Every finding on record at Arabella Health & Wellness of Meridian

Based on interviews, record review, and facility policy review, the facility failed to ensure residents' rights to be free from abuse and neglect when the facility failed to protect Resident A from neglect by failing to initiate the admission process after the resident arrived at the facility following surgical repair of a left hip fracture, and failed to protect Resident #23 from verbal abuse by a Certified Nurse Aide (CNA), for two (2) of (19) sampled residents. The facility's failure to initiate the admission process for Resident A resulted in the resident remaining without a nursing assessment, implementation of physician orders, prescribed medications, pain management, assistance with toileting, and ongoing nursing care for approximately nine (9) hours after arriving at the facility following surgical repair of a left hip fracture, placing the resident at likelihood for serious injury, serious harm, impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and substandard Quality of Care (SQC) that began on 4/28/26 when Resident A arrived at the facility for admission. The facility's Administrator was notified of the IJ on 7/23/26 at 1:40 PM and was presented with the IJ template. The facility provided an acceptable Removal Plan on 7/23/26, in which they alleged all corrective actions to remove the IJ were completed on 7/23/26 and the IJ removed on 7/24/26.The State Agency (SA) validated the Removal Plan on 7/27/26 and determined that the IJ was removed on 7/24/26, prior to exit. Therefore, the scope and severity for 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's Abuse, Neglect, and Exploitation with the reviewed date of 03/10/26, revealed .Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident . that prohibit and prevent abuse, neglect . Definitions: . Verbal Abuse means the use of oral.communication.that willfully includes disparaging or derogatory terms to residents. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Prevention of Abuse, Neglect, and Exploitation: . C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment . H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. Identification of Abuse, Neglect, and Exploitation: . B: . 8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning. Resident A A record review of Resident A' s Medical Records including Discharge Summary Paperwork revealed . report called to (Proper Name) 04/28/2026 at 3:30 PM . Please include: . orders .D/C (discharge) summary . Discharge summary revealed admission date of 04/19/2026 and discharge date and time of 04/28/2026 at 12:49 PM. X-ray in ED (Emergency Department) showed left femoral neck fracture with procedure arthroplasty total hip (left). On 04/28/2026 accepted to facility, stable and ready for discharge. Upon discharge Apixaban (Anticoagulant (clot prevention-blood thinner) 2.5 mg (milligram) BID (twice a day) will be given until 05/20/2026 to finish her 30-day DVT (Deep Vein Thrombus (blood clot)) prophylaxis post hip surgery. Percocet q4 (every four hours) PRN (as needed) for pain. Hip precautions must be followed for at least 3 (three) months. Apixaban 2.5 mg last time was given 04/28/2026 at 8:12 AM and Zanaflex (muscle relaxer) 4 mg last time given was 04/28/2026 at 3:26 PM. Orders noted for Oxycodone-Acetaminophen 5-325 mg (Percocet (pain medication)) ordered 1 (one) tablet every 4 (four) hours as needed for pain. A record review of the Initial Authorization Insurance form for Resident A revealed the admission date of 04/28/2026 and length of stay approved to 05/04/2026. A record review of the Admission/Discharge To/From Report from 04/27/2026 through 05/01/2026 revealed Resident A was not listed. On 07/21/2026 at 10:10 AM, during an interview and record review, the Business Office Manager reported that the only information she could locate for Resident A was the initial hospital referral sent to the facility, which included an encounter date of 04/19/2026 but no discharge date . She provided the facility's admission/discharge log for the period of 04/27/2026 through 05/01/2026, which did not include Resident A. The Business Office Manager stated she remembered Resident A was expected to be admitted on [DATE] and that the planned admission was discussed during the facility's morning stand-up meeting with department heads and the Administrator. She also provided the admission approval documentation for Resident A, which showed an approved admission date of 04/28/2026 with authorization through 05/04/2026. On 07/21/2026 at 3:04 PM, during an interview, the former Director of Nursing (DON), who was serving as the DON at the time of the incident, stated she was aware of the incident involving Resident A, who arrived at the facility following surgical repair of a left hip fracture but was not admitted upon arrival or administered physician-ordered medications. The former DON reported that she, the nurse in charge, and the admission Coordinator had left for the day after instructing the 7:00 PM lead nurse, a Licensed Practical Nurse (LPN), to enter Resident A's information into the computer and complete the admission process. She confirmed Resident A was never admitted into the electronic medical record, no admission assessments were completed, and no admission paperwork was signed. The former DON described the incident as neglect by the facility and that she had reprimanded the staff the following day; however, she could not recall what corrective or disciplinary action was taken because the incident had occurred so long ago. On 07/21/2026 at 3:50 PM, during an interview, the Administrator reported he remembered the day Resident A was scheduled to be admitted after the charge nurse and Director of Nursing (DON) had left for the day. He stated he remained at the facility until approximately 5:00 PM, saw Resident A arrive, and thought nothing further about the admission. He reported seeing Resident A's admission folder at the nurses' station but stated the folder was never located after that night. The Administrator reported the 7:00 PM Licensed Practical Nurse (LPN) was expected to complete the admission process. He stated he learned of the incident the following morning after the hospital called the facility to inquire about Resident A. The Administrator reported he spoke with the LPN responsible for entering Resident A into the electronic medical record about the incident. He stated he was not aware of any investigation or disciplinary action involving staff and did not report the incident as neglect because he believed the LPN's actions were the result of poor prioritization rather than intentional neglect. The Administrator reported the LPN believed passing medications was a higher priority than admitting Resident A. On 07/23/2026 at 9:10 AM, during a telephone interview, Resident A reported she sustained a hip fracture and underwent surgery on 04/19/2026. She stated she required rehabilitation services and her insurance approved placement at the facility. Resident A reported that the hospital informed her the facility had accepted her for admission and all admission paperwork had been faxed from the hospital to the facility at approximately 2:30 PM on 4/28/26. She stated physical therapy instructed her she only needed a rolling walker and could travel by private vehicle, so her brother transported her to the facility, arriving at approximately 4:30 PM on 4/28/26. Resident A reported a staff member brought a wheelchair to the vehicle and assisted her into the facility. As she was taken to her room, she attempted to give staff her admission paperwork but was told the person who completed admissions had already left for the day and she would have to wait until