sent a mass email to each resident's RP and family about the incident. She said they held a resident council meeting and staff meeting where they offered counseling to anybody who needed it. She said they contracted to have security in building because they were not aware if the shooter was arrested. She said CNA C called her when she was on her way to the building and she and CNA B did not have any incidents before that morning. She said CNA C told her that she and CNA B were cool because there was a previous incident where some nurses were trying to discipline her, and CNA B took up for her. CNA C said the incident started when she transferred a resident. She said CNA C told her CNA B said she did it incorrectly, but she previously observed CNA B transfer the resident that same way. She said CNA C told her CNA B said she never saw her do it that way, then they got into it (had a verbal altercation). She said CNA C told her CNA D was in between them and pulled her back while CNA B landed a lick (hit her) and RN A jumped in to get them apart. She said CNA C told her CNA B left, saying she did not have time for that while CNA D and RN A held her back. She said CNA C told her she told RN A and CNA D she was getting her bag and bus pass so she could leave for the day, and they eventually let her go. She said CNA C told her she proceeded out of the building thru the same door CNA B left from so she could walk towards the bus stop. She said CNA C told her she had the gun for her protection. She said she told CNA C it was a felony to go into a skilled nursing facility with a gun and the corporate office called the police. She said CNA C told her she had also called the police herself because they were trying to jump her. She said CNA C said there was a lot of staff outside, but after speaking to staff, they found that nobody else said they were outside. She said the other staff were inside trying to keep CNA C from going outside and nobody was outside trying to jump her. She said CNA D went outside after CNA C. She said the police had already gone to building by the time she arrived, and the shell was found in the parking lot. She said they completed staff education and counselors were going to talk to those who expressed uneasiness about the incident. She said none of the residents stated they were disturbed. She said Resident #2 and Resident #3, who were in the room where the incident started, did not have concerns. She said they had psych (psychiatric) services see both residents to make sure. She said they in-serviced all staff that if you see something, say something. She said they also educated staff on anger management, reporting, abuse/neglect, and having a gun in the facility. <BR/>Observation and interview with Resident #2 on 01/22/2024 beginning at 1:30 p.m., revealed he was a larger male who self-ambulated in an electric wheelchair by using his chin to maneuver the controls. Resident #2 could not move his limbs. He stated CNA C was in his room getting him dressed the day of the incident. He said he usually got up at 7:00 a.m., but it was 6:00 a.m. when CNA C got him up. He said CNA C got frustrated and he got frustrated. He said when CNA B came, she was really calm. He said he heard CNA B say, I don't know how you did things where you came from, but around here, this is how we do it. He said the staff were arguing in the hallway but then things got physical when CNA C hit CNA B first. He said CNA C's arm went from down low and then down on CNA B's shoulder, like a windmill. He said the staff went down to the nurse's station, so he could not see anything after that, and he did not know how it ended. He said CNA D came up and stood beside them and did not get involved at all. Resident #2 said he was already in his chair during the incident, but the chair was not on. He said he was upset because CNA C said she was going to go get other residents up, and he told her she could not abandon him like that. He stated he felt safe at the facility, and he did not have any concerns because it was two girls fighting. <BR/>In an interview with CNA D on 01/22/2024 at 1:40 p.m., she stated she worked the 6:00 a.m. - 2:00 p.m. shift. She stated there were no prior incidents between CNA B and CNA C that she knew of. She said CNA C told her she had an issue with some of the nurses because she got into it (had verbal altercations) with them the weekend before the gun incident about a wrong food tray. She said CNA C told her that she and the nurses argued, it got heated, and they went into the MDS office where they yelled in her face. She said CNA C received a verbal warning, but she felt she should not have gotten anything. She said CNA C said they were going to stop playing with her (stop harassing her), but she never said she was bringing a gun to the facility. She said she heard CNA B and CNA C arguing down the hall. She said the argument was about getting a resident up because CNA C said she saw other staff do it that way and she was tired of people telling her how to do her job. She said CNA C said she had gotten Resident #2 up safely so what did it matter. She said she saw both of their hands going up in each other's face and they were fanning each other's hands down. She said she told them to stop because they would lose their jobs. She said CNA C said, You stole me (hit me), oh no bitch, you stole me! She said she and RN A got between them, but they were going around them. She said CNA C said, I got something for you. She said CNA B had already gone outside and invited CNA C to go meet her outside. She said CNA C got her stuff, but they tried to keep her inside. She said CNA C said, I got something for this bitch. She said CNA C's bag was in the open area under the desk at the nurse's station. She said she and the MDS Nurse were standing at the door trying to calm CNA C down. She said the MDS Nurse said she would call the police if they fought. She said they tried to keep CNA C from going outside, but once she went outside, she instantly started digging in her purse and she came out of the purse with something. She said she and the MDS Nurse were right at the door with CNA C. She said she heard CNA B say, Oh you gone point the gun at me! She said CNA C then raised the gun and shot in the air. She said CNA C was on the sidewalk, near resident rooms when she shot the gun. She said CNA C was about a yard from the building and she was about a yard from CNA B. She said CNA C said, Ya'll bitches gone stop playing with me. She said CNA C said she quit and the MDS Nurse said, We already knew that. She said CNA C could have gone out the front door to catch the bus instead of going out the side door. She said the residents were getting up at that time. <BR/>In an interview with Resident #3 on 01/22/2024 at 2:17 p.m., he stated the incident started in his room and then went to the nurse's station. He said he did not know how it started, but he saw one hit the other. He said one staff swung her hand back, but he did not know if she meant to hit the other staff, or if she just landed one accidentally. He said after that, he went outside and saw two police officers at the facility. Her stated he still felt safe in the facility. <BR/>In a telephone interview with RN A on 01/23/2024 at 12:52 p.m., she stated she was waiting for her relief on 01/18/2024 when she CNA C went and got her because she was having issues with Resident #2's wheelchair. She said when she went to the room, she told CNA C she was not sure how to work the wheelchair, but she would get someone who knew. She said she noticed Resident #2 was already in his chair, so she asked CNA C how she got him in there. She said CNA C said she transferred him by herself. She said she told CNA C it was not safe for her to do that, but she said she could do it that way. She said she told CNA C she needed to get someone else to help her with Resident #2. She said she went to find someone to help control Resident #2's wheelchair and saw CNA B with CNA D in front of the nurse's station. She said she told CNA B that CNA C had already gotten the resident up by herself and that she needed help with the controller on Resident #2's wheelchair. She said CNA B went to the room and then she heard some sounds coming from down the hall. She said she heard someone say, Stop fighting. She said the staff were very close together and one hit the other, but she did not know who hit who first. She said CNA B left the building because she was upset, and they tried to calm CNA C down and told her she could not go outside because CNA B was still out there. She said CNA C kept yelling that she had to get out. She said CNA C took her backpack and left the building. She said by that time, she went out of the building and heard the gunshot. She said she did not go to the door with the other staff. She said she did not hear anybody say anything about a gun while they were inside the building. <BR/>In a follow-up interview with the Medical Records Coordinator on 01/24/2024 at 10:15 a.m., she stated after CNA C got into an altercation with the nurses when they were all in her face, CNA D said she (CNA C) told her, I am not gone worry about it because I got something for them. She said after the shooting incident, CNA C called her and said of course she had a gun because she went to school at night on the bus. She said when she went outside after the shooting incident, she heard CNA B tell CNA D, You been knew she had a gun? Why didn't you tell me? The Medical Records Coordinator said CNA D said she already knew CNA C had a gun in the building. <BR/>Record review of the facility's 'Workplace Violence policy, revised 01/2022 revealed, The facility seeks to provide a safe workplace for all team members and has Zero Tolerance toward any type of workplace violence committed by or against team members. Team members are prohibited from making threats or engaging in violent activities. This list of behaviors, while not inclusive, provides examples of conduct that is prohibited. Causing physical injury to another person; Making threatening remarks; Aggressive or hostile behavior that creates a reasonable fear of injury to another person or subjects another individual to emotional distress; . Possession of a weapon while on facility property or while on facility business; . Any potentially dangerous situations must be reported immediately to a supervisor . Threats, threatening conduct, or any other acts of aggression or violence in the workplace will not be tolerated. Any team members determined to have committed such acts will be subject to disciplinary action, up to and including termination .<BR/>Record review of the facility's policy on Firearms and Other Weapons revised 01/2022 revealed, All applicants, associates, contractors, subcontractors, or any other persons are prohibited from using or possessing (whether concealed or not) any weapons while on company premises, engaged in company business, or at company-related activities. The company follows state and federal laws regarding concealed weapons, and to the extent this policy conflicts with any such law, the applicable law governs.<BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by the DON on safe transfers, including Hoyer Lifts and two-person transfers. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by RN A on reviewing each resident's Kardex (a quick reference for nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) on the plan of care and requesting assistance before providing care. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by the physical therapy department regarding Resident #2's motorized wheelchair, including operation, drive mode, tilting, chin joystick, and recharging. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated by the SW regarding workplace violence and reporting incidents of bullying, harassment, and retaliation and possession of a weapon. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated by the SW regarding Abuse and Neglect. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 02/07/2024 at 9:40 a.m. The DON was notified. The DON was provided with the IJ template on 02/07/2024 at 9:40 a.m. A Plan of Removal was requested at that time. <BR/>The following Plan of Removal submitted by the facility was accepted on 02/08/2024 at 11:52 a.m. :<BR/>The facility failed to ensure that resident environment remained free of accidents and hazards.<BR/>1. <BR/>Immediate Action Taken<BR/>* <BR/>Identified staff were immediately suspended on 1/18/24 and police notified on 1/18/24. The residents that were located near were assessed by the Social Worker and Licensed Nurse to be offered the opportunity to have grief counseling by Psych Services to monitor for Post Traumatic Stress completed on 1/18/2024.<BR/>* <BR/>On 2/7/24 the social worker and Director of Nurses (DON), started education with all staff on the company policy for workplace violence, Use of clear bag policy at the community, and abuse and neglect, completed on 2/7/24. Employees that missed the in-service will not be allowed to work until this education has been completed. <BR/>* <BR/>The company will purchase clear bags for all employees to carry personal belongings into the facility in-service initiated on 1/19/24 and completed on 1/22/24. Clear bag policy was posted all over the community on 2/7/24. <BR/>* <BR/>The social worker and Director of Nursing initiated in- serviced to all staff on handguns prohibition policy, this will be completed on 2/8/24, all staff not available for the in-service will not be allowed to work until the in-service is completed with them. <BR/>* <BR/>An In-service by the Social Worker and corporate HR was started on 1/18/2024 to also provide grief counseling information from the employee through the employee's insurance company. This counseling was an immediate offer and is still available. There is no completion date because it is ongoing. Completed 1/18/2024 and ongoing. <BR/>2. <BR/>Identification of Residents Affected or Likely to be Affected: <BR/>* <BR/>On 1/18/2024 the DON and Social Worker completed the audit for any resident who was near and wanted therapy. We identified no residents that wanted therap[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accidents and hazards as is possible for 22 of 22 residents reviewed for accidents and hazards. <BR/>1. <BR/>CNA B and CNA C engaged in a verbal and physical altercation in the presence of at least two residents, Resident #2, and Resident #3 on 1/18/24 at approximately 6:00 a.m.<BR/>2. <BR/>CNA C left a loaded firearm unattended inside her personal bag in an unsecured cabinet under the nurse's station desk located directly across from a resident TV area for an undetermined amount of days/time. <BR/>3. <BR/>CNA C pointed a loaded firearm at CNA B and discharged the gun outside in the air approximately one yard from resident-occupied rooms on 1/18/24.<BR/>An Immediate Jeopardy (IJ) was identified on 02/07/2024 at 9:40 a.m. The IJ template was provided to the facility on [DATE] at 9:40 a.m. While the IJ was removed on 02/08/2024 , the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures placed all residents at risk possibly being seriously harmed/injured or killed by an unsecured firearm or stray bullet. <BR/>Findings included:<BR/>Observation of the nurse's station on the 100 Hall on 01/22/2024 at 11:00 a.m. revealed the entrance to the nurse's station was directly across from a resident television area. There were open areas underneath the desk with shelves. There were bags, purses, and jackets on the shelves. No staff were observed at the nurse's station at that time. There were three residents in wheelchairs sitting in the television area. <BR/>In an interview with the DON on 01/22/2024 at 9:30 a.m., she stated on 01/18/2024, LVN V called her and said two staff members (CNA B and CNA C) were having an altercation. She could not recall what time LVN V called her, but it was at the start of the 6:00 a.m. - 2:00 p.m. shift. The DON said she told LVN V to get replacement staff and send CNA B and CNA C home. The DON said LVN called her again that morning and said there were gun shots fired outside. The DON said the MDS Nurse called the police after she heard gunshots. The DON said there had not been any prior altercations between the two staff that she knew of. She said CNA C was just hired in December 2023. She said CNA C had not complained about any prior incidents with any other staff. She said their corporate staff were involved in the investigation. She said CNA D tried to separate the two staff when they were fighting. She said all three staff were suspended pending the investigation, but CNA D returned to work on Sunday, 01/21/2024. She said the MDS Nurse was currently in the hospital having emergency surgery. She said the nurses did 12-hour shifts from 6:00 a.m. - 6:00 p.m. and 6:00 p.m. - 6:00 a.m. She said RN A was the night shift nurse and she also witnessed the altercation. <BR/>In an interview with the Administrator on 01/22/2024 at 10:22 a.m., he stated on 01/18/2024, he received a call from a nurse at about 7:15 a.m. He said he could not recall what nurse called him, but the nurse said the Medical Records Coordinator said CNA C had a gun and fired shots in the air. The Administrator said CNA C texted him at 8:11 a.m. after the incident and said the other staff jumped her. He said he sent her a text saying she brought a weapon into the facility when signs were posted everywhere saying it was a felony and then discharged it unsafely. He said CNA C texted back saying she figured he would say that and that it was not a felony to protect herself The Administrator said the police came and did an investigation, but as of Friday, 01/19/2024, they had not found CNA C or arrested her. He said CNA C texted that she rode the bus to work, and the gun was in her bag. The Administrator said he did not know where CNA C's bag was stored inside the facility. He said CNA C told him she brought the gun for safety reasons because she rode the bus at night. He said this was the first time he heard about any incident between CNA B and CNA C. The Administrator said CNA C never told him what the argument was about, but he heard during the investigation that the argument was about an unsafe transfer. He said CNA C transferred Resident #2, who was a two-person transfer, alone and CNA B told her how to do it the right way. The Administrator said Resident #2 told him CNA B was very calm when she approached CNA C and told her how to transfer him the right way. The Administrator said that was when things escalated, and CNA D tried to stop CNA C from going outside to mess with CNA B, who was outside smoking. He said RN A, MDS Nurse, and CNA D all tried to stop CNA C from bothering CNA B outside. He said CNA C went outside and that was when everybody heard guns shots. The Administrator said nobody went outside with CNA C. He said from his understanding, there was a short amount of time when CNA C went outside and when gunshots were heard. He said from his understanding, there was not a physical altercation inside the building because some people said it was physical, and some said it was not. He said CNA C told the VP of Operations she was being bullied, but there were no reports of that to him. He said CNA C never reported being bullied before this incident. He said he always did in-services about staff getting along and workplace violence as part of their ongoing training. He said there were no prior issues with staff having altercations that he knew of. He said staff had lockers available to them outside in the courtyard and in the staff breakroom. He said staff could bring their own locks to secure their personal belongings. He said he did not know if CNA C had a locker or not. The Administrator said he implemented a new rule that staff could only bring clear bags into the facility. He said he also contracted to have security in the building 24-hours daily and in-serviced staff. He said there were always signs posted at every entrance and exit about not bringing guns into the building, but he posted more signs. <BR/>In a telephone interview with CNA C on 01/22/2024 at 10:45 a.m., she