the following morning. She stated the bed was pushed against the wall and did not appear to be completely made, and no staff member assisted her with transferring into bed. Her brother assisted her into bed and left approximately 30 to 40 minutes later. Resident A reported she requested a walker but was told she could not receive one until she had been admitted . She stated she used the wheelchair to take herself to the bathroom because no staff assisted her. Resident A reported she experienced excruciating pain that caused nausea, observed other residents being served dinner, but did not receive a meal until approximately one and one-half hours later. She stated the meal was provided in a to-go container, appeared to have come from other residents' trays, and she was unable to eat it. Resident A reported she requested Tylenol for pain but was told she could not receive any medications. She stated she repeatedly attempted to contact her brother and sister-in-law to pick her up but was unsuccessful. She then posted about the situation on social media, and a neighbor contacted her after seeing the post. Resident A reported she informed staff her neighbor was coming to pick her up and requested the neighbor be allowed into the building. She stated a staff member told her they did not blame her for leaving. Resident A reported she left the facility with her neighbor at approximately 1:45 AM on 4/29/26. She stated the following morning the former Director of Nursing (DON) called, apologized, and asked her to return to the facility. Resident A reported she declined to return, after which the former DON ended the conversation. She also stated the Administrator called and apologized for the incident. On 07/23/2026 at 10:35 AM, during a telephone interview, the Medical Director reported he was not aware of the incident involving Resident A, who had been accepted for admission, arrived at the facility, and did not have the admission process initiated or receive necessary care and services. He stated these actions were not acceptable resident care and that he could not believe the incident had occurred. The Medical Director reported he expected all residents accepted for admission to have the admission process initiated and receive necessary care and services, including medications and assistance. On 07/23/2026 at 10:50 AM, during a telephone interview, Resident A's brother confirmed he transported Resident A from the hospital to the facility, arriving at approximately 4:30 PM. He reported a person leaving the building obtained a wheelchair for Resident A. He stated Resident A wheeled herself into the facility while he carried her belongings. Upon arriving at the nurses' station, Resident A attempted to give staff her admission paperwork but was told the person who completed admissions had already left for the day and she would have to wait until the following day. He reported the bed assigned to Resident A was against the wall in a semi-private room, had not been made, and staff had to locate a pillow before she could get into bed. He stated no staff assisted Resident A into bed. Resident A's brother reported he remained at the facility for approximately 30 to 40 minutes before leaving. At that time, staff were serving dinner and assisting other residents. He reported he missed several telephone calls from Resident A later that evening and felt terrible after learning what had occurred because he believed things would improve once staff had finished serving the evening meal. On 07/24/2026 at 10:20 AM, during an interview, the admission Coordinator reported her responsibilities included marketing for the facility and that she typically left before the end of the day. She reported Resident A arrived after business hours after she had already left the facility. The admission Coordinator explained that referrals are received electronically and are seldom faxed. Once a referral is received, she distributes the information to the clinical team, including the Director of Nursing (DON), Administrator, and Business Office Manager. She reported the Business Office obtains insurance authorization, and once approval is received, she notifies the referring facility that the resident has been accepted for admission. She explained admission paperwork is normally completed and signed on the day of admission. However, because she did not know what time Resident A would arrive, she planned to complete the admission paperwork the following day, but the admission was never completed. She stated completing the admission paperwork the day after arrival was not the usual practice but could occur occasionally. A record review of the facility's Punched In and Out time reports for 04/28/2026 revealed the Director of Nursing (DON) clocked out at 3:00 PM, prior to Resident A's arrival at approximately 4:30 PM. The staffing records also showed licensed nursing staff were on duty throughout Resident A's stay at the facility, including Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) during both the evening and overnight shifts. Despite the presence of licensed nursing staff, Resident A was not admitted into the facility, no admission assessments were completed, and no admission paperwork was initiated. Resident #23 On 7/23/26 at 9:25 AM, the Administrator called the hotline at the State Agency (SA) and reported an allegation of verbal abuse regarding Resident #23. The Administrator notified the survey team of the report to the SA. On 07/23/2026 at 11:27 AM, during an interview, Resident #23 revealed that at approximately 5:00 AM this morning (7/23/26), two (2) Certified Nursing Aides (CNAs) entered his room to help him get dressed. The resident stated that he tried to explain to the CNAs that he wanted his weak arm to go through the sleeve first, then his head and then his other arm. The resident reported that CNA #1 started cussing him and said, I'm not going to have this (expletive) out of you this morning and I have to go through this with you every morning. The resident stated he told CNA #1 that she doesn't have him every morning and reported that CNA #2 was standing and watching everything that occurred. The resident explained that he felt nervous and that he clinched his fist. The resident confirmed he waited until the Social Services Director (SSD) arrived to work and he went to her office to report the incident. On 07/23/2026 at 11:48 AM, during an interview with the Administrator he revealed the resident reported to him that two (2) CNAs came into his room to help him get dressed and he tried to tell them how he wanted his shirt put on. The Administrator noted that this is when CNA #1 started cussing him. The Administrator stated the resident told him the CNA #1 said, I don't have time for this (expletive). The Administrator stated that both CNAs have been suspended pending investigation. On 07/23/2026 at 12:26 PM, during an interview with CNA#1 she revealed that Resident #23 would get aggressive with her every morning. CNA #1 recalled that she and CNA #2 entered the resident's room at approximately 6:00 AM to put on the resident's clothes. CNA #1 noted that she put the resident's arm in the sleeve and he swung at her and he said she was putting his shirt on wrong. CNA #1 attested that she told the resident she was just there to help him and the resident started cussing her and stated, Y'all (expletives), I can do what I want to do. CNA #1 confirmed that she asked the resident why he tried to hit her because she was trying to help him and that nothing was good enough for him. CNA #1 reported that as she finished, CNA #2 left the room, and the Human Resources Director (HRD) was outside the resident's room door. The HRD asked why she was cussing the resident, and CNA #1 replied that she was not cussing him, but that he was cussing her. CNA #1 stated her shift ended; she left the facility and received a voicemail from the HR Director that she would be suspended until further notice. CNA #1 revealed that the resident has a history of talking badly to the staff. On 07/23/2026 at 12:40 PM, during an interview, CNA #2 revealed at around 6:00 AM or 7:00 AM she went into Resident #23's room with CNA #1 because she asked for help due to the residents' aggression with staff. CNA #2 noted that she stood at the door to observe as CNA #1 helped the resident get dressed. CNA #2 reported that when CNA #1 put the resident's shirt on, he pulled away and told her that she put the clothes on rough. CNA #2 stated the resident told CNA #1, You aint got to do (expletive) for me. I can do it on my own. Ya'll don't do nothing right. CNA #2 stated she left the room first and saw the HRD standing outside the door. CNA #2 revealed the HRD asked her if there is any reason she and CNA #1 were cussing. CNA #2 noted that she left the facility at the end of her shift and received a call from the HRD stating that she was suspended pending an investigation. CNA #2 stated that Resident #23 was repeatedly inappropriate with staff. On 07/23/2026 at 12:50 PM, during an interview, the HRD revealed that approximately 6:15-6:30 AM she was on the floor helping a resident when she was flagged down by a housekeeper to come to the resident's room. The HRD reported that the housekeeper told her that a CNA was cussing in the room. The HRD stated she walked toward the resident's room and stopped approximately three (3) feet away from his closed door, but did not hear anything. On 07/23/2026 at 1:12 PM, during an interview with the Housekeeper, she revealed that at approximately 6:10 AM this morning (7/23/26) she saw CNA #2 enter Resident #23's room. The housekeeper noted that the door was closed and shortly after she heard a CNA state, I do for you. You can't (expletive) do for yourself, You're not going to (expletive) talk to me like that. I don't (expletive) care who you are. The housekeeper denied hearing Resident #23 speak during this time. The Housekeeper affirmed she reported what she had heard to the HRD. On 07/23/2026 at 2:15 PM, during an interview with the SSD, she revealed that Resident #23 came to her office this morning and reported that two (2) CNAs were in his room and he tried to explain how he wanted his shirt put on. The SSD noted that the resident went on to say that one of the CNAs cussed him and told him she wasn't going to put up with his (expletive). The allegation was reported to the Administrator. A record review of the admission Record revealed the facility admitted Resident #23 on 08/11/2016 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/08/2026 revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The facility submitted the following acceptable Removal Plan on 07/23/2026: On 7/23/26 at 1:40 PM, the State Agency (SA) presented the Immediate Jeopardy (IJ) template to the facility. Immediate Jeopardy was identified at F-600 because the facility failed to provide the necessary care and services to avoid physical harm, pain, and emotional distress for Resident A after accepting responsibility for the resident's care following discharge from the hospital after surgical repair of a left hip fracture. For approximately nine (9) hours after admission, the facility failed to complete a nursing assessment, implement physician orders, administer prescribed medications, provide pain management, assist with toileting, or provide ongoing nursing care. 1. On 7/23/26 at 3:00 PM, The Registered Nurse (RN) Unit Manager, the Licensed Practical Nurse (LPN) Medical Records Nurse, and Admissions Coordinator completed a review of Resident A's admission process to identify the deficient admission practices that resulted in the IJ. The review identified failures to complete the admission assessment, implement physician orders, administer medications, provide pain management, assist with toileting, and provide ongoing nursing care. 2. On 7/23/26 at 4:00 PM, the RN Unit Manager and the LPN Medical Records Nurse completed an audit of 15 current residents that were admitted within the previous three (3) months. Findings include: Two (2) admission Nursing Assessments were found to be incomplete and were completed by RN Unit Manager on 7/23/26 at 4:00 PM. These incompletions did not put the residents at immediate risk. All physician orders were accurately transcribed and implemented. This was conducted by the RN Unit Manager and the LPN Medical Records Nurse on 7/23/26 at 4:00 PM. On 7/23/26 at 4:00 PM, the LPN Medical Records Nurse verified all Medications were available and administered as ordered. On 7/23/26 at 4:00 PM, The RN Unit Manger verified pain assessments were completed. 3. On 7/23/26 at 5:00 PM, the Facility Administrator implemented an admission Nurse Assignment. Every admission is assigned by the Director of Nursing Services to a specific licensed nurse before the resident arrives. The Licensed Nurse is responsible for the initial assessment, medication reconciliation, physician order implementation, pain assessment, admission documentation, physician communication, and shift handoff. 4. On 7/23/26 at 5:00 PM, the Facility Administrator implemented an admission checklist, which includes admission assessment, skin assessment, pain assessment, medication reconciliation, pharmacy notification, physician orders, medication administration, vital signs, fall precautions, toileting needs, and family notification. The checklist will be reviewed by the Director of Nursing Services, the RN Unit Manager, the Facility Administrator, and the RN Minimum Data Set (MDS) Coordinator before the admission process is considered complete. 5. On 7/23/26 at 5:00 PM, the facility Administrator implemented an admission Acceptance Process. Before accepting any admission, regardless of the time of day, the facility verifies that physician orders have been received and reviewed, a specific licensed nurse has been assigned responsibility for the admission, prescribed medications are available or can be obtained and administered without unnecessary delay. If these requirements cannot be met, the facility will not accept responsibility for the residents until the resources necessary to provide safe care are available. 6. On 7/23/26 at 5:30 PM, education was conducted by the RN Unit Manager. 8 Licensed Practical Nurses, the Admissions Coordinator, the LPN Medical Records Nurse, and the Wound Care LPN received education regarding admission responsibilities, physician order implementation, medication administration, pain management, documentation requirements, and the escalation process for barriers to care. No employee will work until he or she has attended this education and/or in-service. In addition, an Abuse/Neglect in-service was conducted by the Facility Administrator on 7/23/26 at 6:00 PM, totaling 32 staff members received education. No employee will work who hasn't attended the Abuse/Neglect in-service. 7. An emergency Quality Assurance and Performance Improvement (QAPI) Meeting was held on 7/23/26 at 6:00 PM, to review policies on admissions, resident care, and medication administration. No changes were made to the policies. In attendance was the Facility Administrator, RN Unit Manager, LPN Medical Records Nurse, and the Medical Director by telephone. The Facility alleges all actions were completed to remove the immediacy on 7/23/26 and the Immediate Jeopardy was removed on 7/24/26. Validation: The SA validated the removal plan through observations, interviews, and record reviews on 07/27/2026 and the immediacy was removed on 07/24/2026 prior to exit.

Based on interviews, record review, and facility policy review, the facility failed to ensure the services of a Registered Nurse (RN) were provided for at least eight (8) consecutive hours a day, seven (7) days a week, and failed to employ a full-time Director of Nursing (DON) to supervise the nursing services of the facility for three (3) of (3) months reviewed for staffing (May through July 2026). This deficient practice had the potential to affect all residents residing in the facility by reducing nursing supervision, clinical oversight, and continuity of nursing care.Findings include:A review of the facility's policy, Nursing Services and Sufficient Staff, revised 2/19/26, revealed, .Policy: it is the policy of the facility to provide sufficient nursing staff with appropriate competencies and skill sets to assure resident safety and attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individualized plans of care.Policy Explanation and Compliance Guidelines: 2. The facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.8. the facility must use the services of a Registered Nurse (RN) for at least eight (8) consecutive hours a day, seven (7) days a week .A record review of the facility's No RN Coverage Statement, dated 7/24/26, revealed the facility had no RN coverage on 5/25/26, 5/30/26, 5/31/26, 6/20/26, 6/27/26, 6/28/26, 7/4/26, 7/5/26, and 7/11/26.A record review of the Director of Nursing (DON) Time Tracker for June 2026 through July 2026 revealed the DON worked at the facility only on 6/8/26, 6/10/26, 6/15/26, 6/16/26, 7/6/26, 7/8/26, and 7/15/26.On 07/21/26 at 10:00 AM, during an interview, the Scheduler confirmed the facility experienced multiple days without RN coverage. The Scheduler stated she notified the DON and Administrator whenever RN coverage could not be obtained and confirmed no additional RNs were available to work. The Scheduler further stated the DON worked 32 hours per week, primarily remotely, and did not routinely provide on-site RN coverage.On 7/24/26 at 12:37 PM, during an interview, Licensed Practical Nurse (LPN) #1 confirmed she worked on 7/11/26 and there was no Registered Nurse on duty that day. LPN #1 stated the facility had experienced several days without RN coverage.On 07/24/26 at 12:45 PM, during an interview, the DON confirmed she began employment on 06/01/26 and was employed on a 32-hour-per-week schedule. The DON acknowledged the facility had experienced days without RN coverage and stated the facility was attempting to hire additional nursing staff.On 07/24/26 at 12:53 PM, during an interview, the Administrator confirmed the facility experienced multiple days without RN coverage. The Administrator stated attempts to obtain RN coverage had been unsuccessful. The Administrator further confirmed the DON's employment agreement required her to work 32 hours per week and permitted remote work.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure residents dependent on staff for Activities of Daily Living (ADLs) received incontinent care in a timely manner for two (2) of (18) sampled residents reviewed for ADL care. (Residents #34 and #10).Findings include:A review of the facility's policy, Activities of Daily Living (ADLs), revised 2/19/26, revealed, .Care and services will be provided for the following activities of daily living.t3. Toileting.Policy Explanation and Guidelines.3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.A review of the facility's policy, Incontinence, revised 2/19/26, revealed, .Policy; Based on the resident's comprehensive assessment, all resident that are incontinent will receive appropriate treatment and services. Policy Explanation and Compliance Guidelines.4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and restore continence to the extent possible.Resident #34A record review of the admission Record revealed Resident #34 was admitted by the facility on 1/20/26 with diagnoses including Type 2 Diabetes Mellitus.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/7/26 revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident was always incontinent of bowel and bladder.On 7/20/26 at 10:00 AM, during an observation and interview, Resident #34 was lying in bed wearing an incontinent brief. There was a strong odor of urine in the room and the resident's brief was visibly saturated with urine. The resident stated he had repeatedly requested assistance, but there was no Certified Nurse Aide (CNA) assigned to the hall. The resident's family member reported the resident had been wet since approximately 8:00 AM. On 7/20/26 at 11:00 AM, during a follow-up observation, Resident #34 remained in the same saturated incontinent brief and the room continued to have a strong urine odor.On 7/20/26 at 11:56 AM, during an interview, CNA #5 acknowledged Resident #34 needed to be changed and reported staff had been busy providing morning care to other residents. CNA #5 stated she had just been called in to work.On 7/20/26 at 12:15 PM, during an interview, Registered Nurse (RN) #5 reported residents were expected to receive incontinent care promptly after staff became aware they were incontinent. RN #5 confirmed there had not been nursing staff assigned to that hall until approximately 11:56 AM.Resident #10A record review of the admission Record revealed Resident #10 was admitted by the facility on 3/20/26 and he had diagnoses including End Stage Renal Disease.A record review of the Quarterly MDS with an ARD of 7/2/26 revealed Resident #10 had a BIMS score of 15, indicating the resident was cognitively intact. Further review revealed the resident was always incontinent of bowel.On 7/20/26 at 10:35 AM, during an observation and interview, Resident #10 activated the call light to alert staff he required assistance. He stated he needed to be changed.On 7/20/26 at 11:45 AM, during a follow-up observation and interview, the call light remained activated. Resident #10 reported that he was still waiting for staff assistance and stated the incontinent brief contained bowel movement and was causing him to have discomfort.On 7/20/26 at 12:30 PM, during an interview, CNA #1 acknowledged Resident #10 had been waiting for assistance and stated staffing shortages delayed incontinent care. CNA #1 reported she had just been called in to assist on the hall.On 7/21/26 at 2:20 PM, during an interview, the Director of Nursing (DON) stated residents were expected to receive incontinent care promptly to prevent skin breakdown, maintain dignity, and promote comfort. The DON acknowledged the delays observed were not consistent with facility expectations.On 7/21/26 at 3:00 PM, during an interview, the Administrator stated staff were expected to provide timely incontinent care according to each resident's assessed needs and facility policy.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide the care and services necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being by failing to ensure physician-directed care and services were implemented and coordinated in accordance with residents' assessed needs and accepted standards of practice. These failures included implementing contact isolation without a physician order or supporting clinical indication for Resident #2; failing to ensure timely transportation for physician-ordered dialysis treatments for Residents #60 and #70 and a scheduled physician appointment for Resident #70; and failing to ensure physician-ordered pain medications were available and administered following admission for Resident #79. This deficient practice affected four (4) of (18) sampled residents (Residents #2, #60, #70, and #79).Findings include:A record review of the facility's policy Infection Prevention and Control Program with reviewed date 2/19/2026 revealed . The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDS guidelines.A record review of the facility's policy Medication Administration with reviewed date of 02/19/2026 revealed . Medications are administered by licensed nurses . as ordered by the physician and in accordance with professional standards of practice . correct any discrepancies and report to the nurse manager.A review of the facility's policy, Transfer and Discharge (including AMA) Date Reviewed 2/19/26 revealed, .10. Emergency Transfers and Acute Care.The facility will obtain a physician's order for emergency transfer or discharge, stating the reason for transfer or discharge.Resident #2On 07/20/2026 at 11:30 AM, during an observation and interview, two (2) staff members donned Personal Protective Equipment (PPE) before entering Resident #2's room. Signage on the resident's door indicated Contact Isolation, and an Enhanced Barrier Precautions sign was posted on the wall beside the door. Registered Nurse (RN) #3 reported she believed Resident #2 was on contact isolation because the resident was Human Immunodeficiency Virus (HIV) positive, put her hands in her bowel movements, and management had instructed staff to wear