stated she took responsibility for what she did because they (the Administrator and VP of Operations) told her having weapon on the premises was a felony. She said she only had the gun because she rode the bus at night to and from school. She stated she worked the 6:00 a.m. - 2:00 p.m. shift, but on 01/18/2024, she arrived early and clocked in at 5:45 a.m. She said she got Resident #2 up because he wanted to get up. She said she gave him a bed bath and transferred him safely with a Hoyer Lift to his wheelchair. She said RN A went to Resident #2's room because he was rambling and going on (she did not say what Resident #2 was rambling about). She said RN A said, Oh, you got him up, it was not time to get him up and you were not supposed to get him up by yourself. She said she was still in Resident #2's room and was leaving out right at 6:00 a.m. when CNA B approached her and was very aggressive about it. She said CNA B told her, I don't know what you think you are doing, but this is a two-person assist and you are going to get yourself fired. CNA C said she did not know what CNA B's problem was because she came down the hallway with her hands up like she was going to hit her. CNA C said CNA B swung at her and she backed up and asked CNA B not to do that. She said CNA B told her RN A asked her to come talk to her. She said she asked CNA B why she was so mad, and CNA B said she was done talking and was about to burst her upside her head. CNA C said she previously observed CNA B get Resident #2 up unassisted and CNA B said, I don't care what you thought you saw. CNA C said CNA B kept pushing and chest butting her. CNA C said she was walking away when CNA D grabbed her hand and said, Don't run up behind CNA B like that. CNA C said she told the rest of the staff she was leaving and showed them her bus pass. She said while CNA D held her, CNA B punched her on left side of her face. She said nobody let her leave. She said CNA B said, You about to go outside and get your ass whooped. CNA C said there were 3 - 4 people standing outside with CNA B and they were bullying her, so she pulled her gun out and shot into the air. She said she did not know the names of the other staff who were outside with CNA B. She said she called the Administrator and the VP of Operations after the incident. She said her car was broken, so she had to ride the bus. She said she went to class from 5:00 p.m. - 9:00 p.m. and she stored her bag behind the nurse's station, under the cabinet where there was an open area. She said that was where all the staff kept their things. She said she left her bag with the gun inside on the bottom shelf, next to the computer and chair on hall 100. She said her weapon was not exposed. She said RN A was there when CNA B hit her in the face. She said CNA B and another staff were already outside when she tried to leave the building and CNA D held her back and would not let her leave. She said she did not know if CNA D made it outside before her, but she saw some people at the door yapping their mouth (yelling at her and bullying her). She said she went out the side door of the building and was in the middle of the parking lot when she fired the shot in the air. She said she did not aim the gun at anybody, and she did not try to hurt anybody. She said the other staff were nowhere near her when she fired the shot. She said the other staff were more than 200 - 300 ft. away from her. She said the Medical Records Coordinator heard her telling the other staff to get off her. She said she told the Medical Records Coordinator and another CNA that she was being bullied by CNA B. She said during the week prior to the incident, she was mistreated by some African staff and CNA B defended her, so she did not understand why CNA B hit her in the face. She said she never reported to the Administrator or other management staff that she was being bullied. She said 01/18/2024 was the first day she brought her gun inside the building. She said she had never gone inside the building with a bag before because she previously had her car. She said her car broke down a couple of weeks before the incident. She said she never noticed or paid attention to the posted signs that said she could not bring a gun inside the building. She said she did not know she could not have the gun to protect herself. She said none of the residents had access to it because it was behind nurse station under the open cabinet.<BR/>In an interview with the Medical Records Coordinator on 01/22/2024 at 11:15 a.m., she stated days before the incident on 01/1/2024, CNA C told her some other staff were messing with her and the nurses were always hostile to her. She said she told CNA C file a grievance because the Administrator had an open-door policy. She said CNA C told her that on Saturday, 01/13/2024, some nurses got her into the medication room and got in her face. She said CNA C told her that on the day of the incidents, CNA C came and told her she could not get Resident #2 up or change him by herself even though she previously observed CNA C transfer him alone. The Medical Records Coordinator said RN A told CNA B to go and tell CNA C she could not transfer Resident #2 alone. She said the two staff had a verbal and physical altercation in the residents' room. She said Resident #2 told her CNA C hit CNA B first. She said CNA C told her CNA B hit her first. She said CNA C and CNA B never had any disagreements. She said CNA D told her (Medical Records Coordinator) that CNA C said she had a gun and she had 'something for them' if this (when the nurses cornered her in the medication room and got into her face) happened again. She said CNA C told CNA D she had a gun possibly days before the shooting incident. She said CNA B was a smoker and usually went out to the patio in the courtyard to smoke, but on 01/18/2024, CNA B called CNA out and said, Come outside if you got something for me. The Medical Records Coordinator said she was at the table in the front of the building and saw people running. She said she heard staff saying, No! Let my purse go, let me go! and She got a gun! She said by the time she got to the side of the building: CNA C was already gone. She said she did not hear the gun shot. She said the incident occurred around 6:00 a.m., so of course residents were up at that time and roaming around the building. She said none of the residents were outside. She said CNA D was outside when CNA C shot the gun. She said CNA D tried to keep CNA C from leaving with her purse because she knew the gun was in there. She said CNA C's bag was probably behind the nurse station, but staff were supposed to keep their belongings in the lockers. <BR/>In a telephone interview with CNA B on 01/22/2024 at 11:35 a.m., she stated she worked the 6:00 a.m. - 2:00 p.m. shift and there had not been any other incidents or animosity between her and CNA C. She said the two of them usually got along. She said on 01/18/2024, she had just gotten to work when RN A asked her to talk to CNA C because she got Resident #2 up way too early and she transferred him alone. She said RN A told her CNA C would not listen to her. She said she and CNA D went to the room and saw CNA C in there. She said she asked CNA C to come to the door and then told her RN A asked her to go and talk to her because Resident #2 was a two-person transfer. She said CNA C got mad and clapped her hands saying she was tired of people telling her what to do. CNA B said she told CNA C she was just trying to keep her from getting in trouble. CNA B said she walked away and told RN A it was too early for this. CNA B said the altercation was only verbal and never got physical. CNA B said they went to the nurse's station and continued arguing back and forth. She said RN A and CNA D were there trying to separate them. She said she tried to go outside and smoke to diffuse the situation, but it was brought up that CNA C had a gun. CNA B said CNA D knew CNA C had a gun. She said CNA D said, Don't let her get her purse! CNA B said at that time, CNA C was going for her purse behind the nurse's station desk. She said CNA D said, Don't let her get it because she got a gun! and CNA C said, And Do (meaning she did have a gun). CNA B said she was getting her stuff to go smoke and CNA B walked up on her back (walked closely behind her). She said as she walked down the hall to go smoke, the other staff were still in the building. She said once she got outside, she could see CNA C walking towards her thru the glass door. She said she saw CNA C's bag under left arm and her right hand was inside the bag. She said when CNA C walked outside, she was talking and pointed the gun at her as soon as she got outside. She said she heard CNA C ranting and raving that she was tired of people telling her what to do. She said when CNA C pointed the gun at her, she (CNA C) was about one or two feet away from the building and about three feet away from her. She said CNA C stood right by residents' windows. She said the police found the bullet shell next to building where she shot the gun. She said after CNA C pointed the gun at her, she backed up and pointed it in the air and fired. She said she did not know CNA C had a gun in building before the incident. She said she previously heard CNA C say they would not catch her like that again. She said CNA C was referring to an incident with some other nurses who attacked her. She said CNA C never reported that incident, but other staff knew because she was upset about it. She said CNA C told her the nurses were in her face and talking loudly because she gave a resident the wrong food tray. <BR/>In an interview with LVN V on 01/22/2024 at 12:20 p.m., she stated on 01/18/2024, she had the on-call phone and RN A called her to say there were two staff at the nurse's station fighting. She said she asked RN A what the situation was, and RN A said she and other staff pulled them apart and they walked out of the building. She said she called the DON, and the DON said the staff had to write a statement and leave the building. She said when she called CNA B and told her she needed to leave, CNA B went off on her (got very angry). She said CNA B told her she would not give her a statement. <BR/>In a telephone interview with the VP of Operations on 01/22/2024 at 12:40 p.m., she stated she was first notified of the incident the morning of 01/18/2024, when the Administrator called her. She said she told the Administrator to interview staff who witnessed the incident and call the police. She said when she arrived at the facility on 01/18/2024, they started safe survey interviews with all residents on the 100 hall, where the staff fought and on the 200 hall, where the staff was when she shot the gun. She said they talked to all staff who worked that day and sent a mass email to each resident's RP and family about the incident. She said they held a resident council meeting and staff meeting where they offered counseling to anybody who needed it. She said they contracted to have security in building because they were not aware if the shooter was arrested. She said CNA C called her when she was on her way to the building and she and CNA B did not have any incidents before that morning. She said CNA C told her that she and CNA B were cool because there was a previous incident where some nurses were trying to discipline her, and CNA B took up for her. CNA C said the incident started when she transferred a resident. She said CNA C told her CNA B said she did it incorrectly, but she previously observed CNA B transfer the resident that same way. She said CNA C told her CNA B said she never saw her do it that way, then they got into it (had a verbal altercation). She said CNA C told her CNA D was in between them and pulled her back while CNA B landed a lick (hit her) and RN A jumped in to get them apart. She said CNA C told her CNA B left, saying she did not have time for that while CNA D and RN A held her back. She said CNA C told her she told RN A and CNA D she was getting her bag and bus pass so she could leave for the day, and they eventually let her go. She said CNA C told her she proceeded out of the building thru the same door CNA B left from so she could walk towards the bus stop. She said CNA C told her she had the gun for her protection. She said she told CNA C it was a felony to go into a skilled nursing facility with a gun and the corporate office called the police. She said CNA C told her she had also called the police herself because they were trying to jump her. She said CNA C said there was a lot of staff outside, but after speaking to staff, they found that nobody else said they were outside. She said the other staff were inside trying to keep CNA C from going outside and nobody was outside trying to jump her. She said CNA D went outside after CNA C. She said the police had already gone to building by the time she arrived, and the shell was found in the parking lot. She said they completed staff education and counselors were going to talk to those who expressed uneasiness about the incident. She said none of the residents stated they were disturbed. She said Resident #2 and Resident #3, who were in the room where the incident started, did not have concerns. She said they had psych (psychiatric) services see both residents to make sure. She said they in-serviced all staff that if you see something, say something. She said they also educated staff on anger management, reporting, abuse/neglect, and having a gun in the facility. <BR/>Observation and interview with Resident #2 on 01/22/2024 beginning at 1:30 p.m., revealed he was a larger male who self-ambulated in an electric wheelchair by using his chin to maneuver the controls. Resident #2 could not move his limbs. He stated CNA C was in his room getting him dressed the day of the incident. He said he usually got up at 7:00 a.m., but it was 6:00 a.m. when CNA C got him up. He said CNA C got frustrated and he got frustrated. He said when CNA B came, she was really calm. He said he heard CNA B say, I don't know how you did things where you came from, but around here, this is how we do it. He said the staff were arguing in the hallway but then things got physical when CNA C hit CNA B first. He said CNA C's arm went from down low and then down on CNA B's shoulder, like a windmill. He said the staff went down to the nurse's station, so he could not see anything after that, and he did not know how it ended. He said CNA D came up and stood beside them and did not get involved at all. Resident #2 said he was already in his chair during the incident, but the chair was not on. He said he was upset because CNA C said she was going to go get other residents up, and he told her she could not abandon him like that. He stated he felt safe at the facility, and he did not have any concerns because it was two girls fighting. <BR/>In an interview with CNA D on 01/22/2024 at 1:40 p.m., she stated she worked the 6:00 a.m. - 2:00 p.m. shift. She stated there were no prior incidents between CNA B and CNA C that she knew of. She said CNA C told her she had an issue with some of the nurses because she got into it (had verbal altercations) with them the weekend before the gun incident about a wrong food tray. She said CNA C told her that she and the nurses argued, it got heated, and they went into the MDS office where they yelled in her face. She said CNA C received a verbal warning, but she felt she should not have gotten anything. She said CNA C said they were going to stop playing with her (stop harassing her), but she never said she was bringing a gun to the facility. She said she heard CNA B and CNA C arguing down the hall. She said the argument was about getting a resident up because CNA C said she saw other staff do it that way and she was tired of people telling her how to do her job. She said CNA C said she had gotten Resident #2 up safely so what did it matter. She said she saw both of their hands going up in each other's face and they were fanning each other's hands down. She said she told them to stop because they would lose their jobs. She said CNA C said, You stole me (hit me), oh no bitch, you stole me! She said she and RN A got between them, but they were going around them. She said CNA C said, I got something for you. She said CNA B had already gone outside and invited CNA C to go meet her outside. She said CNA C got her stuff, but they tried to keep her inside. She said CNA C said, I got something for this bitch. She said CNA C's bag was in the open area under the desk at the nurse's station. She said she and the MDS Nurse were standing at the door trying to calm CNA C down. She said the MDS Nurse said she would call the police if they fought. She said they tried to keep CNA C from going outside, but once she went outside, she instantly started digging in her purse and she came out of the purse with something. She said she and the MDS Nurse were right at the door with CNA C. She said she heard CNA B say, Oh you gone point the gun at me! She said CNA C then raised the gun and shot in the air. She said CNA C was on the sidewalk, near resident rooms when she shot the gun. She said CNA C was about a yard from the building and she was about a yard from CNA B. She said CNA C said, Ya'll bitches gone stop playing with me. She said CNA C said she quit and the MDS Nurse said, We already knew that. She said CNA C could have gone out the front door to catch the bus instead of going out the side door. She said the residents were getting up at that time. <BR/>In an interview with Resident #3 on 01/22/2024 at 2:17 p.m., he stated the incident started in his room and then went to the nurse's station. He said he did not know how it started, but he saw one hit the other. He said one staff swung her hand back, but he did not know if she meant to hit the other staff, or if she just landed one accidentally. He said after that, he went outside and saw two police officers at the facility. Her stated he still felt safe in the facility. <BR/>In a telephone interview with RN A on 01/23/2024 at 12:52 p.m., she stated she was waiting for her relief on 01/18/2024 when she CNA C went and got her because she was having issues with Resident #2's wheelchair. She said when she went to the room, she told CNA C she was not sure how to work the wheelchair, but she would get someone who knew. She said she noticed Resident #2 was already in his chair, so she asked CNA C how she got him in there. She said CNA C said she transferred him by herself. She said she told CNA C it was not safe for her to do that, but she said she could do it that way. She said she told CNA C she needed to get someone else to help her with Resident #2. She said she went to find someone to help control Resident #2's wheelchair and saw CNA B with CNA D in front of the nurse's station. She said she told CNA B that CNA C had already gotten the resident up by herself and that she needed help with the controller on Resident #2's wheelchair. She said CNA B went to the room and then she heard some sounds coming from down the hall. She said she heard someone say, Stop fighting. She said the staff were very close together and one hit the other, but she did not know who hit who first. She said CNA B left the building because she was upset, and they tried to calm CNA C down and told her she could not go outside because CNA B was still out there. She said CNA C kept yelling that she had to get out. She said CNA C took her backpack and left the building. She said by that time, she went out of the building and heard the gunshot. She said she did not go to the door with the other staff. She said she did not hear anybody say anything about a gun while they were inside the building. <BR/>In a follow-up interview with the Medical Records Coordinator on 01/24/2024 at 10:15 a.m., she stated after CNA C got into an altercation with the nurses when they were all in her face, CNA D said she (CNA C) told her, I am not gone worry about it because I got something for them. She said after the shooting incident, CNA C called her and said of course she had a gun because she went to school at night on the bus. She said when she went outside after the shooting incident, she heard CNA B tell CNA D, You been knew she had a gun? Why didn't you tell me? The Medical Records Coordinator said CNA D said she already knew CNA C had a gun in the building. <BR/>Record review of the facility's 'Workplace Violence policy, revised 01/2022 revealed, The facility seeks to provide a safe workplace for all team members and has Zero Tolerance toward any type of workplace violence committed by or against team members. Team members are prohibited from making threats or engaging in violent activities. This list of behaviors, while not inclusive, provides examples of conduct that is prohibited. Causing physical injury to another person; Making threatening remarks; Aggressive or hostile behavior that creates a reasonable fear of injury to another person or subjects another individual to emotional distress; . Possession of a weapon while on facility property or while on facility business; . Any potentially dangerous situations must be reported immediately to a supervisor . Threats, threatening conduct, or any other acts of aggression or violence in the workplace will not be tolerated. Any team members determined to have committed such acts will be subject to disciplinary action, up to and including termination .