PPE whenever entering the resident's room. RN #3 stated this was her fourth day at the facility and Resident #2 had been on contact isolation since she started working at the facility.On 07/20/2026 at 12:10 PM, during an observation, two trash cans were located on the left side of Resident #2's bed, one lined with a red bag and the other with a yellow bag. Resident #2 was receiving continuous tube feeding through a feeding pump, and an indwelling urinary catheter was connected to bedside drainage.On 07/22/2026 at 11:35 AM, during an interview and observation, Certified Nurse Aide (CNA) #3 reported Resident #2 had been on Enhanced Barrier Precautions (EBP) since admission but was unsure how long the resident had been on Contact Isolation. CNA #3 stated she believed the resident was on Contact Isolation because the resident had HIV, Herpes, and put her hands in her bowel movements. She reported Resident #2 was incontinent of bowel, put her hands in her bowel movements, and all bowel movements were loose. CNA #3 denied observing blood in the resident's bowel movements and stated the resident did not have any open sores or wounds, but Contact Isolation remained in place. During catheter and perineal care, there was no open lesions observed to the perianal or rectal area.On 07/22/2026 at 2:10 PM, during an interview, Licensed Practical Nurse (LPN) #3 confirmed Resident #2 had no wounds to the sacral or rectal area. LPN #3 reported the resident had been diagnosed with Herpes involving the rectal area while hospitalized ; however, upon admission to the facility, the lesions were dry and no longer open.On 07/22/2026 at 3:00 PM, during an interview, the Director of Nursing (DON) reported there were no residents in the facility on Contact Isolation. The DON confirmed Contact Isolation was not indicated for residents with HIV or Herpes when no open lesions were present and that Standard Precautions were appropriate. She confirmed Resident #2 had a Contact Isolation sign posted on the resident's door and an Enhanced Barrier Precautions sign posted beside the door. The DON stated she did not know how long the Contact Isolation signage had been in place, who placed it, or how long the designated waste containers had been in the resident's room.A record review of Resident #2's admission Record revealed the facility admitted the resident on 05/07/2026 with diagnoses including Herpes Viral Infection of Perianal Skin and Rectum. There was no diagnosis listed or supporting evidence indicating Resident #2 had a medical diagnosis of HIV. A record review of Resident #2's Order Summary Report revealed orders for . Enhance Barrier Precautions R/T (related to) Sacral wound, Foley, and PEG . No orders noted for Contact Isolation.A record review of Resident #2's 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/08/2026 revealed section C1000 Cognitive Skills for Daily Decision Making severely impaired. Section H revealed indwelling catheter and always incontinent bowels. Section J revealed the resident had a peg tube. Resident #60 On 07/20/2026 at 11:20 AM, during an observation and interview, Resident #60 was being assisted by a staff member in a wheelchair. Resident #60 reported he was in a hurry because he had to get to his dialysis appointment and could not be late. He stated he would speak with the surveyor the following morning.On 07/21/2026 at 1:20 PM, during an interview and observation, Resident #60 was observed lying in bed. Resident #60 reported he had been receiving dialysis treatments for years. He stated his biggest complaint with the facility was arriving late for dialysis treatments and waiting to be picked up after dialysis. He reported the facility had not used its transportation van for at least four (4) months and he had been transported by ambulance instead. Resident #60 stated the ambulance service had been late picking him up from the facility, causing him to arrive late for dialysis treatments, and that after dialysis he had waited more than two (2) hours to be picked up and returned to the facility. He reported that after dialysis he was exhausted and wanted to return to the facility to rest. Resident #60 stated he had complained to the Administrator and other staff members about the transportation delays.A record review of Resident #60's admission Record revealed the facility admitted the resident initially on 09/01/2022 and reentry on 01/30/2026 with diagnoses including End Stage Renal Disease and Dependence on Renal Dialysis. A record review of Resident #60's Order Summary Report revealed an order for . Dialysis at Proper Name Kidney Care M-W-F (Monday, Wednesday, Friday) Chair time: 11:50 AM .A record review of Resident #60's Quarterly MDS with an ARD of 07/09/2026 revealed a Brief Interview for Mental Status (BIMS) Summary Score of 14, which indicated cognitively intact. Section O revealed resident received dialysis while a resident. Resident #70On 07/20/2026 at 1:52 PM, during an interview and observation, Resident #70 was observed sitting on the side of the bed. Resident #70 reported he had resided at the facility for several years and had been receiving dialysis treatments for some time. He stated his biggest concern was transportation to and from dialysis treatments and other medical appointments. Resident #70 reported the facility no longer used its transportation van and he was transported by ambulance. He stated he was transported in his wheelchair Monday through Friday and by stretcher on Saturdays. Although he preferred traveling by wheelchair, his primary concern was that after dialysis treatments ended at approximately 3:00 PM, he often waited two (2) hours to be picked up and returned to the facility. He reported he was tired, hungry, and ready to rest after dialysis. Resident #70 also reported he missed a scheduled eye appointment because the ambulance service did not arrive in time to transport him. He stated he had glaucoma and was experiencing vision problems. The eye clinic scheduled the appointment on a Friday before closing at noon, with an appointment time of 10:00 AM; however, he had not left the facility by the appointment time, and the appointment was canceled.On 07/21/2026 at 9:45 AM, during an interview, Licensed Practical Nurse (LPN) #1 reported ambulance transportation had been inconsistent with pickup times. She stated the ambulance service was aware of Resident #70's dialysis schedule but did not always arrive on time. LPN #1 confirmed Resident #70 had complained about arriving late for dialysis treatments and returning late to the facility after dialysis. She also confirmed Resident #70 had to reschedule an eye appointment because transportation did not arrive in time and his wife was unable to transport him to the appointment that day.On 07/21/2026 at 5:15 PM, during an observation and interview, Resident #70 had just returned from dialysis. Resident #70 reported he again waited more than two (2) hours to be picked up and returned to the facility after completing dialysis. He stated he arrived on time for his dialysis chair time that day but was exhausted from waiting to return to the facility. Resident #70 reported his dialysis chair time was approximately 11:00 AM, dialysis was completed at approximately 3:00 PM, and he did not return to the facility until 5:15 PM.On 07/22/2026 at 4:00 PM, in a telephone interview, Resident #70's family member confirmed Resident #70 had to reschedule an eye appointment because transportation did not arrive in time to take him to the appointment. She reported the appointment was scheduled in May for 10:00 AM, but Resident #70 had not left the facility by his appointment time, and the physician's office canceled the appointment because it closed at 12:00 PM. She stated that since then, she had transported him to medical appointments whenever possible, except for dialysis treatments. Resident #70's family member also reported he had complained about arriving late for dialysis chair times, although the dialysis center worked him into the schedule, and that he routinely waited more than two (2) hours after dialysis before being transported back to the facility.On 07/23/2026 at 9:00 AM, during a telephone interview, an employee at Resident #70's eye clinic confirmed Resident #70's appointment scheduled for May 1, 2026, was rescheduled for the following week because transportation was not available.On 07/23/2026 at 9:20 AM, during a telephone interview, a Registered Nurse (RN) at Resident #60's and Resident #70's dialysis center confirmed Residents #60 and #70 had repeatedly arrived late for their scheduled dialysis chair times and routinely waited more than two (2) hours after completing dialysis before being transported back to the facility. The RN reported the dialysis center had contacted the facility regarding the importance of residents arriving on time for their scheduled chair times because late arrivals delayed dialysis treatments for other