<BR/>Record review of the facility's policy on Firearms and Other Weapons revised 01/2022 revealed, All applicants, associates, contractors, subcontractors, or any other persons are prohibited from using or possessing (whether concealed or not) any weapons while on company premises, engaged in company business, or at company-related activities. The company follows state and federal laws regarding concealed weapons, and to the extent this policy conflicts with any such law, the applicable law governs.<BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by the DON on safe transfers, including Hoyer Lifts and two-person transfers. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by RN A on reviewing each resident's Kardex (a quick reference for nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) on the plan of care and requesting assistance before providing care. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all nursing staff were educated by the physical therapy department regarding Resident #2's motorized wheelchair, including operation, drive mode, tilting, chin joystick, and recharging. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated by the SW regarding workplace violence and reporting incidents of bullying, harassment, and retaliation and possession of a weapon. <BR/>Record review of In-Service Training Report dated 01/18/2024 revealed all facility staff were educated by the SW regarding Abuse and Neglect. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 02/07/2024 at 9:40 a.m. The DON was notified. The DON was provided with the IJ template on 02/07/2024 at 9:40 a.m. A Plan of Removal was requested at that time. <BR/>The following Plan of Removal submitted by the facility was accepted on 02/08/2024 at 11:52 a.m. :<BR/>The facility failed to ensure that resident environment remained free of accidents and hazards.<BR/>1. <BR/>Immediate Action Taken<BR/>* <BR/>Identified staff were immediately suspended on 1/18/24 and police notified on 1/18/24. The residents that were located near were assessed by the Social Worker and Licensed Nurse to be offered the opportunity to have grief counseling by Psych Services to monitor for Post Traumatic Stress completed on 1/18/2024.<BR/>* <BR/>On 2/7/24 the social worker and Director of Nurses (DON), started education with all staff on the company policy for workplace violence, Use of clear bag policy at the community, and abuse and neglect, completed on 2/7/24. Employees that missed the in-service will not be allowed to work until this education has been completed. <BR/>* <BR/>The company will purchase clear bags for all employees to carry personal belongings into the facility in-service initiated on 1/19/24 and completed on 1/22/24. Clear bag policy was posted all over the community on 2/7/24. <BR/>* <BR/>The social worker and Director of Nursing initiated in- serviced to all staff on handguns prohibition policy, this will be completed on 2/8/24, all staff not available for the in-service will not be allowed to work until the in-service is completed with them. <BR/>* <BR/>An In-service by the Social Worker and corporate HR was started on 1/18/2024 to also provide grief counseling information from the employee through the employee's insurance company. This counseling was an immediate offer and is still available. There is no completion date because it is ongoing. Completed 1/18/2024 and ongoing. <BR/>2. <BR/>Identification of Residents Affected or Likely to be Affected: <BR/>* <BR/>On 1/18/2024 the DON and Social Worker completed the audit for any resident who was near and wanted therapy. We identified no residents that wanted therap[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, which included tracheostomy care and tracheal suctioning, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 1 of 2 residents (Resident #65) reviewed for oxygen therapy.<BR/>The facility failed to ensure Resident #65's oxygen was set according to physician orders. <BR/>This failure could place residents at risk of respiratory distress.<BR/>The findings were:<BR/>Record review of Resident #65's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. He had diagnoses which included chronic respiratory failure (long-term condition that happens when your lungs cannot get enough oxygen into your blood), cerebral infarction (stroke), and seizures.<BR/>Record review of Resident #65's quarterly MDS assessment, dated 2/18/23, revealed a staff assessment for mental status was completed and indicated his cognitive skills for daily decision making were severely impaired. The resident was on oxygen therapy.<BR/>Record review of Resident #65's care plan, dated 1/24/23, revealed the resident was on oxygen therapy related to respiratory illness. Interventions included oxygen settings: O2 via nasal cannula.<BR/>Record review of Resident #65's Order Summary Report for April 2023, revealed an order for oxygen at 4 L via trach collar (trach collar is a medical device used to secure a trach tube in its position) every shift, order date 7/19/22.<BR/>Record review of Resident #65's Licensed Nurse Medication Administration Record for April 2023 revealed his O2 saturation (measure of how much oxygen is traveling through your body in your red blood cells) was 98 % on 4/18/23, 4/19/23, and 4/20/23. (Oxygen saturation level in healthy patients is considered normal between 97 percent and 99 percent).<BR/>In an observation on 4/18/23 at 11:37 a.m. revealed Resident #65's oxygen was between 9 and 10 L. The resident was lying in bed asleep with the oxygen tube in place.<BR/>In an observation on 4/19/23 at 10:43 a.m. revealed Resident #65's oxygen was on 5 L. The resident was lying in bed asleep with the oxygen tube in place.<BR/>In an observation on 4/20/23 at 9:15 a.m. revealed Resident #65's oxygen was between 5 and 6 L. The resident was lying in bed asleep with the oxygen tube in place.<BR/>In an observation and interview on 4/20/23 at 11:26 a.m. revealed LVN Z looked at Resident #65's oxygen machine and said the oxygen was around 5 L. LVN Z said Resident #65 should be on 4 L of oxygen per physician's order. She said the level on the oxygen machine would sometimes move and pop up. She said she would need to get a new machine if that occurred. She said at every shift, the nurse was responsible for verifying the O2 level. She said the oxygen helped Resident #65 breathe and dry out his mucus. She said if the level was on 5 L it could make him more restless and dry the mucous up more. <BR/>In an interview on 4/21/23 at 11:29 a.m., the DON said the O2 level on the machine did not normally jump up but they would replace the concentrator for Resident #65. She said she expected nurses to check O2 levels every shift and have the O2 level at the prescribed MD order because they must follow the MD order. She said if the O2 level needed to increase, the resident would need to be evaluated and receive a new order. She said if the O2 level was set higher than prescribed Resident #65 could accumulate more carbon dioxide. She said Resident #65's lung capacity was assessed at the prescribed level. <BR/>Record review of the facility's Oxygen Therapy policy, dated 4/2021, read in part, . it is the policy of this community to ensure all oxygen administration is conducted in a safe manner . Procedure: 1. Verify there is an order for oxygen administration to include: . b. flow rate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 6% based on 2 errors out of 31 opportunities, which involved 2 of 7 residents (Residents #36 and #32) reviewed for medication errors.<BR/>1. MA CC failed to apply Resident #36's lidocaine patch to the knee and foot, according to physician orders and applied a Lidocaine patch to Resident #36's shoulder only. <BR/>2. LVN Z failed to administer Reglan to Resident #32 according to physician orders and administered 12 mL instead of 10 mL.<BR/>These failures could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications.<BR/>Findings include: <BR/>1. Record review of Resident #36's face sheet revealed a [AGE] year-old female who was readmitted to the facility on [DATE]. She had diagnoses which included chronic pain, rheumatoid arthritis (a chronic inflammatory disease that affects the joints. This results in painful joints, swelling and stiffness in the joints), cerebral infarction (stroke), and hypertension (elevated blood pressure).<BR/>Record review of Resident #36's quarterly MDS assessment, dated 1/13/23, revealed a BIMS score of 15 out of 15, which indicated intact cognition. She required extensive assistance to total dependence on 1-2 staff for ADL care.<BR/>Record review of Resident #36's, undated, care plan revealed she had joint pain (personal history of shoulder pain and knee pain), and arthritis. Her interventions were to administer pain medications as ordered.<BR/>Record review of Resident #36's Order Summary Report for April 2023 revealed an order for Lidoderm external patch 5% (Lidocaine) apply to left, shoulder, knee, foot topically one time a day for pain .order date 3/8/23.<BR/>In an observation on 4/19/23 at 8:56 a.m. MA CC applied one Lidocaine patch 5% to Resident #36's left shoulder. <BR/>In an interview on 4/19/23 at 10:55 a.m., Resident #36 said MA CC did not apply a Lidocaine patch to her knee today. She said her knee always hurt and the patch helped very little. She said staff normally applied the Lidocaine patch to her left shoulder and sometimes applied it to her left knee and left foot. <BR/>In an observation on 4/19/23 at 1:26 p.m. with a CNA (unknown name) revealed there was no Lidocaine patch on Resident #36's left knee or left foot.<BR/>In an observation and interview on 4/19/23 at 1:37 p.m., MA CC said she applied the Lidoderm patch to Resident #36's left shoulder only because she was under the notion the order was for one patch as it was previously. She said she checked the eMAR and the label on the Lidocaine box for the directions to make sure it was given correctly. She said she was not sure what the order was this morning when she applied the patch. Observation of the pharmacy label on the Lidocaine box for Resident #36 revealed: apply to left shoulder, knee, foot topically, dated 4/8/23. MA CC reviewed the physicians order and said the directions were to apply the patch to the shoulder, knee and foot. MA CC said the Lidocaine patch was used for arthritis and said if they were not applied to her knee and foot the resident could be in pain. She said the DON and the ADON conducted the in-service to ensure staff administered the right medication and verified with the computer for accuracy.<BR/>In an interview on 4/21/23 at 11:36 a.m., the DON said Resident #36 was supposed to have three patches applied to her left side. She said Lidocaine was a local patch and if it was not applied to the knee or the foot, it would not work there. She said it could affect the resident because it was a pain patch. She said the physicians order instructed MA CC on how many patches to apply and where to put them.<BR/>2. Record review of Resident #32's face sheet revealed a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnosis included gastro-esophageal reflux disease (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), pneumonitis (mainly refers to inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath and fatigue) due to inhalation of food and vomit, acute embolism (blockage in the arterial (oxygen rich blood which flows from the heart to rest of the body) or venous (which carry deoxygenated blood from the organs to the heart) blood flow due to a blood clot), and thrombosis (the formation or presence of a blood clot in a blood vessel) of unspecified vein and dementia. <BR/>Record review of Resident #32's quarterly MDS assessment, dated 3/8/23, revealed a BIMS score of 11 out of 15, which indicated moderate cognitive impairment. She required extensive assistance of two staff for ADL care.<BR/>Record review of Resident #32's, undated, care plan revealed she had GERD and was at risk for abdominal pain and discomfort. Interventions were to give medications as ordered.<BR/>Record review of Resident #32's Order Summary Report for April 2023 revealed an order for Metoclopramide solution 5 mg / 5 mL give 10 mg by mouth every 6 hours for GERD, order date 3/27/23.<BR/>In an observation and interview on 4/18/23 at 12:57 p.m. revealed LVN Z prepared and administered 12.5 mL of Metoclopramide 5 mg/mL to Resident #32 by g-tube instead of 10 mL as prescribed by the physician. LVN Z said there was 10 mL of Metoclopramide and said she knew it was 10 mL because she referred to the line. The amount of red Metoclopramide liquid that LVN Z prepared was observed and was noticeably above the 10 mL line at eye level.<BR/>In an observation and interview on 4/18/23 at 1:25 p.m., LVN Z said she referred to the MD order to determine how much Metoclopramide to administer. The State Surveyor showed LVN Z the picture of the Metoclopramide liquid (which was taken by the State Surveyor) that was prepared for Resident #32 by LVN Z on 4/18/23 at 12:57 p.m. LVN Z said again the liquid was at 10 mL. She said Resident #32 was prescribed Reglan (Metoclopramide) for gas and acid reflux.<BR/>In an observation and interview on 4/21/23 at 11:36 a.m. the State Surveyor showed the DON, the same picture that was shown to LVN Z on 4/18/23 at 1:25 p.m. of the Metoclopramide liquid that was prepared for Resident #32 by LVN Z on 4/18/23 at 12:57 p.m. The DON said the Metoclopramide liquid was above the 10 mL line. She said staff were expected to prepare the liquid and verify it at eye level. She said Reglan was used for acid reflux and was a medication error if more liquid was given.<BR/>Record review of the facility's Oral Medication Administration policy, dated 9/2018, read in part, .medications will be administered in a safe and effective manner . Procedures: . 2. Review and confirm medication orders for each individual resident on the MAR prior to administering medications to each resident . 4. For liquid medications . b. pour the correct amount of medication directly into a graduated/calibrated medication sup or measuring device or use an oral syringe to pull up the correct amount. Measure the volume on a flat surface at eye level and read the volume from the bottom of the meniscus (curve)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>1. The facility failed to ensure the commercial oven, stove and wall were not soiled with any gummy/greasy substances. <BR/>2. The facility failed to ensure the deep fryer was not full of odiferous grease. <BR/>3. The facility failed to ensure 7 full-size sheet pans did not have baked-on brown substances.<BR/>These deficient practices could place residents at-risk by contributing to foodborne illness, poor intake, and/or weight loss.<BR/>Finding include: <BR/>Observation on 04/18/23 at 8:35 a.m. revealed the deep fryer was full of odiferous grease and had floating crumbs and debris on the surface. The commercial stove and oven were soiled with crumbs and dust on top and the wall behind it was soiled with a gummy substance. <BR/>Observation on 04/19/23 at 2:39 p.m. revealed the deep fryer was full of odiferous grease and had floating crumbs and debris on the surface. The commercial stove and oven were soiled with crumbs and dust on top and the wall behind it was soiled with a gummy substance. Further observation revealed a clean rack of dishes had 7 full-size sheet pan with baked-on brown substances. <BR/>Observation and interview on 04/19/23 3:01p.m., the Dietary Manager stated the commercial stove and oven were soiled with crumbs and dust was on top and the wall behind it was soiled with a gummy substance. She stated the deep fryer contained oil that was murky and soiled with crumbs and debris. When asked who was responsible for ensuring the walls were cleaned and who was responsible for changing the oil in the [NAME]. Why was it important for these items to be cleaned. How could the residents be affected by this failure. The Dietary Manager said frying oil was replaced by the cooks with fresh oil every Sunday because the facility served fish fry every Fridays. She said there were 3 cooks who worked at the kitchen. She said the AM cook made and served breakfast and made lunch. The PM cook served the lunch and made dinner. She said each cook was supposed to clean the stove after each meal. She said, this looks weeks worth of mess not just todays. She said there were some burn stains, but grease could easily be cleaned. She said, the could not get the baking tray to scrub and the would need new ones. The Dietary Manager stated she told the Administrator the kitchen needed new pans. She said she told the Administrator when she started working in the facility 3 and half months ago.<BR/>Observation and interview on 04/19/23 at 3:30 p.m. with the Dietary Manager and [NAME] A. when asked how often they cleaned. Why were these items not cleaned. Why was there build up. [NAME] A said each cook needed to clean the stove after cooking the meal because build up could catch on fire. <BR/>In an interview on 4/20/2023 at 10:20 a.m. with [NAME] B, she said she was the AM cook and stayed until 1:30 p.m. She said, sometimes they needed help because they had so many things and it's easy to fall behind and everything was on the line to be served and had to go out to the residents. She said the cook who came for lunch and dinner was supposed to wash their own dishes, everybody was responsible for cleaning the stove. [NAME] B stated Sometimes we are just too busy to clean the stove and it is all of our responsibility. <BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-602.13 Nonfood-Contact Surfaces, Nonfood-Contact Surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. <BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean.<BR/>Record review of the facility's Food Safety policy (effective date: 01/2018) read in part: .Policy: All food purchased will be wholesome, manufactured, processed, and prepared in compliance with all State, Federal, and local laws and regulations. Food will be handled in a safe and sanitary method to prevent contamination and food-borne illness .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure there was a communication process, which included how the communication would be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day for 1 of 2 residents (Resident #64) reviewed for hospice services. <BR/>-The facility failed to ensure there was hospice communication documentation for Resident #64 in her medical record or hospice communication binder.<BR/>This deficient practice could place residents at risk of treatments and services not being coordinated.<BR/>Findings include:<BR/>Record review of the admission sheet for Resident #64 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. She had diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) cognitive communication deficit (an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness) and dysphagia (Difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage).<BR/>Record review of Resident #64's Quarterly MDS, dated [DATE], revealed the BIMS score was 00. The staff assessment for mental status was conducted, the resident was unable to complete interview. Resident #64 had a short term memory problem, long term memory problem, and cognitive skills for daily decision making was severely impaired and she never/rarely made decision. She required total dependence from one-person physical assist for personal hygiene, toilet and transfer. The resident was always incontinent of bowel and bladder.<BR/>Record review of Resident #64's physician order, dated 02/27/23, revealed Resident admitted to [Hospice company name] with terminal DX: Alzheimer's Disease under the care of Dr. [AA] with n/o to continue all current treatments and medications.<BR/>Record review of Resident #64's Care plan, initiated 04/01/2019 and revised on 04/19/2023, revealed the following: <BR/>Focus: [Resident #64] admitted to [Hospice company] with terminal DX: Alzheimer's Disease<BR/>Goal: The resident's dignity and autonomy will be maintained at highest level through the review date<BR/>Interventions: Consult with physician and Social Services to have Hospice care for resident in the facility. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met.<BR/>Record review of Resident #64's Visitor Sign-in sheet revealed hospice staff visited her on the following days: 02/23/23, 02/24/23, 02/27/23, 03/06/23, 03/07/23 and 04/04/23. <BR/>Record Review of Resident #64's medical file revealed there was no documentation of any coordination of care or any communication with hospice company. <BR/>Observation and attempted interview with Resident #64 on 4/18/23 at 9:40 a.m., revealed the resident was resting on an air mattress. The resident did not respond to the questions asked about her stay at the facility. <BR/>In an interview and record review with LVN Z on 4/19/23 at 1: 37 p.m., she said she was the nurse for Resident #64. She said Resident #64 was receiving hospice services. She said she was not sure exactly what days the hospice came but she knew they came weekly. She said when the hospice aides came, they gave the resident a bed bath and the nurse would do assessments. She said the hospice staff always announced when they were there and asked the nurse if there were any concerns or anything they should be aware of or if they needed meds refilled. LVN Z said hospice staff communicated with the facility by always logging in their binder when they were there. She said they told them verbally what they did, and they also documented in their binders. When asked when was the last time the hospice came and what they did when they were there, she said, I need to check the binder. She reviewed the binder for Resident #64 with the State Surveyor and said, Looks like they were last here on today 04/04/23. LVN Z checked the hospice binder and said she could not find the documentation which stated what Hospice did while they were there. She checked the binder and said, there is no RN initial assessment or the weekly assessment. LVN Z stated she did not know who was responsible for ensuring hospice was documenting in the binder.<BR/>In an interview and record review on 4/19/23 at 2:02 p.m., with the DON reviewed Resident #64's hospice binder and said the hospice nurse came once a week and the hospice aides were supposed to come 3 times a week. When asked who was responsible for ensuring hospice notes were documented and the residents had a hospice plan of care. The DON said, she would get with hospice company to see what the plan was and to request current notes for the binder. She said it was important to have the current hospice plan of care for the resident if there were any changes to keep the facility informed and for communication purpose. <BR/>In an interview and record review on 4/20/23 at 12:02 p.m., with the Administrator and the DON, the DON said the Administrator contacted the hospice company yesterday (04/19/23) to send hospice documentation. The Administrator said the hospice company said the facility should have another hospice binder with all the communications/ documentation regarding Resident #64. The DON said, We told the hospice company we were unable to locate such folder. <BR/>Record review of facility's Hospice Program (Revised July 2017) read in part: .10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: d. communicating with the hospice provider (and documenting such communication) to ensure that the needs of the residents are addressed and met 24 hours per day. Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident; (2) Hospice election form; (3) physician certification and recertification of the terminal illness specific to each resident; (4) Names and contact information for hospice personnel involved in hospice care of each resident; (5) Instructions on how to access the hospice's 24-hour-on-call system; (6) Hospice medication information specific to each resident; and (7) Hospice physician and attending physician (if any) orders specific to each resident. 13. Coordinated care pan for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control process designed to provide safe and sanitary environment and to help prevent the development and transmission of diseases and infections for four (Residents #33, #37, #40 and #106) out of five Residents observed for infection control during medication administration: in handling of laundry and in wearing of face mask, in that:<BR/> - <BR/>LVN D and CMA E failed to sanitize blood pressure machine used for multiple residents during medication administration for residents #33, #37, #40 and #106.<BR/>- <BR/>The facility failed to ensure Laundry Provider D was transporting clean resident clothes down the 200 Hall with laundry cart covered. <BR/>- <BR/>The facility failed to ensure CNA A, and CNA B wore N95 masks properly. <BR/>These failures could place residents at risk of cross contamination and contracting of infectious diseases.<BR/>Findings included:<BR/>Transmission-Based Precautions<BR/>Observation on 02/22/22 at 12:04 PM revealed CNA A, and CNA B were not wearing N95 masks properly. The backstrap of the N95 was hanging underneath their chins. <BR/>During an interview on 02/22/22 at 12:09 PM, CNA A said he was not wearing his mask properly because he could hardly breath.<BR/>During a follow-up interview on 02/23/22 12:28 PM with CNA A, he said he was trained on infection control a couple of weeks ago. He said the training covered wearing masks appropriately, proper hand hygiene, donning and doffing PPE. <BR/>During an interview on 02/22/22 at 12:12 PM, CNA B said she was not wearing her mask properly because she could hardly breath and she forgot to put it on properly.<BR/>Observation on 02/22/22 at 12:15 PM revealed the Speech Therapist making contact with residents. She did not wash her hands or use hand sanitizer while cutting food for a resident during lunch service. <BR/>During an interview on 02/22/22 at 1:34 PM with the Speech Therapist, she said she was supposed to wash her hands in between residents during dining. She said there was not that many sanitizing stations in the area, so it was just easier to help the resident in need rather than to walk over to the sanitizing station. She said she normally used hand sanitizer at her building because there were sanitation stations on every wall which was not the case in this facility.<BR/>Observation and interview on 02/22/22 at 1:50 PM revealed the Activity Director passing out snacks. She said her role was to clean up her cart and pass out coffee, snacks, and other items. She said she also passed out juice, yogurt, and water. She said staff was supposed wash their hands and wear gloves and wash again between residents. She said she did not wear gloves today because it was a bad habit. She said she would do better. She said the facility could benefit from adding more sanitizing stations.<BR/>Universal Precautions<BR/>During observation on 2/23/2022 at 7:53 AM LVN D on the 200 Hall was using a blood pressure machine to check Resident #106 blood pressure but failed to sanitize the blood pressure machine after using it.<BR/>During observation on 2/23/2022 at 8:31AM LVN D went to Resident #40 to check his blood pressure using the same blood pressure machine she used on Resident #106 - again, LVN D failed to sanitize blood pressure machine before using it on Resident #40 and failed to sanitize the blood pressure machine after using it on the Resident #40. <BR/>During interview on 2/23/2022 at 9:49 AM LVN D agreed that failure to sanitize the equipment used for multiple residents was a compromise of infection control which could affect the residents.<BR/>During an observation on 2/23/2022 at 8:53 AM CMA E was took the blood pressure of Resident #37 but failed to sanitize the blood pressure machine after using it for the resident.<BR/>During an observation on 2/23/2022 at 9:15 AM, CMA E checked Resident #33's blood pressure using the same blood pressure machine she used on Resident #37 - again, CMA E failed to sanitize blood pressure machine before using it on Resident #33 she also failed to sanitize the blood pressure machine after using it on Resident #33. <BR/>During an interview on 2/23/2022 at 9:42 AM CMA E stated that she forgot. She stated that she had proper infection control training and was aware this could place residents at risk for infection. <BR/>Laundry<BR/>During an observation and interview on 2/23/22 at 9:00 am revealed Laundry Provider D was transporting clean resident clothes down the 200 Hall in an uncovered laundry cart. Laundry Provider D did not know if the clothing should have been covered while transporting it down the hallway. <BR/>Interview on 2/24/22 at 2:30 pm, the Director of Laundry Services revealed the laundry cart was always covered with a plastic tarp unless it was being loaded with clean clothing and should always be covered when it was transported down the hallways for infection control purposes. She stated it was important to make sure the clean clothing was not contaminated by anything it might contact while it was being moved down the hallways. <BR/>During an interview on 2/24/22 at 8:57 AM with the DON and the ADON, the DON stated they always trained their staff during hiring process and they provided ongoing training for them. The ADON stated they also had an online training portal where all employees were being assigned training on a regular basis. Both the DON and the ADON agreed staff were required to sanitize equipment used for multiple residents, as failure to sanitize equipment posed infection risk to residents, because they could pass any disease or virus from one patient to another.<BR/>During an interview on 2/24/22 at 8:57 AM with the DON, she said staff were supposed to wash or sanitize their hands when feeding the residents. She said after feeding one resident, staff should wash or sanitize before feeding another resident. She said all staff members were required to wear face mask to always cover mouth and nose. She said alteration of facemasks was not acceptable. She said staff were not required to wear gloves when passing out food, but they were required to wash or sanitize their hands.<BR/>During an interview on 2/24/22 at 10:00 AM surveyor requested a facility policy on infection control regarding equipment used for multiple residents, the DON stated they did not have any specific policy regarding equipment such as blood pressure machine used for multiple residents. However, DON stated it was required of employees to sanitize equipment such as stethoscope, blood pressure machine, Oxygen saturation machine, thermometer, etc. used for multiple residents. <BR/>Interview with the DON on 2/24/22 at 3:40 pm revealed the clean laundry cart should be covered with a plastic tarp or similar cover while it was being used to transport clean laundry down the hallways, to make sure it did not become contaminated with dust or anything it might touch. <BR/>Record review of facility's policy Departmental (Environmental Services) - Laundry and Linen, revised January 2014, revealed, in part: clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean carts .<BR/>Record review of the website https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html#g revealed, in part: .transport and store clean textiles and fabrics by methods that will ensure their cleanliness and protect them from dust and soil during interfacility loading, transport, and unloading .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 3 residents (CR#1 and Resident #2) reviewed for clinical records. <BR/>-The facility failed to ensure staff documented wound care treatments on CR#1 and Resident #2's MAR/TAR. <BR/>This failure could affect residents that received wound care and place them at risk of inaccurate or incomplete clinical records.<BR/>Findings include:<BR/>CR#1<BR/>Record review of the admission sheet (undated) for CR #1 revealed an [AGE] year-old female admitted to the facility on [DATE] and discharged on 08/31/2023. Her diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and hypertension (a condition in which the force of the blood against the artery walls is too high). <BR/>Record review of CR #1's Quarterly MDS assessment, dated 08/07/2023, revealed the BIMS score 05 out of 15 indicating severely impaired cognitively. She required total dependence from staff physical assist for personal hygiene, toilet and transfer. Resident was always incontinent of bowel and bladder. Further review of the MDS Section M: Skin Conditions. Risk for Pressure Ulcers/Injuries- Is this resident at risk of developing pressure ulcers/injuries coded Yes Unhealed pressure ulcers/injuries- Does this resident have one or more unhealed pressure ulcers/injuries coded No Number of Venous and Arterial Ulcers -Enter the total number of venous and arterial ulcer present was coded-0.<BR/>Record review of CR #1's care plan initiated 07/21/23 and revised on 8/24/23 revealed the following: <BR/>Focus: Resident has current skin concerns: DTI to right heel. Change to Arterial wound. DTI to left heel. Change to Arterial Wound. Vascular Consult. Goal: Areas will resolve without complications within the review date. Interventions/Task: 1. Perform treatments per MD orders. 2. Monitor areas for increase breakdown, s/s of infection and report to MD. 3. Monitor for pain, give med per order, monitor for relief. 4. Encourage PO and fluid intake within dietary limits. 5. Keep MD and RP informed of resident's progress.6. Assess skin weekly and record findings in clinical record.<BR/>Record review of CR#1's physician order dated 07/24/23 revealed an order to Clean right heel with wound cleanser, pat dry, apply skin prep daily. Leave open to air. Every day shift for Skin integrity. The order was discontinued on 08/14/23. <BR/>Record review of CR#1's physician order dated 08/24/23 revealed an order to clean left heel Arterial wound with wound cleanser. Pat dry apply Betadine solution cover with dry dressing everyday. Every day shift for Wound care.<BR/>Record review of CR#1's physician order dated 08/24/23 revealed an order to clean right heel arterial wound with wound cleanser. Pat dry apply Betadine cover with dry dressing everyday. Every day shift for Wound care.<BR/>Record review of CR #1's MAR/TAR for the month of August 2023 revealed Left heel and Right heel had blanks on the TAR indicating the treatment did not occur on 08/06/23, 08/10/23 and 08/29/23. <BR/>Record review of CR #1's nurses note for the month of August 2023 revealed there was no documentation of CR#1's treatments not being done, notification to the MD or a Nurse Practitioner of treatment not being done, or of CR#1's refusing treatment. There was no documentation indicating why the scheduled treatment was withheld or not administered as ordered.<BR/>Resident #2<BR/>Record review of the admission sheet (undated) for Resident #2 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), type 1 diabetes mellitus without complications (a chronic condition in which the pancreas produces little or no insulin) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). <BR/>Record review of Resident #2's Quarterly MDS assessment, dated 07/19/2023, revealed the BIMS score was 00. Assessment for mental status was conducted resident was unable to complete interview. Resident#2 has short term memory problem, long term memory problem, and cognitive skills for daily decision making is severely impaired never/rarely made decision. Further review of the MDS revealed she required supervision from staff for personal hygiene, toilet and transfer. Further review of Section M Skin Conditions F. Unstageable- Slough and/or eschar: Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar was coded-1.<BR/>Record review of Resident #2's Care plan initiated 06/14/2021 and revised on 08/01/2023 revealed the following: <BR/>Focus: Resident has current skin concerns: DTI to left heel. Goal: Areas will resolve without complications within the review date. Interventions/Task: 1. Perform treatments per MD orders. 2. Monitor areas for increase breakdown, s/s of infection and report to MD. 3. Monitor for pain, give med per order, monitor for relief. 4. Encourage PO and fluid intake within dietary limits. 5. Keep MD and RP informed of resident's progress. 6. Assess skin weekly and record findings in clinical record.<BR/>Record review of Resident#2's physician order dated 08/24/23 revealed an order to clean stage 4 left heel wound with wound cleanser. Pat dry apply hydrogel cover with dry dressing Every day. every day shift for Wound care.<BR/>Record review of Resident#2's MAR/TAR for the month of September 2023 revealed stage 4 left heel had blanks on the TAR indicating the treatment did not occur on 09/08/2023 and 09/09/2023. <BR/>Record review of Resident #2's nurses note for the month of September 2023 revealed there was no documentation of Resident#2's treatments not being done, notification to the MD or a Nurse Practitioner of treatment not being done, or of Resident#2's refusing treatment. There was no documentation indicating why the scheduled treatment was withheld or not administered as ordered.<BR/>In an interview on 09/18/2023 at 1:10p.m., with RN A, she said Wound Care Nurse performed wound care Monday to Friday. She said the floor nurses were responsible to perform wound care on the weekends and PRN dressing changes and to document on the TAR. <BR/>In an interview and record review on 09/18/2023 at 1:50p.m., Surveyor reviewed CR#1's and Resident #2's TAR/MAR, physician order and nurses note with the Wound Care Nurse. The Wound Care Nurse said for CR#1 Right heel and Left heel for 8/6/23, 8/10/23 and 8/29/23 and Resident#2's Left heel stage 4 treatment on 09/08/23 and 09/09/2023 the orders on the PCC (electronic medical record) were showing red indicating the treatment was not completed on those dates. She said once the treatment was completed, and the nurse signed off on the TAR the order would turn green. She said, maybe the system was down, and I forgot to go back and sign it. She said she worked Monday through Friday at this facility as a wound care nurse and was responsible for performing the facility's wound care and skin assessments. She said the floor nurses were responsible for completing the wound care on the weekends. She said one of the dates mentioned above was on a Saturday (09/09/2023). The Wound Care Nurse said she would go back and make a nurses notes that the treatment was performed for the open/blank spaces in TAR. <BR/>In an interview and record review on 09/18/2023 at 2:01p.m., Surveyor reviewed CR#1's and Resident #2's TAR, physician order and nurses note with the DON. The DON confirmed the Wound Care Nurse, and the floor nurses did not document on the TAR after performing the treatments in August/September 2023. She said there should not be any open/blank spaces in the MAR/TAR and that if it was not documented it means it was not completed. The DON said, there was no explanation for the holes in the MAR. The DON said she went over MAR/TAR once a week. She said there was an issue with PCC and the corporate had to send an email with issues. The DON said she could not recall the date when the PCC was having issues. <BR/>In an interview on 09/18/2023 at 2:09p.m., with the Administrator and the DON, the Administrator said PCC was having a glitch and some people's documentation were affected as it was shooting out multiple charting/documentation entries. The Administrator said he could not recall the dates when the PCC had a glitch and said he would email the Surveyor a copy of the email that was sent from corporate to PCC with the issues. <BR/>As of 09/25/23 Surveyor had not received any correspondence from the Administrator or the DON. <BR/>Record review of facility's Skin Management Policy (last revised: 10/06/2022) revealed read in part: .4. Treatment: Residents who decide not to comply with physician orders or nursing interventions will be educated on risk, physician and responsible party notified, and documentation will be completed in resident's chart. Nursing staff will provide ongoing education and documentation as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of (Residents #41, #26, #16, #46) of 14 residents reviewed for care plans. <BR/>- <BR/>The facility failed to ensure Resident #41 was care planned for hospice care <BR/>- <BR/>The facility failed to ensure Resident #16 and #46 were care planned for ADL's.<BR/>- <BR/>The facility failed to ensure Resident #26 was care planned for behaviors.<BR/>These failure could place residents at risk of not receiving care and services related to their identified needs.<BR/>Findings included: <BR/>Resident #41<BR/>1. Record review of Resident # 41's admission records face sheet dated 2/23/22 revealed he was [AGE] year-old male admitted to the facility 10/12/20 His diagnoses included Epilepsy, benign tumor (soft tissue tumors). Muscle wasting, urinary tract infection and age-related physical conditions. <BR/>Review of Resident #41's Physician Orders dated 05/07/21 revealed -admission to local Hospice <BR/>Record review of Resident #41's MDS assessment dated [DATE] revealed section O on specialized treatment, procedure and program was checked for hospice care.<BR/>Record review of Resident #41's care plan dated 05/04/21 revealed no care plan for hospice care. <BR/>During an interview with the facility DON on 02/24/22 at 2:00PM she said the MDS coordinators are responsible for ensuring that the MDS accurately reflect Resident's condition. <BR/> During an interview with MDS Nurse A on 02/24/22 at 3:30pm, he acknowledged that the care plan for Resident # 41 was not accurate. He said Resident # 41's care plan would be corrected to reflect their condition. He said he was responsible for ensuring that all MDS assessments reflect Resident's condition.<BR/>Resident #26<BR/>2. Record review of Resident #26's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, hypertension, and multiple sclerosis.<BR/>Record review of Resident #26's MDS, dated [DATE] revealed the resident's BIMS assessment was unable to be completed due to resident being never or rarely understood. The resident was not assessed to have any psychiatric disorders.<BR/>Record review of Resident #26's physician's orders, dated as of 02/22/2022 revealed the resident was taking clonazepam and buspirone for anxiety starting 12/17/2021, trazadone for sleep/depression starting 12/17/2021, Seroquel for bipolar disorder starting 02/17/2021.<BR/>Record review of Resident #26's care plan, as of 02/22/2022, revealed the only note made about resident's behavior was, . The resident has a behavior problem in which she sits on the floors and other objects despite encouragement not to do so. There were no other notes regarding resident behavior or psychiatric-related diagnoses.<BR/>Record review of Resident #95's face sheet revealed an [AGE] year-old male who was admitted on [DATE] and was diagnosed with cognitive communication deficit, psychosis and dementia. <BR/>Observations of Resident #26 and #95 on 02/22/22 at 10:30AM revealed Resident #26 sitting in a wheelchair while yelling at and cursing out surveyor after surveyor asked for CMA J and LVN R for location of a room number. Resident #26 was then observed passing nearby Resident #95 as he slept in the hallway on a Geri-chair. Resident #26 yelled wake-up while swiftly brushing Resident #95's cheek with her hand. CMA J was observed to quickly remove Resident #26 from Resident #95. Resident #26 was later observed to cry out loud while asking for her son.<BR/>In an interview with CMA J on 02/24/22 at 1:05 PM, she stated Resident #26 was aggressive, gets upset and calls her sons' name. She said the resident gets up to fight with staff as if she is preparing to defend her son. She went up towards Resident #95 on 02/22/22 and brushed his face she believed with the intention to get his attention so he could move out of the way. She usually does not fight other residents. <BR/>In an interview with LVN R on 02/24/22 at 1:50PM, she stated Resident #26's behaviors included shouting and looking for her children and when hearing a random person's voice, she thinks its her son talking. She does not harm residents but she touches residents sometimes with the intention of going where she wants to go or probably due to vision problems. She stated this type of behavior should be documented and care planned. <BR/>In an interview with the Administrator on 02/25/22 at 10:31AM he stated has never seen Resident #26 hit a resident before but he knows the resident has her outbursts due to her behaviors. He stated he expects behavior monitoring to be care planned for her psychiatric diagnoses as well as psychotropic medication usage.<BR/>In an interview with the DON on 02/25/22 PM, she stated Resident #26's only behavior that she had noticed was screaming and yelling. She stated she is on medications that have been adjusted by her psych provider. She said this type of behavior should be care planned. She stated they usually have care meetings on Friday with nurse department team and they make updates to resident care plans then. She said her care plan was likely missed because they did not talk about her behaviors during a meeting yet. She stated the implication of not care planning behaviors is not having care and needs followed up on with interventions and goals to manage behaviors in place<BR/>In an interview with MDS Nurse A and MDS Nurse B on 02/25/22 at 11:44AM, MDS Nurse A stated Resident #26 was initially in the secured unit and shows aggressive behavior and curses people out and therefore had to leave the secured unit. He said she admitted back into the facility's general community after getting her medications adjusted during her discharge. He stated behaviors settled down but slowly came back. MDS Nurse B said these behaviors should have been care planned and if the resident is on psych meds it should have been triggered in the care plan as well. <BR/>Resident #16<BR/>3. Record review of the face sheet for Resident # 16 revealed a [AGE] year-old female with initial admission date of 6/7/21, and re-admission date 2/15/22. Diagnoses included Schizophrenia, Bipolar disorder, anxiety disorder, dementia without behavioral disturbance, Epileptic seizures, hypertension, and Multiple Sclerosis. <BR/>Record review of the quarterly MDS dated [DATE] revealed Resident # 16 had unclear speech and sometimes understood and sometimes understands others. Resident # 16's BIMS score was 3 indicating severely impaired cognitive skills for daily decision making and required total staff assistance for bed mobility, transfer, dressing, hygiene, toileting, and bathing. <BR/>Record review of Resident# 16's care plan, undated, revealed there was no care plan developed for ADL's, including interventions for ADL assistance. <BR/>Observation and attempted interview with Resident # 16 on 2/22/22 at 9:40 am revealed she was in bed, awake and alert. Resident had clean linens, catheter bag at bedside draining clear urine, and an IV pole with medications being infused for UTI. Resident # 16 stated I'm tired and closed her eyes when an interview was attempted. <BR/>Observation and attempted interview with Resident # 16 on 2/23/22 at 9:15 am revealed she was in bed, awake and alert. Resident # 16 stated Who are you? Bye and closed her eyes when an interview was attempted.<BR/>Resident #46<BR/>4. Record review of the face sheet for Resident #46 revealed a [AGE] year-old male with admission date of 1/06/21. Diagnoses included Parkinson's disease, need for assistance with personal care, dementia without behavioral disturbance, Diabetes, hypertension, Schizophrenia, Benign Prostatic Hyperplasia (enlarged prostate), and paralysis following cerebral infarction (stroke). <BR/>Record review of the Annual MDS dated [DATE] revealed Resident # 46's cognitive skills for daily decision making were moderately impaired, and he required extensive assistance from staff for bed mobility, transfer, dressing, hygiene, toileting, and bathing. Record review of the Care Area Assessment (CAA) Summary revealed ADL/Functional/Rehabilitation Potential was not triggered. <BR/>Record review of Resident #46's care plan, undated, revealed there was no care plan developed for ADL assistance, including appropriate interventions for ADL care. <BR/>In an interview with MDS Nurse A on 2/24/22 at 10:10 am revealed ADLs were not triggered in the Care Area Assessment for Resident's # 16 and #46, so the care plan for ADL's was not developed. MDS Nurse A stated the care plans were developed from the comprehensive assessment for each resident, and if the CAA's are triggered for a particular area, a care plan would be done for that care area. <BR/>Record review of the facility policy Care Planning - Interdisciplinary Team, dated September 2013, revealed, in part: .the care plan is based on the resident's comprehensive assessment and is developed by the Care Planning/Interdisciplinary Team .<BR/>Record review of facility's provided care plans policy dated 2001 revised September 2013 read in part . our facility 's care planning/interdisciplinary team is the responsibility for the development of an individualized comprehensive care plan for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Resident #3) reviewed for pressure ulcers received care to prevent pressure ulcers and necessary treatment and services, consistent with professional standards of practice, to promote healing, in that:<BR/>- <BR/>Resident #3 was noted to have a wound on her sacrum by CNA R on 01/22/22, but no wound assessment, wound care or treatment was provided to the resident until 01/26/22.<BR/>- <BR/>The facility nursing staff assessed Resident #3 to have no skin abnormalities on 01/21/22 but on 01/26/22 was later assessed to have two stage 3 pressure ulcers - full thickness skin loss potentially extending into subcutaneous tissue layers.<BR/>This failure caused a resident to develop pressure ulcers and could place other residents at risk of development or worsening of pressure ulcers.<BR/>Findings included:<BR/>Record review of Resident #3's undated face sheet revealed a [AGE] year-old female who was admitted into the facility initially on 10/29/2014, and was diagnosed with protein-calorie malnutrition, abnormal weight loss and dysphagia.<BR/>Record review of Resident #3's Braden scale for predicting pressure ulcer risk, dated 02/08/2022, revealed resident was categorized to have a moderate risk for developing pressure ulcers with a score of 14, with 18 being the highest risk score.<BR/>Record review of Resident #3's care plan, dated 02/24/2022, revealed the resident was at risk for skin breakdown/pressure ulcers due to incontinence and immobility. The goal was for the resident to maintain or develop intact skin with the invention of inspecting skin morning and evenings and during showers or ADL care, also, to document each incident of skin problems to prevent further occurrences.<BR/>Record review of Resident #3's MDS, dated [DATE], revealed the resident had an incomplete BIMS score, indicating assessment of cognition level was unable to be done or the resident was rarely/never understood, and was a two+ person assist for bed mobility and transfers.<BR/>Record review of Resident #3's weekly skin assessments revealed the resident was noted to not have any skin issues on 01/07/22, 01/14/22, and 01/21/22. <BR/>Record review of Resident #3's skin monitoring/shower review sheets revealed on 01/22/22, the resident was noted to have a wound on sacrum by CNA R. This review was signed off by an unidentified nurse. <BR/>Record review of Resident #3's nurses notes revealed no notes were written concerning resident skin condition from 01/21/22 to 01/25/22. <BR/>Record review of Resident #3's weekly wound assessment, dated 01/26/22, revealed a new stage 3 pressure wound on her coccyx measuring 0.4cm by 0.5cm by 0.1cm with an open wound bed with moderate, clear exudate. Treatments for this wound included calcium alginate, daily wound treatment and low air loss mattress. The resident's physician and family member were notified on this date.<BR/>Record review of Resident #3's weekly wound assessment, dated 01/26/22, revealed a new stage 3 pressure wound on her sacrum measuring 3.1cm by 4.2cm by 0.1cm with an open wound bed with moderate, clear exudate. Treatment for this wound included calcium alginate daily, daily wound treatment, vitamin therapy, protein supplement and low air loss mattress. The resident's physician and family member were notified on this date.<BR/>In an interview with the Wound Care Nurse on 02/24/2022 at 10:54AM, she stated she was the main wound care and treatment nurse that stages the wounds during assessments. Other nurses' duties for wound care are to document on resident skin discoloration, open skin, redness and any change of conditions should be notified to her. She stated the date 01/26/2022 was when she was made aware of Resident #3's wounds. She stated wounds can happen overnight, especially with the resident not getting adequate nutrition or is experiencing a decline. She stated she does not go through the shower sheets but they usually verbally report to her if there are resident skin concerns. She stated she could not remember if she was notified about Resident #3's wound by another nursing staff or if she caught it during routine weekly assessments. She stated she was unaware of the note on the wound on sacrum made on Resident #3's skin shower sheet, dated 01/22/22 but based on the timing of the documentation, there was a delay in treatment if no assessment was done on that day. She stated the consequences of not documenting and communicating skin concerns could lead to possible neglect of the health of the resident.<BR/>A phone interview was attempted with CNA R on 02/24/22 at 12:16PM. Both attempts failed.<BR/>In an interview with the CNA M on 02/24/22 at 11:34AM, she stated she had given Resident #3 a shower and if she were to see any skin issues such as redness, or marks, she would notify her charge nurse because she knew it could have the potential of developing into a wound. She stated sometime in January, date unknown, she remembered notifying a charge nurse, likely LVN R but she was not sure, about seeing a red mark on her butt and got the nurse to assess it. She stated there was no open skin at that time but the charge nurse applied A&D ointment and said it was okay. She said the charge nurse thanked her for letting her see it and walk out of the room, she did not know if anything was done afterwards about it.<BR/>In an interview with CNA D on 02/24/22 at 11:45AM, she stated, she had worked with Resident #3 and gave the resident a bed bath, date unknown. She stated remember while doing her bed bath at one point, the resident's back looked red on the middle part of her back and on the side of her cheek, but there was no sore on it. She stated she notified her charge nurse, unsure which nurse, and put A&D ointment on the resident. She stated she forgot to note anything on her shower sheet indicating the redness and where it was located. She said it slipped her mind to do it but generally it was supposed to be done.<BR/>In an interview with LVN R on 02/24/22 at 1:50PM, she said she did not sign off on any of the shower sheets from 01/18 /22 - 01/25/22. When asked if she was expected to sign it, she said sometimes the sheets can go unsigned for up to two days because they rushed and dropped it in the resident's room, so she and nurses will sign it later based on seeing if it appears as if the resident had a bath. She said around the time the resident was assessed with the wound, she stated she was notified by a CNA of the redness that was seen near the resident's sacrum. She said she went to look at the patient and saw no broken skin but it just looked like she was laying on her side too long. At the moment she remembers applying A&D ointment and as she came out of the room, she saw the Wound Care Nurse and notified her at that time about the redness. She stated she did not document her findings because the Wound Care Nurse is usually good about following up on the resident's skin conditions. She said she was unaware of the shower sheet written on 1/22/22 that noted the wound on Resident #3's sacrum. She said based on the time the note was made and the assessment was documented 1/26/22, she recognized there was a delay in communication. She said she remembered on a Monday, 01/24/22 she had said to herself how come no one said that this woman's butt is red . Oh, so nobody said anything throughout the weekend? She stated the expectation of CNAs were to report skin abnormalities to her. She stated that she, as the charge nurse, she was supposed to notify the physician and family and the wound nurse all verbally or over the phone, but she did not document it because she would only take full responsibility of assessing and documenting skin concerns unless the Wound Care Nurse was not in the building at the time. She said in the nursing field if she did not write it down it meant she did not do it. <BR/>In an interview with the DON on 02/24/22 at 4:00PM, she stated nursing care to prevent skin breakdown includes turning, more frequent changes, use of cream A&D and zinc ointment. She said Resident #3 used to get up but resident stopped eating because she was grinding her teeth and could no longer open her mouth, and as a result, she had peg tube placed in February 2022. She stated due to Resident #3's decline with weight loss, the bony areas become more prominent placing her at risk for skin breakdown. She said redness of the skin is usually the first sign for skin breakdown and if CNAs saw it, they are expected to document on the shower sheet and notify the nurse, the nurse is expected to notify the doctor and who would place a standing order for wound care. She stated the nurses are responsible for noting skin concerns and if the skin is open, the nurse should notify the doctor, and put in an order for wound care that would have started no later than the next day. She said she was not notified of resident having red skin before the Resident #3's was diagnosed with stage 3 wounds. She said the nurse on duty at the time the wound was first noted should have had the order placed that day and dress the wound herself. She stated the Wound Care Nurse wound be responsible for re-assessing the wounds with measurements and provided additional treatments if necessary. She stated based on the timing from which the wound was first noted on the shower sheet to when the wounds were assessed, there was a delay in the provision of care or care the was not being documented at all. She said the implication of not documenting the development of a wound and relying on wound care to make all assessments is a delay in treatment.<BR/>Observation of Resident #3's wound care on 02/25/22 at 11:09AM, one sacral wound 8 by 5 cm with eschar tissue in the center and white skin on the edges of the wound.<BR/>Record review of the facility's policy on Skin Management System, undated, stated, . Routine weekly checks will be completed on the Skin observation Tool on every resident; if skin is intact it will be noted as such. If a new pressure sore is noted, a Weekly Wound Observation Form will be started CNA's will note any alteration in skin integrity during care in [EHR] and reported to the Charge Nurse . Keep open lines of communication with physicians, families, and residents regarding status of wounds.