residents. The RN confirmed the transportation delays to and from dialysis continued at the time of the survey.On 07/23/2026 at 10:00 AM, during an interview, the facility scheduler reported she was responsible for scheduling resident appointments. She confirmed residents receiving dialysis, the dialysis center, and physician offices had complained about residents arriving late for appointments and appointments having to be rescheduled because of transportation delays. She also confirmed the dialysis center had contacted the facility regarding residents waiting extended periods after completing dialysis before being transported back to the facility. The scheduler reported that on the previous day, a physician's office contacted the facility because it was closing at 4:00 PM and a resident was still waiting for transportation.A record review of the admission Record revealed the facility admitted Resident #70 initially on 09/30/2022 and reentry on 02/09/2026 with the diagnoses including End Stage Renal Disease and Dependence on Renal Dialysis. A record review of the Order Summary Report revealed Resident #70 had an order for . Dialysis at Proper Name Kidney Care T-Th-S (Tuesday, Thursday, Saturday) Chair time: 11:10 AM .A record review of Resident #70's Quarterly MDS with an ARD of 07/13/2026 revealed a BIMS Summary Score of 15, which indicated he was cognitively intact. Section O revealed resident received dialysis while a resident. Resident #79On 07/20/2026 at 1:47 PM, during an interview and observation, Resident #79 was observed lying in bed on her right side. Resident #79 reported she had experienced a stroke and was at the facility for rehabilitation. She stated she had experienced pain and muscle twitching since being admitted to the facility. Resident #79 reported she had previously been treated by a pain management provider and had been prescribed Lyrica and Percocet. She stated she informed the facility staff of the medications she had been taking before admission and told them they could contact her pain management provider if additional information was needed. Resident #79 reported she never heard whether anyone contacted the pain management provider and continued to experience pain and muscle twitching.On 07/21/2026 at 10:55 AM, during an observation and interview, Resident #79's bed was made, and the resident was not in the room. Registered Nurse (RN) #2 reported Resident #79 had been transferred to the hospital earlier that morning because of low blood sugar. RN #2 confirmed Resident #79 had received her morning medications and stated the resident's Lyrica and pain medication had been delivered to the facility that morning (7/21/26).On 07/22/2026 at 9:15 AM, during an interview, the Nurse Practitioner (NP) reported she was notified over the weekend that Resident #79 needed prescriptions for medications. The NP stated she was informed the resident had been admitted on [DATE] without the written prescriptions for the ordered narcotic medications. She reported the written prescriptions were provided to the facility on [DATE] for the pharmacy. The NP stated she ordered Tylenol 650 milligrams (mg) because the written prescriptions for the narcotic medications had already been completed and she did not want to issue duplicate written prescriptions.On 07/22/2026 at 3:00 PM, during an interview, the Director of Nursing (DON) reported the facility used one pharmacy, and medications were delivered twice daily. The DON stated she had not been informed Resident #79 had not received the ordered medications since admission or over the weekend. She reported the former RN Supervisor had emailed her copies of the written prescriptions and stated she did not understand why the prescriptions had not been faxed to the pharmacy or picked up during the pharmacy's scheduled delivery on 07/17/2026. The DON reported she expected all ordered medications to be available when a resident was admitted to the facility and that no resident should have to wait several days to receive medications ordered upon admission.On 07/23/2026 at 10:35 AM, during a telephone interview, the Medical Director reported he was not aware residents had not received physician-ordered medications. He stated he expected nursing staff to notify him whenever ordered medications were unavailable or omitted so that he could provide alternative orders or other necessary instructions. The Medical Director reported he expected residents to have ordered medications available upon admission and to receive care and treatment as ordered.On 07/23/2026 at 11:36 AM, during a telephone interview, Registered Nurse (RN) #5 confirmed she was working on 07/16/2026 when Resident #79 was admitted and the written prescriptions from the hospital were not included in the admission packet. She reported she did not contact the hospital that evening; however, the written prescriptions were received on 07/17/2026 and placed on the medication cart for the nurse to provide to the pharmacy. RN #5 reported she was not working over the weekend and did not follow up to determine whether the medications had been obtained. She stated she sent an email to the Director of Nursing (DON) on 07/17/2026 notifying her that the written prescriptions had been received but did not know what occurred after that.On 07/23/2026 at 1:20 PM, during an observation, interview, and record review, Registered Nurse (RN) #6 reported the facility maintained a Med Bank for medications as needed; however, not all nurses, including RN #6, had access to the Med Bank. Review of the facility's Inventory on Hand, C11 sheet for the Med Bank, dated 02/02/2026, revealed the Med Bank contained Lyrica and other pain medications available for resident use.On 07/23/2026 at 1:50 PM, during an interview, Licensed Practical Nurse (LPN) #5 reported the facility used only one pharmacy and did not have a backup pharmacy. She explained that when medications were needed from a local pharmacy, the facility's pharmacy was responsible for arranging delivery. LPN #5 confirmed Resident #79 did not have Lyrica or pain medication available throughout the weekend. She stated she was not informed the written prescriptions for the narcotic medications had not been sent to the pharmacy and was instructed to document the medications as on order. LPN #5 reported she did not notify the physician or Resident #79 that the medications were unavailable; however, she informed the Unit Manager on 07/17/2026 that Resident #79 was experiencing pain and did not have pain medication available. She also reported she did not have access to the facility's Med Bank.On 07/23/2026 at 2:10 PM, during a telephone interview, a Pharmacy Representative for the facility's pharmacy reported the pharmacy did not receive the physician's orders or written prescriptions for Resident #79's Lyrica and Percocet until 11:00 AM on 07/20/2026. The Pharmacy Representative confirmed Resident #79's remaining admission medications had been delivered to the facility on [DATE].On 07/23/2026 at 4:00 PM, during an interview, the Administrator reported he expected staff to follow facility policies and standards of practice and to notify management when concerns were identified. He stated the facility maintained electronic medical records and expected all physician orders to be entered into each resident's electronic medical record. The Administrator reported he expected residents to receive medications as ordered and staff to follow facility policies and procedures when ordered medications were unavailable. He also confirmed he was aware residents had complained about arriving late for appointments and expected residents to arrive on time for scheduled appointments and to be transported back to the facility in a timely manner after appointments were completed. The Administrator was asked to provide a list of nurses with access to the Med Bank; however, no list was provided prior to the survey exit.A record review of the admission Record revealed the facility admitted Resident #79 on 7/16/26 with diagnoses including Cerebral Infarction.A record review of the Order Summary Report revealed Resident #79 had a physician's orders, 7/16/26 for Lyrica 50 milligrams (mg) and Percocet 10-325 mg.A record review of the admission MDS with an ARD of 7/22/26 revealed Resident #79 had a BIMS summary score of 14, which indicated she was cognitively intact.A record review of the Medication Administration Record (MAR) revealed Lyrica was coded as 9 (Other/See Progress Notes) for the 9:00 PM doses from 07/16/2026 through 07/20/2026 and for the 9:00 AM doses on 07/18/2026 and 07/20/2026. Lyrica was coded as 5 (Hold/See Progress Notes) for the 9:00 AM doses on 07/17/2026 and 07/19/2026. Further review revealed there was no documentation that Percocet had been administered.A review of the Progress Notes for Resident #79 revealed there was no documentation explaining why Lyrica was not administered as prescribed.

Based on observations, interviews, record review, and facility policy review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet residents' assessed needs, resulting in delays in providing incontinent care for two (2) of (18) residents reviewed for Activities of Daily Living (ADLs). Residents #10 and #34. This deficient practice had the potential to affect all residents residing in the facility who depended on staff for nursing care and assistance with activities of daily living.Findings Include:A review of the facility's policy, Nursing Services and Sufficient Staff, revised 2/19/26, revealed, .Policy: it is the policy of the facility to provide sufficient nursing staff with appropriate competencies and skill sets to assure resident safety and attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individualized plans of care.A review of the facility's Facility Assessment, dated 6/25/26, revealed the facility identified staffing needs based on resident census, acuity, admissions, discharges, infection prevention needs, and resident outcomes. The assessment documented an average daily census of 72 residents with staffing resources consisting of two (2) Registered Nurses (RN), five (5) Licensed Practical Nurses (LPN), and thirteen (13) Certified Nursing Assistants (CNA).Cross Reference: F727The facility failed to ensure the services of a Registered Nurse (RN) were provided for at least eight (8) consecutive hours a day, seven (7) days a week, and failed to employ a full-time Director of Nursing (DON) to supervise the nursing services of the facility for three (3) of (3) months reviewed for staffing (May through July 2026), reducing nursing supervision, clinical oversight, and continuity of nursing care.Resident #34A record review of Resident #34's admission Record revealed the resident admitted to the facility on [DATE] with diagnoses including Morbid Obesity, Urgency of Urination, Generalized Muscle Weakness, and Need for Assistance with Personal Care.A record review of Resident #34's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 7/7/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. A review of Section H revealed the resident was always incontinent of bowel and bladder.A record review of the Care Plan Report revealed a focus for bowel and bladder incontinence related to overactive bladder with interventions including, clean peri-area with each incontinent episode. An additional focus for ADL self-care performance deficit related to morbid obesity and limited mobility with interventions including required assistance of two (2) staff for toileting and toileting hygiene.On 7/20/26 at 10:00 AM, Resident #34 was observed lying in bed in a visibly saturated incontinent brief with a strong urine odor. The resident stated staff had not responded to the requests for assistance. The resident's family member reported the resident had been wet since approximately 8:00 AM. Resident #34 stated there was no Certified Nursing Assistant (CNA) assigned to the hall.On 7/20/26 at 11:00 AM, Resident #34 remained in the same saturated brief. No staff had provided incontinent care.On 7/20/26 at 11:56 AM, CNA #5 acknowledged the resident required changing but reported staff had been busy providing morning care and she had just been called in to work.On 7/20/26 at 12:15 PM, RN #5 confirmed there had been no CNA assigned to that hall until approximately 11:56 AM and stated residents requiring incontinent care should receive assistance promptly.Resident #10A record review of Resident #10's admission Record revealed the resident admitted to the facility on [DATE] with diagnoses including acquired absence of the left leg below the knee and end-stage renal disease.A record review of Resident #10's Quarterly MDS with ARD 7/2/26 revealed a BIMS score of 15, indicating intact cognition. Review of Section H revealed the resident was always incontinent of bowel.A record review of Resident #10's Care Plan Report revealed a focus for ADL self-care performance deficit related to amputation left BKA (below the knee amputation) with interventions including the resident requires assistance of one (1) staff for toileting and hygiene needs.On 7/20/26 at 10:35 AM, Resident #10 activated the call light requesting assistance with incontinent care.On 7/20/26 at 11:45 AM, the call light remained on. Resident #10 reported remaining in a bowel movement-soiled incontinent brief for over one hour, causing discomfort.On 7/20/26 at 12:30 PM, CNA #1 acknowledged the resident had been waiting for assistance and reported staffing shortages delayed incontinent care because she had just been called in to assist on the hall.On 7/20/26 at 12:15 PM, Registered Nurse (RN) #5 reported four (4) CNAs called in that morning. She reassigned two restorative CNAs, the transportation aide, and called in one additional CNA; however, one hall remained without CNA coverage until additional staff arrived. Registered Nurse (RN) #5 stated she frequently had difficulty obtaining staff, often worked double shifts, and staffing shortages occurred regularly.On 7/21/26 at 9:30 AM, the Local Ombudsman reported receiving complaints from facility staff regarding mandatory double shifts because relief staff were unavailable. The Ombudsman stated she discussed staffing concerns with the Administrator and Director of Nursing and informed them she would report the staffing shortages to the State Agency.On 7/21/26 at 10:00 AM, the Scheduler confirmed the facility frequently experienced staffing shortages, numerous employee call-offs, and several days without RN coverage. The Scheduler reported she had no additional staff available to call in and that the facility did not utilize agency staff.On 7/22/26 at 3:04 PM, the former Director of Nursing (DON) stated she resigned on 5/19/26 because the facility did not have sufficient staff to meet resident needs. She reported frequently working as floor staff, including weekends, and stated the company would not allow the use of agency nursing personnel despite staffing shortages.On 7/24/26 at 12:37 PM, Licensed Practical Nurse (LPN) #1 confirmed the facility experienced ongoing staffing shortages and stated it was difficult to provide resident care when sufficient staff were unavailable. The nurse stated staff do the best they can.On 7/24/26 at 12:45 PM, the DON acknowledged she worked 32 hours per week. The DON acknowledged the facility continued to experience staffing shortages, and stated efforts were underway to recruit additional nursing staff.On 7/24/26 at 12:53 PM, the Administrator confirmed the facility had multiple staffing shortages, difficulty recruiting and retaining staff, frequent weekend call-offs, significant CNA turnover, and resident acuity that exceeded available staffing resources. The Administrator acknowledged the facility did not have sufficient nursing staff to consistently meet resident needs.