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control process designed to provide safe and sanitary environment and to help prevent the development and transmission of diseases and infections for four (Residents #33, #37, #40 and #106) out of five Residents observed for infection control during medication administration: in handling of laundry and in wearing of face mask, in that:<BR/> - <BR/>LVN D and CMA E failed to sanitize blood pressure machine used for multiple residents during medication administration for residents #33, #37, #40 and #106.<BR/>- <BR/>The facility failed to ensure Laundry Provider D was transporting clean resident clothes down the 200 Hall with laundry cart covered. <BR/>- <BR/>The facility failed to ensure CNA A, and CNA B wore N95 masks properly. <BR/>These failures could place residents at risk of cross contamination and contracting of infectious diseases.<BR/>Findings included:<BR/>Transmission-Based Precautions<BR/>Observation on 02/22/22 at 12:04 PM revealed CNA A, and CNA B were not wearing N95 masks properly. The backstrap of the N95 was hanging underneath their chins. <BR/>During an interview on 02/22/22 at 12:09 PM, CNA A said he was not wearing his mask properly because he could hardly breath.<BR/>During a follow-up interview on 02/23/22 12:28 PM with CNA A, he said he was trained on infection control a couple of weeks ago. He said the training covered wearing masks appropriately, proper hand hygiene, donning and doffing PPE. <BR/>During an interview on 02/22/22 at 12:12 PM, CNA B said she was not wearing her mask properly because she could hardly breath and she forgot to put it on properly.<BR/>Observation on 02/22/22 at 12:15 PM revealed the Speech Therapist making contact with residents. She did not wash her hands or use hand sanitizer while cutting food for a resident during lunch service. <BR/>During an interview on 02/22/22 at 1:34 PM with the Speech Therapist, she said she was supposed to wash her hands in between residents during dining. She said there was not that many sanitizing stations in the area, so it was just easier to help the resident in need rather than to walk over to the sanitizing station. She said she normally used hand sanitizer at her building because there were sanitation stations on every wall which was not the case in this facility.<BR/>Observation and interview on 02/22/22 at 1:50 PM revealed the Activity Director passing out snacks. She said her role was to clean up her cart and pass out coffee, snacks, and other items. She said she also passed out juice, yogurt, and water. She said staff was supposed wash their hands and wear gloves and wash again between residents. She said she did not wear gloves today because it was a bad habit. She said she would do better. She said the facility could benefit from adding more sanitizing stations.<BR/>Universal Precautions<BR/>During observation on 2/23/2022 at 7:53 AM LVN D on the 200 Hall was using a blood pressure machine to check Resident #106 blood pressure but failed to sanitize the blood pressure machine after using it.<BR/>During observation on 2/23/2022 at 8:31AM LVN D went to Resident #40 to check his blood pressure using the same blood pressure machine she used on Resident #106 - again, LVN D failed to sanitize blood pressure machine before using it on Resident #40 and failed to sanitize the blood pressure machine after using it on the Resident #40. <BR/>During interview on 2/23/2022 at 9:49 AM LVN D agreed that failure to sanitize the equipment used for multiple residents was a compromise of infection control which could affect the residents.<BR/>During an observation on 2/23/2022 at 8:53 AM CMA E was took the blood pressure of Resident #37 but failed to sanitize the blood pressure machine after using it for the resident.<BR/>During an observation on 2/23/2022 at 9:15 AM, CMA E checked Resident #33's blood pressure using the same blood pressure machine she used on Resident #37 - again, CMA E failed to sanitize blood pressure machine before using it on Resident #33 she also failed to sanitize the blood pressure machine after using it on Resident #33. <BR/>During an interview on 2/23/2022 at 9:42 AM CMA E stated that she forgot. She stated that she had proper infection control training and was aware this could place residents at risk for infection. <BR/>Laundry<BR/>During an observation and interview on 2/23/22 at 9:00 am revealed Laundry Provider D was transporting clean resident clothes down the 200 Hall in an uncovered laundry cart. Laundry Provider D did not know if the clothing should have been covered while transporting it down the hallway. <BR/>Interview on 2/24/22 at 2:30 pm, the Director of Laundry Services revealed the laundry cart was always covered with a plastic tarp unless it was being loaded with clean clothing and should always be covered when it was transported down the hallways for infection control purposes. She stated it was important to make sure the clean clothing was not contaminated by anything it might contact while it was being moved down the hallways. <BR/>During an interview on 2/24/22 at 8:57 AM with the DON and the ADON, the DON stated they always trained their staff during hiring process and they provided ongoing training for them. The ADON stated they also had an online training portal where all employees were being assigned training on a regular basis. Both the DON and the ADON agreed staff were required to sanitize equipment used for multiple residents, as failure to sanitize equipment posed infection risk to residents, because they could pass any disease or virus from one patient to another.<BR/>During an interview on 2/24/22 at 8:57 AM with the DON, she said staff were supposed to wash or sanitize their hands when feeding the residents. She said after feeding one resident, staff should wash or sanitize before feeding another resident. She said all staff members were required to wear face mask to always cover mouth and nose. She said alteration of facemasks was not acceptable. She said staff were not required to wear gloves when passing out food, but they were required to wash or sanitize their hands.<BR/>During an interview on 2/24/22 at 10:00 AM surveyor requested a facility policy on infection control regarding equipment used for multiple residents, the DON stated they did not have any specific policy regarding equipment such as blood pressure machine used for multiple residents. However, DON stated it was required of employees to sanitize equipment such as stethoscope, blood pressure machine, Oxygen saturation machine, thermometer, etc. used for multiple residents. <BR/>Interview with the DON on 2/24/22 at 3:40 pm revealed the clean laundry cart should be covered with a plastic tarp or similar cover while it was being used to transport clean laundry down the hallways, to make sure it did not become contaminated with dust or anything it might touch. <BR/>Record review of facility's policy Departmental (Environmental Services) - Laundry and Linen, revised January 2014, revealed, in part: clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean carts .<BR/>Record review of the website https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html#g revealed, in part: .transport and store clean textiles and fabrics by methods that will ensure their cleanliness and protect them from dust and soil during interfacility loading, transport, and unloading .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to have evidence that all alleged violations are thoroughly investigated for 6 of 7 residents reviewed for abuse and neglect (Resident #1, #2, #3, #4, #5, #6).<BR/>- The facility failed to have evidence that a thorough investigation was conducted, failed to complete a provider investigative report (Form 3613A) and failed to report the results of the investigation to the State Survey Agency within 5 working days the results of the investigation for an allegation of Neglect for Resident #1. <BR/>-The facility failed to have evidence that a thorough investigation was conducted, failed to complete a provider investigative report (Form 3613A) and failed to report the results of the investigation to the State Survey Agency within 5 working days the results of the investigation for an allegation of abuse when Resident #2 and Resident #3 had a resident-to resident altercation. <BR/>-The facility failed to have evidence that a thorough investigation was conducted, failed to complete a provider investigative report (Form 3613A) and failed to report the results of the investigation to the State Survey Agency within 5 working days the results of the investigation for an allegation injury of unknown origin for Resident #4.<BR/>- The facility failed to have evidence that a thorough investigation was conducted, failed to complete a provider investigative report (Form 3613A) and failed to report the results of the investigation to the State Survey Agency within 5 working days the results of the investigation for an allegation injury of unknown origin for Resident #5.<BR/>-The facility failed to have evidence that a thorough investigation was conducted, failed to complete a provider investigative report (Form 3613A) and failed to report the results of the investigation to the State Survey Agency within 5 working days the results of the investigation for an allegation of Neglect for Resident #6.<BR/>These deficient practice could affect residents and could contribute to further neglect.<BR/>Findings included:<BR/>Resident #1<BR/>Record review of the admission sheet undated for Resident # 1 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included Huntington's disease (a progressive brain disorder caused by a defective gene), fracture of medial orbital wall, right side, subsequent encounter for fracture with routine healing (a break or crack in the bone that surrounds and protects your eye) and cognitive communication deficit (difficulty with thinking and how someone uses language). <BR/>Record Review of Resident #1's comprehensive MDS assessment dated [DATE] revealed the BIMS score was 00 indicating severely impaired cognitive skills. Further review of the MDS revealed that she required extensive assistance from staff for dressing, toilet use and personal hygiene. The resident was incontinent of bowel and bladder.<BR/>Record Review of Resident #1's Care Plan dated 09/23/2021 revealed the following: <BR/>Focus: I am at risk for increased falls and fractures as evidence by: Huntington diseases physical impairment, unsteady gait 12/6/2022: Resident reported with fracture of the right median orbital wall at the hospital post transfer to hospital. <BR/>Goal: Will be free from preventable falls through review date. <BR/>Interventions: Anticipate needs, provide prompt assistance. Assure lighting is adequate and areas are free of clutter. <BR/>Observation and attempted interview on 01/30/23 at 10:04 a.m., revealed Resident #1 was laying on the floor mat next to her bed, gesturing for the Surveyor to pick her off the floor mat. At this time, Surveyor requested help from CNA A to get resident off the floor mat to her bed. The resident had a helmet on. The resident mumbled for 5 minutes while being interviewed and could not make self-understood and did not respond appropriately to asked questions. <BR/>Record review of intake# 392853 dated 12/6/22 read in part: . the reporter first learned of the incident on 12/06/2022, at 03:14 pm. On 11/28/2022, [Resident #1] had a witnessed fall as she was running and fell forward. The resident was assessed by LVN A, on 11/28/2022, at 08:30 am, noting the resident had a split on her lips. The next day, the resident had a change in condition, with redness around her eye and slight confusion. She was transported to [hospital name], where there were zero findings when she was sent out initially on 11/28/2022. On 11/29/2022, the resident was transported to [hospital name], where it was discovered that the resident has an orbital fracture . <BR/>Record review of intake# 392171 dated 12/02/22 read in part: .the complainant reported the doctor stated [Resident#1]'s injuries are worrisome for possible other otology as opposed to a fall. The doctor is concerned the injury does not match the fall. The incident was unwitnessed. The resident has history of self injuries [sic] behavior and banging of head on the wall. [Resident #1] has been evaluated by doctors. CT scan results show no acute intercranial hemorrhage or significant mass effect. The resident is diagnosed with aspiration pneumonitis, fall, medial orbital wall right side closed fracture .<BR/>Record review of Resident #1's chart revealed there was no documentation indicating that an in-house investigation had been done. There were no interviews from staff members. No written statement was collected from the nurse and CNAs on duty. There was no Provider Investigation Report form 3613A in the folder. <BR/>Record review in TULIP revealed a 3613 was not submitted as of 01/30/2023<BR/>Resident #2<BR/>Record review of a face sheet and physician orders dated November 2022 indicated Resident #2 was a [AGE] year-old male admitted on [DATE]. His diagnoses included loss of memory with a mental disorder characterized by a disconnection from reality, high blood pressure, and a condition in which the kidneys are damaged and cannot filter blood as well as they should.<BR/>Record review of Resident #2's comprehensive MDS dated [DATE], reflected Resident had severely impaired cognition and he had no behaviors. <BR/>Record review of a care plan dated 10/15/22 indicated Resident #2 had no behaviors and received an antipsychotic medication. <BR/>Resident #3<BR/>Record review of a face sheet and physician orders dated October 2022 indicated Resident #3 was a [AGE] year-old male admitted on [DATE]. His diagnoses included loss of memory; a serious mental illness that affects how a person thinks, feels, and behaves; a disorder associated with episodes of mood swings ranging from depressive lows to manic highs; a mental disorder characterized by a disconnection from reality; a chronic condition that affects the way the body processes blood sugar; high blood pressure; and a condition in which the kidneys are damaged and cannot filter blood as well as they should.<BR/>Record review Resident #3's MDS dated [DATE] indicated Resident had moderately impaired cognition; had wandering behaviors and other behavioral symptoms not directed toward others 1-3 days during the lookback period; and required limited assistance in performing all activities of daily living. <BR/>Record review of a care plan dated 09/29/22 indicated Resident #3<BR/>-had potential to be physically aggressive r/t Anger, Dementia, Poor impulse control AEB<BR/>8/18/22- Physically aggressive towards another resident<BR/>10/8/22- Physically aggressive towards another resident; <BR/>-received an antidepressant for depression;<BR/>-received an antipsychotic for psychosis; and<BR/>-received an antianxiety for anxiety.<BR/>Record review of an investigation folder provided by the facility regarding an incident with Resident #2 and Resident #3 dated 10/08/22 included the residents' face sheets; an incident report dated 10/08/22 about Resident #2 being hit in the face by Resident #3, there was small red mark found during the assessment on Resident #2's face, Resident #3 was placed on 1:1; and Resident #3 was sent to a psychiatric hospital for admission; and a Provider Investigation Report form 3613A dated 10/08/22. There were no interviews with other residents, there were no interviews with staff about the incident, there was no in-service on abuse and neglect, and there was no indication the report or investigation had been sent to the State Agency.<BR/>Record review in TULIP revealed a 3613 was not submitted as of 01/30/2023<BR/>Resident #4<BR/>Record review of her face sheet and physician orders dated January 2023, indicated Resident #4 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included alcohol dependence with alcohol-induced loss of memory; a serious mental illness that affects how a person thinks, feels, and behaves; a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania; major depression disorder; and a chronic condition that affects the way the body processes blood sugar.<BR/>Record review of an MDS dated [DATE] indicated Resident #4 had severely impaired cognition. <BR/>During an observation and interview on 01/30/23 Resident #4 was in her bed. She was clean, well-groomed with no unpleasant odor. There was no visible bruising, skin tears or marks. She said she was fine and everyone was really nice.<BR/>Record review of an investigation folder provided by the facility regarding an incident with Resident #4 dated 12/12/22 included her face sheet, an incident report dated 12/12/22 about the resident being found with a discoloration to her face and the resident saying her roommate tapped her on her face while she was asleep, an x-ray report dated 12/12/22 indicating no injury, and abuse questionnaires conducted with other residents. There were no interviews with staff regarding the incident, there was no in-service on abuse and neglect, there was no Provider Investigation Report form 3613A in the folder. <BR/>Record review in TULIP revealed a 3613 was not submitted as of 01/30/2023<BR/>Resident #5<BR/>Record review of the admission sheet undated for Resident # 5 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included fracture of unspecified part of neck of right femur, cognitive communication deficit and hyperlipemia. <BR/>Record Review of Resident #5's comprehensive MDS assessment dated [DATE] revealed the BIMS score was 00 indicating severely impaired cognitive skills. Further review of the MDS revealed that she required extensive assistance from staff for dressing, toilet use and personal hygiene. The resident was incontinent of bowel and bladder.<BR/>Record review of Resident#5's care plan initiated 10/18/22 revealed the following: <BR/>Focus: I have a HX of falls and am at risk for increased falls and fractures as evidence by: History of falls, cognitive impairment, unsteady gait, generalized weakness.<BR/>Goal: will be free from preventable falls through review date.<BR/>Interventions: (1/13/23) actual fall, anticipate needs, provide prompt assistance. <BR/>Record review of Resident #5's incident report dated 1/13/2023 read in part: .Incident description: Assigned aid [sic] observe resident in the restroom sitting on the floor upon making round. Nurse asses [sic] resident with redness noted to right side of the face. Resident Description: Resident unable to give description .<BR/>Record review of Resident #5's chart revealed there was no documentation indicating that an in-house investigation had been done. There were no interviews from staff members. No written statement was collected from the nurse and CNAs on duty. There was no Provider Investigation Report form 3613A in the folder. <BR/>Record review in TULIP revealed a 3613 was not submitted as of 01/30/2023<BR/>Observation and attempted interview on 01/30/23 at 10:32 a.m., revealed Resident #5 was resting in bed, alert and well groomed. The resident mumbled for 5 minutes while being interviewed and could not make self-understood and did not respond appropriately to asked questions. <BR/>Resident #6<BR/>Record review of the admission sheet undated for Resident # 6 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cognitive communication deficit, anxiety disorder and unspecified dementia, moderate with agitation.<BR/>Record Review of Resident #6's comprehensive MDS assessment dated [DATE] revealed the BIMS score was 03 indicating severely impaired cognitive skills. Further review of the MDS revealed that she required extensive assistance from staff for dressing, toilet use and personal hygiene. The resident was incontinent of bowel and bladder.<BR/>Record review of Resident #6's care plan initiated 10/07/2022 revealed the following: <BR/>Focus: 12/17/22 Resident #6 slammed door on her right finger, has acute mildly displaced fracture of the ring finger. <BR/>Goal: I will maintain ADL/current mobility status throughout the review date. <BR/>Interventions: Assess resident's potential for restorative program as needed. Provide appropriate level of assistance to promote safety of resident. <BR/>Record review of Resident #6's incident report dated 12/12/2022 read in part: .Self-inflicted. Incident Description: writer observed resident slammed the door to her room on the right hand while trying to stop another resident to her room .<BR/>Record review of intake# 395082 dated 12/17/22 read in part: .12/17/2022, at 12:00 pm, [Resident #6] was trying to prevent another resident from entering the room and her right hand was caught in the door. On 12/17/2022, at 12:00 pm, the resident was assessed by lvn charge nurse. The third and fourth finger was noted to be swollen. x-ray ordered and revealed a fracture to the right ring finger. The resident was not transported to the hospital .<BR/>Record review of Resident #6's chart revealed there was no documentation indicating that an in-house investigation had been done. There were no interviews from staff members. No written statement was collected from the nurse and CNAs on duty. There was no Provider Investigation Report form 3613A in the folder. <BR/>Record review in TULIP revealed a 3613 was not submitted as of 01/30/2023.<BR/>Observation and attempted interview on 01/30/23 at 11:09 a.m., revealed Resident #6 was resting in bed, alert and well groomed. The resident mumbled for 5 minutes while being interviewed and could not make self-understood and did not respond appropriately to asked questions. <BR/>In an interview on 01/30/23 at 8:20 a.m., with the MDS Coordinator, ADON B and the Administrator (on phone), the Administrator said he had a death in the family and was unable to come to the facility. He said in his absence the DON was his designee and the DON was on her way to the facility. At this time, the Surveyors explained that there was no provider investigation reports (3613) on TULIP and the Surveyors would need copies of the full investigation report for the self-reported incidents during this visit. The Administrator said the investigation reports were sitting on his office and the DON would be able to provide that to the Surveyors. <BR/>In an interview and record review on 01/30/23 at 3:28p.m., with the DON, Surveyor A and B reviewed TULIP and investigation reports provided by the DON. There was no documentation indicating that an in-house investigation had been done. There were no interviews from staff members. No written statement was collected from the nurse and CNAs on duty. There was no Provider Investigation Report form 3613s in the investigation folder for intake # 392853, #395082, #400546, 381907 and #394068. The DON said the Administrator had a family emergency and was unable to come to the facility. The Administrator had 3613s on his computer that the Surveyors were investigating, and she was not able to access his computer to print them for the Surveyors during this visit. She said the Administrator was in charge of completing the 3613-provider investigation reports and thoroughly investigating the incidents. She said in the Administrator's absence she was his designee. She said 3613s were submitted within 5 days of reporting self-reported incidents. She said, these incidents occurred sometime in December 2022 he should have investigated and submitted the PIRs. <BR/>Record review on 01/31/2023 at 9:52am Surveyor A received an email from the Administrator, with the attachments of the 3613s for the intake#400546, #392853,#395082,#394068 the email revealed read in part: .I had these on my computer and was not able to send them until now. Please accept these as part of the investigation . This email was received after exit.<BR/>Record review of facility's Abuse policy (last revised: 01/27/2020) read in part: .Policy: The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, intimidation, involuntary seclusion/confinement, and or misappropriation of property. Reporting/Investigation: The abuse coordinator with the Director of Nursing/designee will investigate all allegations and use the appropriate forms to document the investigation and turn it in to HHS within 5 calendar days. Upon completion of an investigation, the Director of Nursing and Administrator will analyze the occurrences, and determine what changes, if any, are needed to prevent further occurrence. All documentation of investigation must be protected and made available upon request .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 10 residents (CR #1) reviewed for Quality of Care.<BR/>1.The facility failed to immediately transfer CR #1, who was cognitively impaired and received Eliquis (an anticoagulant/blood thinner) when CR #1 went to the hospital after an unwitnessed fall on 09/22/2023 at 4:55 a.m. and sustaining a head injury. CR #1 was transferred to the hospital via non-emergency transportation service as a replacement for 911 emergency services. <BR/>An Immediate Jeopardy (IJ) was identified on 01/18/2024 at 10:49 a.m. The IJ template was provided to the facility on [DATE] at 10:49 a.m. While the IJ was removed on 01/19/2024, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>2.The facility failed to assess CR #1 in her primary language of Spanish when she sustained a head injury on 09/22/2023. <BR/>These failures placed residents on anticoagulant therapy who experience falls with injuries at risk of progression of the injury, prolonged pain, excessive bleeding, intracranial hemorrhage, and possible death. <BR/>Findings included:<BR/>Record review of CR #1's face sheet dated 01/17/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. CR #1's diagnoses included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), unspecified dementia (dementia without a specific diagnosis), epilepsy (brain condition that causes recurring seizures) and epileptic syndromes (a type of epilepsy identified by a specific seizure type), abnormality of gait (unusual walking pattern), heart failure (a chronic condition in which the heart does not pump blood as well as it should), dysphagia-oropharyngeal phase (reduced ability to feel food, liquid, or saliva that remains in the mouth or throat after swallowing), cognitive communication deficit (deficits which result in difficulty with thinking and how someone uses language), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), vascular dementia (brain damage caused by multiple strokes that causes memory loss in older adults), essential hypertension (abnormally high blood pressure that is not the result of a medical condition), and joint pain (physical discomfort where two or more bones meet to form a joint). CR #1 was discharged from the facility on 09/28/2023. <BR/>Record review of CR #1's quarterly MDS assessment dated [DATE] revealed she was Hispanic or Latino; her preferred language was Spanish and she needed/wanted an interpreter to communicate with a doctor or health care staff; she had a BIMS score of 00 (severe cognitive impairment); she required extensive physical assistance from at least one staff for bed mobility, locomotion, dressing, eating, toilet use, and personal hygiene and she was totally dependent on staff for transfers and bathing; she was wheelchair bound; she was always incontinent of bowel and bladder; she was prescribed anticoagulant medication; and she received hospice services.<BR/>Record review of CR #1's care plan updated on 09/25/2023 revealed the following areas of concern:<BR/>* <BR/>The resident was at risk for increased falls and fractures as evidence by confusion and incontinence. Goals included: The resident will be free of falls through the review date. Interventions included: Anticipate and meet the resident's needs. Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs.<BR/>* <BR/>The resident had a communication problem related to dementia and language barrier; speaks Spanish. Spanish speaking however nonsensical due to dementia majority of the time. Communication effective with simple basic<BR/>terms. Goals included: The resident will maintain current level of communication function by next review. Interventions included: Anticipate and meet needs. Monitor/document/report PRN any changes in: ability to communicate, potential contributing factors for communication problems, potential for improvement. Speak on an adult level, speaking clearly and slower than normal. The resident is able to communicate by: gestures, translator (Spanish).<BR/>* <BR/>Resident at Risk for Falls as evidenced by: Cognitive Impairment. Goals included: Dignity will be maintained. Resident will not experience falls or injuries from falls throughout the review date. Interventions included: Assure lighting is adequate and areas are free of clutter. Encourage resident to ask for assistance of staff. Ensure call light is in reach and answer promptly. Therapy to evaluate and treat per orders.<BR/>* <BR/>9/22/23 I have had an actual fall with minor laceration to forehead related to poor balance, unsteady gait. Goals included: The resident's (Specify: injured areas [no injuries were noted] ) will resolve without complication by review date. Interventions included: 9/22/23 Clean the forehead laceration with wound cleanser, pat dry and apply dry dressing. 9/22/23 Continue interventions on the at-risk plan. 9/22/23 Give PRN Tylenol per physician order for pain. 9/22/23 Neuro-checks x 72 hours per facility protocol. 9/25/23 Neuro-checks x 72 hours per facility protocol. 9/22/23 PT consult for strength and mobility. 9/22/23 Send resident to ER for CT scan without contrast. 9/25/23 Check range of motion every shift daily. 9/25/23 For no apparent acute injury, determine and address causative factors of the fall. 9/25/23 Monitor/document /report PRN x 72h to MD for signs and symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation.<BR/>Further review of CR #1's care plan revealed no documentation of a care area, goal, or interventions related to CR #1's anticoagulant therapy. <BR/>Record review of CR #1's Nursing Progress Notes for March 2023 revealed the following:<BR/>On 03/07/2023, the SW (no longer employed at the facility) wrote, SW met with resident in the common area of Station C to complete a quarterly social service assessment . SW utilized an interpreter to assist with the assessments, as resident is Spanish speaking .<BR/>Record review of CR #1's physician's orders for September 2023 revealed the following orders:<BR/>* <BR/>Admit to hospice with diagnosis: Alzheimer's Disease. Order date - 05/28/2023.<BR/>* <BR/>Eliquis Oral Tablet 5 MG. Give 1 tablet by mouth two times a day for DVT (blood clot) until 10/17/2023. Order date - 04/17/2023. End date - 10/17/2023. <BR/>* <BR/>Acetaminophen Oral Tablet. Give 2 tablets by mouth every 4 hours as needed for pain. Order date - 04/18/2023.<BR/>Record review of CR #1's MAR for September 2023 revealed:<BR/>* <BR/>Acetaminophen Oral Tablet. Give 2 tablets by mouth every 4 hours as needed for pain. There was no documentation to show this medication was administered in September 2023. <BR/>* <BR/>Eliquis Oral Tablet 5 MG. Give 1 tablet by mouth two times a day for DVT until 10/17/2023. This medication was administered daily as prescribed (except for the 8:00 a.m. dose on 09/22/2023) for the month of September 2023 until she was discharged on 09/28/2023. <BR/>Record review of drugwatch.com's article, Eliquis revised 10/15/2023 and written by a board-certified patient advocate revealed Eliquis was a powerful blood thinner prescribed to prevent strokes and potentially fatal clots. The article stated doctors prescribed Eliquis to people after knee or hip replacement surgery to prevent deep vein thrombosis (DVT) which was when blood clots formed in veins deep in the body. The article stated Eliquis' effects lasted for at least 24 hours after the last dose, according to the drugs label. The label stated serious and potentially life-threatening bleeding was the most severe side effect. <BR/>Record review of the undated Eliquis medication guide on Eliquis.bmscustomerconnect.com, revealed Eliquis can cause bleeding which can be serious and rarely may lead to death. <BR/>Record review of premierneurologycenter.com's undated article , Blood Thinners and Head Injuries: What You Need to Know revealed, . Blood thinners are medications that help prevent blood clots from forming, however they can increase the risk of delayed intracranial hemorrhage (bleeding with the skull) after a head injury. Therefore, if you are taking a blood thinner, it is important to be aware of the risks associated with head injuries. If you experience a bump, blow, or jolt to the head, it is important to seek medical attention right away. Even if you do not feel any symptoms after the injury, it is still important to be evaluated by a doctor .<BR/>Record review of CR #1's Nursing Progress Notes for September 2023 revealed the following:<BR/>On 09/22/2023, RN A wrote, 4:55 a.m. - Upon rounds, resident was observed lying on her right side on the left side of her floor mat by the window with bed on the lowest position, upon assessment, resident was observed with laceration on her forehead area, resident was alert and awake, small blood was seen on the handle of her dresser which appears that she bump her head on the dresser handle, bed was moved away from the dresser, resident was assisted to her bed, area was cleaned with wound cleanser, pat dry with dry dressing applied, PRN Tylenol administered for possible pain and was well tolerated. Hospice Nurse notified of the situation and gave a phone order for resident to be sent to ER for CT scan of the head, order noted and carried out, report given to ER nurse, RP made aware, DON and Administrator made aware. Non-emergency transportation service notified, and resident was picked up via stretcher by 2 EMS alert and awake, no s/s of distress noted, no active bleeding noted on her forehead area, dressing intact, respirations even and unlabored. NP also made aware <BR/>Record review of CR #1's Pain Tool completed by RN A and dated 09/22/2023 revealed, A. Location - For each site listed, describe type of pain (stabbing, burning, sharp, dull, throbbing), duration and frequency and whether it is continuous or intermittent in the description box. Site: 1) Top of Scalp. Description: Laceration to forehead area (no further description was detailed in the description box). B. Current Pain Level. 1. Faces Scale: Hurts a Little Bit . C. What Makes the Pain Better? 1. What makes the pain better? Forehead area cleaned with wound cleanser and pat dry and dry dressing applied, bleeding stopped, PRN Tylenol administered for possible pain with good effect .<BR/>Record review of CR #1's incident report completed by RN A and dated 09/22/2023 revealed, . Injuries Observed at Time of Incident: Laceration. Injury Location: Top of Scalp. Level of Pain: 3 ( . Negative Vocalization: Score 0 [None], Facial Expression: Score 1 [Sad, Frightened, Frown], Body Language: Score 1 [Tensed, Distressed Pacing], Consolability: Score 1 [Distracted or Reassured by Voice or Touch]. Mental Status: Oriented to Person . Predisposing Physiological Factors: Confused .<BR/>Record review of CR #1's fall assessment completed by RN A and dated 09/22/2023 revealed, Score: 55 . History Of Falling: Has Resident ever fallen before? Yes. Secondary Diagnosis. Does the resident have more than one diagnosis on the chart? Yes . Scoring: High Risk: 45 and higher .<BR/>Record review of CR #1's Neuro Assessment completed by RN A and dated 09/22/2023 revealed: 1. Q15 (4:55 a.m.) - . 4. Glascow Coma Score (a clinical scale used to reliably measure a person's level of consciousness after a brain injury. The scale assesses a person based on their ability to perform eye movements, speak, and move their body) . B. Best Verbal Response: 5. Oriented . 6. Obeys Commands. 5. Other Neurological Abnormalities . B. Headache: 2. No .<BR/>Further review of CR #1's Neuro Assessment dated 09/22/2023 revealed neurological assessments were also conducted at 5:10 a.m., 5:25 a.m., 5:40 a.m., and 6:10 a.m. with the same exact documentation as the 4:55 a.m. assessment. <BR/>Record review of CR #1's Transfer Form completed by RN A, dated 09/22/2023 revealed, . 5. Primary Language: Spanish .2. Transfer/Discharge Details: Sent to hospital. Date: 09/22/2023, 6:41 (a.m.) . Reason: Fall . 4. Pain. 1. Most Recent Pain Level: 3 - Date: 09/22/2023 at 7:43 (a.m.). 2. Pain Location. Site: Top of Scalp. Laceration to forehead area. 3. Most Recent Pain Medication. Orders: Acetaminophen Oral Tablet. Last Administered: 05/20/2023 at 2:08 p.m. Risk Alerts: Other Risks 12. A. Anticoagulation. 12b. Specify medication used: Eliquis. 12c. Specify reason for use: blood thinner. 13. Are there any additional risks present: b. Falls, i. Seizures . <BR/>Record review of CR #1's Ambulance Transport Run Report dated 09/22/2023 revealed she was transported to a local acute care hospital ER via non-emergency transportation service. The document read, . Arrived at Scene: 6:31 (a.m.) Left Scene: 6:42 (a.m.) Destination: 6:57 (a.m.) . Got dispatched to an [AGE] year-old Hispanic female with chief complaint of fall. Upon arrival, patient is confused but able to talk. Patient is Spanish speaking only . Nurse believes her head bumped the drawer of nightstand. Patient taking blood thinner. Patient condition is stable .<BR/>Record review of CR #1's hospital records dated 09/22/2023 revealed she arrived at the hospital's ER on [DATE] at 6:57 a.m. and was discharged on 09/22/2023 at 11:49 a.m. The document read in part, . Glascow Coma . Best Verbal Response: Confused . Diagnosis: Acute head injury, dementia, fall, forehead laceration . ED Triage Information . Tracking Acuity: 3 - Urgent . Trauma Indication: Yes . History of Present Illness: The patient presents following a fall out of bed. The location where the incident occurred was at a nursing home. Location: scalp. Forehead. The character of symptoms is bleeding. Risk factors consist of anemia, bed bound and vascular dementia. The patient is an [AGE] year-old female with a past medical history of vascular dementia, anemia and is bed bound. Presents to the ED via EMS from her nursing home for evaluation s/p unwitnessed fall. Per EMS the patient was found at 5 a.m. after falling from bed and hitting her head on a dresser at bedside. EMS reports that the patient is on blood thinners and is confused at baseline. Injury is sustained to the forehead and scalp. No other symptoms or complaints reported at this time. Limited HPI secondary to patient's clinical condition . Trauma Brain without contrast CT - 09/22/2023. Impression: 1. No acute intracranial process. No intracranial hemorrhage, edema, or skull fracture. 2. Stable chronic changes. 3. Laceration of the superior scalp, superficial . Her laceration inspected, irrigated, closed with staples . Problems Addressed: Patient presents with a problem that potentially represents a highly morbid condition with a possible threat to life or bodily function . Description/repair: Laceration 3 cm in length. Face: forehead. Shape: irregular. Depth: subcutaneous . Skin closure: 3 staples . <BR/>Record review of CR #1's progress notes for September 2023 revealed: <BR/>On 09/22/2023 at 12:27 p.m., LVN E wrote, Back from hospital ER via stretcher accompanied by 2 attendants. Resident was awake, alert. Laceration with 3 staples and dry blood remained visible to forehead. Neuro checks in progress and WNL .<BR/>In an interview with CR #1's family member on 01/17/2024 at 8:15 a.m., she stated CR #1 passed away in November 2023. She stated she missed three calls from the facility on 09/22/2023, so she called the hospice nurse. The family member said the facility failed to assess the seriousness of CR #1's injury and did not send her out for two hours. She stated CR #1 was transferred to another facility after the incident. She said CR #1 did not speak English, but she could understand it. She stated CR #1's dementia had progressed, so she really could not voice her needs. <BR/>In an interview with the DON on 01/17/2024 at 11:23 a.m., she stated she thought CR #1 had a fall and went out to the hospital but returned the same day. She said after the fall, CR #1's RP requested her to transfer to a sister facility. She said CR #1 was on hospice. The DON stated if a resident experienced a fall and hit their head with swelling or anything, the staff automatically sent them out for a CT scan just to be on the safe side. She said the staff would call hospice because some hospice residents were still full code (no DNR). The DON said if the fall incident occurred at 4:55 a.m., the nurse would start neurological assessments immediately but whether or not 911 was called to transport the resident depended on the nurse's assessment. The DON said if a resident had a bleeding laceration, they should be sent out 911, but it depended on what the nurse assessed. She said the risk of failing to immediately transport someone on a blood thinner who experienced a fall with head injury would have been possible internal bleeding, which may not have been assessed. She said there was no active bleeding, but since CR #1 was on Eliquis. there may have been internal bleeding that the nurse was not able to see. She stated the facility did not have a policy on quality of care or any policy specific to CR #1's incident. <BR/>In an interview with the Administrator on 01/17/2024 at 12:15 p.m., he stated he thought the 6:41 a.m. transfer time documented on CR #1's transfer form dated 09/22/2023 was a documentation error. He said he thought CR #1 was sent out to the hospital before that time. He said the facility's nurses would not send a resident out right away unless they were profusely bleeding. He said there were no changes to CR #1's level of consciousness and she was not actively bleeding, so there could have been some delay in transferring her to the ER. He said he thought the nurse applied pressure to CR #1's wound and it was stable. <BR/>In a telephone interview with Hospice RN on 01/17/2024 at 1:20 p.m., she stated she could not recall what time the facility called her, but if the fall happened at 4 a.m., she must have been the on-call nurse. She said she could not recall if the facility nurse called her before or after they sent CR #1 out to the ER after she fell and hit her head. She stated the details of the incident would be in her notes. <BR/>In a follow-up telephone interview with Hospice RN on 01/17/2024 at 1:40 p.m., she stated RN A called her at 5:00 a.m. on 9/22/23 and said CR #1 struck her head on the bed, but she initially denied there was a fall. Hospice RN said RN A eventually said an aide told her CR #1 did fall and hit her head on the dresser. Hospice RN said RN A told her CR #1 sustained a laceration to her head and was bleeding. She said CR #1 was sent out for evaluation and CT for a subdural hematoma (a pool of blood between the brain and its outermost covering). She said RN A told her she had already called EMS.<BR/>In a telephone interview with RN A on 01/17/2024 at 2:26 p.m., she stated she recalled CR #1, who was on hospice. She stated CR #1 was alert, but only spoke Spanish, so she could not understand her. RN A said on the night CR #1 fell, she was asleep until she (RN A) made her final rounds for the night. RN A said she worked from 6:00 p.m. - 6:00 a.m. She said when she walked into CR #1's room, she was on the floor mat. RN A said CR #1's bed was very low to the ground, so it appeared she rolled out of bed or something. She said she saw that CR #1's face had blood and the bottom drawer of the dresser had a blood stain on it. RN A said CR #1's face was positioned near the dresser area. She said the laceration was like a line that resembled the dresser drawer handle. RN A said she cleaned CR #1's wound and she was still alert and talking (in Spanish). She said she rounded every two hours and the laceration appeared to be fresh like the fall had just happened. RN A said CR #1 could not really communicate with her, but she cleaned the wound and saw the line from the laceration. She said she called hospice and spoke with the nurse. RN A said she told Hospice RN that CR #1 needed to go to the hospital, so she gave the order to send CR #1 to the ER. She said the incident happened at the end of her shift. She said as soon as she wiped the blood from CR #1's laceration, the bleeding stopped so she covered it with a dry dressing. RN A said she knew CR #1 had to go to hospital because it was their policy. She said she called their non-emergency transportation company, and they came almost immediately. She said CR #1 left the building while she (RN A) was still in the building. RN A said she knew CR #1 was on Eliquis. She said she knew CR #1 had to go to the hospital but spoke to the hospice nurse before she called the transportation company. She stated the hospice nurse never mentioned calling 911. RN A said the ETA for the transportation company was soon because they were in the area. <BR/>In a follow up telephone interview with RN A on 01/23/2024 at 12:52 p.m., she stated CR #1 could speak some English, but mostly Spanish. She said CR #1 could say, Yes in English and could say, Poquito ('a little' in Spanish) when she was in pain. RN A said when she conducted a ROM assessment on CR #1, there was no sign of pain, but when she felt around the laceration area, CR #1 jerked a little and said, Poquito. RN A said CR #1 was speaking in Spanish the morning she fell, and none of the staff could speak Spanish to her. She said she gave CR #1 Tylenol, if she was not mistaken. She said the Tylenol administration was probably not on CR #1's MAR, but she thought she gave it to her. <BR/>In an interview with CR #1's NP on 01/17/2024 at 3:45 p.m., she stated she did not recall CR #1's fall in September 2023. She stated if a resident was cognitively impaired, confused, and had a communication barrier experienced a fall with a head injury and was on Eliquis, it did not necessarily mean the nurse should have called 911. She stated CR #1 was on hospice and usually, hospice patients did not go to the hospital unless the hospice agency said to send them out. She said if a resident hit their head and was bleeding, they would send the resident out for a CT to ensure there were no injuries. CR #1's NP said if CR #1 had a head injury that was bleeding and there was a two-hour delay in getting her to the hospital, you would have to be very careful, but if she was not actively bleeding and there was just a skin laceration, the situation was not urgent to her. She said if a resident had a brain bleed for two hours, that would be an emergency. She said CR #1 was in a low bed, so she could not say for sure if there was a possibility for her to have sustained a brain bleed as a result of the fall. The NP said it depended on how hard CR #1 hit her head. She said a normal person would have had altered mental status if they had a brain bleed, but CR #1 was already confused. <BR/>In another telephone interview with Hospice RN on 01/18/2024, at 9:40 a.m., she stated she ordered RN A to send CR #1 out after the fall to evaluate for subdural hematoma because she could have had a brain bleed. She stated going out to the hospital was not usually recommended for residents on hospice unless their family wanted it. Hospice RN said, CR #1 could have had a brain bleed and being on a blood thinner would have exacerbated that condition. She said typically, a family would not treat a brain bleed if the resident was on hospice. She said if a resident was not on hospice, a two-hour delay would not be appropriate for this situation. She said CR #1 could not speak any English at all. She said she took over as CR #1's primary hospice nurse after she experienced the fall in September 2023 and followed her to the other facility (after she was discharged from the facility). She said CR #1 had dementia, so even when she spoke Spanish, she could not communicate her needs. <BR/>In an interview with the Administrator, VP of Operations and Regional Nurse on 01/18/2024 at 10:50 a.m., the VP of Operations stated she was previously the administrator at the facility, and she recalled that CR #1 could speak some English. The Regional Nurse stated she was previously the DON at the facility and CR #1 did speak some English and was able to communicate some although she was selective who she spoke English to. The Administrator, who was also an RN stated Eliquis acted different from blood thinners like Coumadin. The Administrator said doctors prescribed Eliquis because it controlled the blood/bleeding better. The Administrator said CR #1 could speak some English and they sent her to the hospital for evaluation. The Administrator said it was not an emergency because staff were monitoring CR #1 during the time she was in the facility, and she was stable. <BR/>In an interview with CNA C on 01/22/2024, at 1:40 p.m., she stated she cared for CR #1 a few times and she only spoke Spanish. <BR/>In an interview with LVN E on 01/23/2024 at 12:30 p.m., she stated she cared for CR #1 while she was there and every one-in-a while, CR #1 would say thank you in English. LVN E said CR #1 spoke some English before she declined a few months before she left the facility, but after the decline, she only spoke Spanish. <BR/>In an interview with MA F on 01/23/204 at 12:30 p.m., she stated she administered CR #1's medications when she was at the facility. She stated she recalled that CR #1 required total care and did not speak any English. She said CR #1 only spoke Spanish. <BR/>Record review of the facility's Change in Condition policy dated 11/01/2019 revealed, Communities will use the facility's definition for a Change in Condition. It will be the policy that once the nurse has notified the physician for a change in condition the resident/patient will be monitored for 1 hour until the physician has responded. The monitoring will include vital signs, pulse ox, and finger stick blood sugar if a diabetic (one time only). A physical assessment should be completed relative to the symptoms present and a pain assessment . If the resident/patient condition appears emergent, Transfer to local ER may occur without physician order.<BR/>Record review of the facility's Incident and Accident policy dated 03/01/2017 revealed, 3. Licensed nurse will complete a fall investigation report after every fall to include vital signs, pain assessment, and environmental assessment . A head-to-toe assessment must be completed at the time of the incident . 10. All residents are at risk for falls. A risk assessment will be conducted on admission and the findings of that assessment will be included in the plan of care . 12. A fall is defined as unintentionally coming to rest on the floor, ground or lower level . b. a resident found on the floor is considered to have fallen . 13. A neurological check form is to be completed for any fall involving the head or any unwitnessed fall .<BR/>This was determined to be an Immediate Jeopardy (IJ) on 01/18/2024 at 10:49 a.m. The Administrator, VP of Operations, and the Regional Nurse were notified. The Administrator, VP of Operations, and Regional Nurse were provided with the IJ template on 01/18/2024 at 10:49 a.m. A Plan of Removal was requested at that time. <BR/>The following Plan of Removal submitted by the facility was accepted on 01/18/2024 at 3:09 p.m.:<BR/>1. <BR/>Immediate Action Taken<BR/>* <BR/>Resident was discharged to another facility.<BR/>* <BR/>On 1/18/2024 the Director of Nurses (DON) or designee, started education with all license nurse on the guidelines for sending out residents via 911emergency services that are on anticoagulant therapy. This will guide the clinical team on ensuring that each resident receives emergency care immediately, and services in the event of a unwitnessed fall when a resident is on anticoagulant therapy. This education will be completed at 3:00 pm on 1/19/2024, and no license nurse will be allowed to work until this education has been completed.<BR/>* <BR/>An In-service by the Social Worker was started on 1/18/2024 on the use of the language line and the communication charts. This education will be completed on 1/19/2024. <BR/>* <BR/>An in-service initiated on 1/18/2024 by the DON for licensed nurses on proper assessment of a resident with fall with injury to include language barriers. To be completed by 1/19/2024<BR/>* <BR/>The below policies were reviewed on 1/18/2024 and there are no changes to current policy.<BR/>o <BR/>Falls (Incident and Accident) to include witnessed and unwitnessed falls<BR/>* <BR/>Anticoagulation therapy information pamphlets<BR/>o <BR/>Communication<BR/>* <BR/>Using Language Line for Non-English-Speaking Residents.<BR/>2. <BR/>Identification of Residents Affected or Likely to be Affected: <BR/>* <BR/>On 1/18/2024 the DON completed the audit for any resident who was on anticoagulant therapy. We identified 8 residents on anticoagulant. An audit was completed on 1/18/2024 by the DON and Assistant Director of Nurses (ADON) on resident with falls within the past 72 hours to validate that no other residents failed to receive emergency care, that were on anticoagulant therapy. This is to be completed by 1/18/2024.<BR/>* <BR/>Licensed nurses will use the resident clinical records (Medical Administration Records), to identify residents on anticoagulants. If resident is on anticoagulant, they will immediately be transferred to Higher Level of Care (Hospital) via 911 emergency. <BR/>3.Actions to Prevent Occurrence/Recurrence: <BR/>* <BR/>The DON/Designee will validate daily x 30 days, that the Incident and Accidents are reviewed daily during morning meeting to ensure no delays in services. <BR/>* <BR/>Any new licensed nurse hired by the facility will receive education upon hire on: <BR/>o <BR/>Education on the guidelines for sending out residents that are on anticoagulant therapy.<BR/>o <BR/>The use of the language line and the communication charts.<BR/>o <BR/>Proper assessments with a resident with a fall with injury to include language barriers.<BR/>On 1/18/2024 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to failure to provide treatment and care in accordance with professional standards of practice and reviewed plan to sustain compliance.<BR/>Monit[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder condition for level II resident review upon a significant change in status assessment for 1 of 4 residents (Resident #14) reviewed for PASARR screening, in that:<BR/>This facility failed to refer Resident #14 for PASARR level 2 assessment after being diagnosed with multiple mental disorder.<BR/>This failure could place PASARR positive residents at risk of not having their medical and psychosocial needs met due to not receiving the appropriate services and medical equipment.<BR/>Findings included: <BR/>Review of face sheet revealed Resident #14 was a [AGE] year-old female who was initially admitted the facility on 10/06/2018, current admission date was 12/30/2018. Resident #14's diagnosis included Dementia, Anxiety disorder, Psychosis, Major Depressive disorder, schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly).<BR/>Record review of Resident #14's PASARR level 1 dated 10/05/2018 was negative. However, facility failed to refer Resident #14 for PASARR level 2 assessment after Resident was diagnosed with the following:<BR/>Anxiety disorder - diagnosed on [DATE]<BR/>Psychosis diagnosed on [DATE]<BR/>Schizophrenia diagnosed on [DATE]<BR/>Major Depressive disorder diagnosed on [DATE]<BR/>During interview on 2/24/2022 at 4:42 PM, MDS Nurse A said Resident #14 did not have the PASARR II done and the MDS nurse agreed that facility failed to perform PASARR II assessment on Resident #14. The MDS nurse agreed this failure could affect the resident by not getting the service suitable for them. The MDS nurse stated the facility did not have specific PASARR policy, he said they only follow the State requirement.

Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly for dumpster A and Dumpster B of 2 dumpster reviewed for Food and nutrition services. <BR/>-The facility failed to ensure dumpster A and dumpster B's lids and doors were secured.<BR/>This failure could place residents at risk of infection from improperly disposed garbage.<BR/>Findings included:<BR/>Observation on 06-26-24 at 1:15 pm, revealed the facility's dumpster area, had 2 commercial -size dumpsters (dumpster A and dumpster B) &frac34; full of garbage and the doors were open.<BR/>In an interview on 06-26-24 at 3:45 pm, with the Food Service Manager, she stated that the dumpster doors must always be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. She further stated that housekeeping, and nursing also discard their waste garbage in the dumpster. It was the responsibility of staff from dietary, nursing and housekeeping for ensuring the food waste will properly be removed and disposed for from the community.<BR/>Record review of facility's Policies and Procedures on waste disposal dated 11/ 2023 revealed that food waste will be properly removed and disposed for from the community to ensure the food safety for the residents. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. Outside dumpster provided by garbage pickup services will be kept closed and free of surrounding litter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 2 of 14 residents (Resident #10 and #41) reviewed for accuracy of assessments.<BR/> -Resident #10 was not assessed for his falls and not accurately assessed on his ID/IDD on annual MDS assessment dated [DATE].<BR/>-Resident #41 was not assessed for his Condition\s related to ID/IDD and catheter status on his Annual MDS assessment dated [DATE]. <BR/>These failures could place placed residents at risk of not having their needs met.<BR/>Findings included:<BR/>Resident #10 <BR/>Record review of Resident #10's face sheet dated 2/23/22 revealed he was [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included developmental disability, muscle wasting<BR/>Record review of Resident #10's annual MDS dated [DATE] revealed his BIMS score was 13 out of 15, which indicated he was cognitively intact. <BR/>Section J Fall history since admission, entry\re-entry and prior assessment was checked 0 meaning no falls since last assessment. Section Section A PASRR ID\IDD of the MDS was checked as having intellectual disability. Review section A conditions related to ID\IDD was left blank. <BR/>Record review of Facility's accidents\incidents list revealed Resident # 10 had two an unwitnessed falls on 8/27/21 and on 09/17/21.<BR/>Resident #41<BR/>Record review of Resident # 41's face sheet dated 2/23/22 revealed he was [AGE] year-old male admitted to the facility 10/12/20 His diagnoses included Epilepsy , benign tumor (soft tissue tumors). urinary tract infection and age-related physical conditions. <BR/>Record review of Resident #41's annual MDS dated [DATE] revealed his BIMs score was 00 indicating he was severely impaired mentally. <BR/>Section A, condition related to ID\IDD, was left blank. <BR/>Section H, Bladder and bowel was assessed as 0 meaning he was incontinent of bowel and bladder.<BR/>Record review Resident #41's physician's order dated 10/21/20 revealed he had a catheter related to sacral wound.<BR/>Observation on 02/22/22 at 10:00AM, revealed Resident #41 was in bed, alert, and had a catheter to his bed side with about 300 cc of urine in the bag. <BR/>During an interview with the facility DON on 02/24/22 at 2:00PM she said the MDS coordinators are responsible for ensuring the MDS accurately reflect Resident's condition . <BR/> During an interview with MDS Nurse A on 02/24/22 at 3:30pm, he said the care plan for Resident #10 was not accurate. He said inaccurate assessment would affect residents by not getting the appropriate care needed to improve or maintain their health. He said Resident #10's MDS would be corrected to reflect their condition. He said he was responsible for ensuring that all MDS assessments reflect Resident's condition. <BR/>Record review of the facility's policy on accuracy of assessment was requested from the DON on 02/25/22 at 11:00 PM. provided policy dated 2001 revised September 2013 did not address accuracy of MDS.