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was five (5) percent (%) or less for three (3) of (35) medication opportunities. Medication error rate of 8.57% Findings Include: A review of facility policy titled, Medication Administration revised on 2/19/26, revealed, Policy: Medications are administered by licensed nurses.as ordered by the physician and in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines.24. Correct any discrepancies and report to nurse manager.Resident #15On 07/22/26 at 9:31 AM, during a medication pass observation, Licensed Practical Nurse (LPN) #4 prepared medications for Resident #15. During medication preparation, the State Agency (SA) and LPN #4 identified that Linzess, Sulfasalazine, and Folic Acid were unavailable for administration. LPN #4 stated she would contact the pharmacy to determine the status of the medications. LPN #4 administered the remaining scheduled medications but did not administer Linzess, Sulfasalazine, or Folic Acid as ordered because the medications were unavailable.A record review of Resident #15's Medication Administration Record (MAR) dated 07/22/26 revealed code 11 was documented for Linzess, Sulfasalazine, and Folic Acid. The MAR legend identified code 11 as Held due to ordered parameters.A record review of Resident #15's Progress Notes dated 07/22/26 at 11:40 AM revealed the three medications remained pending from the pharmacy.A record review of Resident #15's Order Listing Report failed to identify physician orders or parameters for Linzess, Sulfasalazine, or Folic Acid to be held on 07/22/26. Review of the medical record revealed the medications were unavailable because they had not been supplied by the pharmacy and not because physician-ordered parameters existed to withhold administration.A record review of Resident #15's Order Summary Report revealed active physician orders for . folic acid tab 1 mg (milligram) give 1 tablet orally one time a day related to iron deficiency anemia, order date 3/23/26, Linzess Oral Capsule 72 mcg (microgram) give 1 capsule by mouth one time a day every other day related to Mixed Irritable Bowel Syndrome, order date 5/5/26, and Sulfasalazine tab 500 mg give 1 tablet orally two times a day related to Rheumatoid arthritis, order date 3/23/26 .On 07/23/26 at 10:05 AM, during an interview, LPN #4 stated she did not obtain a physician's order regarding the unavailable medications because she had been instructed to contact the pharmacy to verify when the medications would be available. LPN #4 acknowledged documenting code 11 on the MAR, indicating the medications were held due to ordered parameters. LPN #4 confirmed there were no physician orders or parameters for the medications to be held. LPN #4 further confirmed she did not notify the physician or Resident #15 that the medications were unavailable.On 07/23/26 at 10:20 AM, during an interview, Resident #15 stated she received all of her medications that morning. She further stated she had not been informed the previous day that three of her prescribed medications were unavailable and had not been administered.A record review of Resident #15's admission Record revealed the facility admitted the resident on 06/15/2025 with diagnoses including Other Rheumatoid Arthritis with Rheumatoid Factor of Unspecified Site, Mixed Irritable Bowel Syndrome, and Iron Deficiency Anemia, Unspecified. A record review of Resident #15's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/06/2026 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. On 07/23/26 at 4:00 PM, during an interview, the Administrator stated all physician orders are entered electronically, and the facility does not maintain paper physician orders. The Administrator stated he expected medications to be administered as ordered and staff to follow facility policy when medications were unavailable, including obtaining physician direction when medications could not be administered.

Based on interview, record review and facility policy review, the facility failed to provide written and detailed notification of transfer to the Resident's Representative (RR) upon the resident's discharge from the facility with return anticipated for two (2) of (18) residents sampled. Residents #16 and #74.Findings include:A review of the facility's policy, Transfer and Discharge, dated 2/19/26 revealed, .It is the policy of this facility to permit each resident to remain in the facility, and not transfer.the resident from the facility, except in limited circumstances.Policy Explanation and Compliance Guidelines.3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge.Resident #16A record review of the admission Record revealed the facility admitted Resident #16 on 05/14/2025 with diagnoses including Congestive Heart Failure.A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/18/2026 revealed Resident #16 was discharged from the facility with return anticipated to a short-term general hospital.A review of Resident #16's medical record revealed there was no Transfer Notification for the resident's transfer to the hospital on [DATE].Resident #74A record review of the admission Record revealed the facility admitted Resident #74 on 06/18/2026 with diagnoses including Cerebral Infarction.A record review of the Discharge MDS with an ARD of 6/28/2026 revealed Resident #74 was discharged from the facility with return anticipated to a short-term general hospital.A review of Resident #74's medical record revealed no Transfer Notification for the resident's transfer to the hospital on [DATE].On 07/22/2026 at 4:22 PM, during an interview with the Director of Nursing (DON) she revealed that she is aware that there were no transfer notification forms related to the hospitalization for Resident #16 on 06/18/2026 and Resident #74 on 06/28/2026. The DON stated it was the responsibility of the Social Services Director (SSD) to fill out the hospital transfer form and provide a written copy to the RR. The DON stated it is important to provide a hospital transfer notification to the RR at the time of the resident's hospital because they need to know what is happening with their loved one.On 07/22/2026 at 4:44 PM, during an interview with the SSD, she revealed that she did not send written transfer notification forms to the RR related to the hospitalization for Resident #16 on 06/18/2026 and Resident #74 on 06/28/2026. The SSD stated that previously she would only call the RR to inform them of the resident being sent to the hospital. The SSD conceded that she was not aware that she was supposed to provide a written transfer notification.On 07/22/2026 at 4:50 PM, during an interview with the Administrator, he revealed that he was made aware that no transfer notifications were sent to the RRs for Resident #16 for a hospitalization on 06/18/2026 and Resident #74 for a hospitalization on 06/28/2026. The Administrator stated the importance of informing the families that residents have been transferred to the hospital is to allow them to be assured of a continuation of care is still available post hospitalization, and to allow them information on the reason for the hospitalization.

Based on interviews, record review, and facility policy review, the facility failed to ensure residents received letters and packages delivered to the facility in a timely manner for two (2) of (18) residents reviewed for resident rights. (Residents #3 and #23). Findings include:A review of the facility's policy, Resident Rights revised 2/19/26, revealed, .The resident has a right to.communication with and access to.services inside and outside the facility.Information and communication.i. The resident has the right to.receive mail, and to receive letters, packages and other materials delivered to the facility for the resident.On 07/21/26 at 2:07 PM, during the Resident Council meeting, Resident #3 and Resident #23 reported the United States Postal Service delivered mail to the facility on Saturdays. They stated the mail carrier placed letters in a mailbox outside the Human Resources (HR) office door and left packages that would not fit in the mailbox on the floor outside the HR office. Resident #3 and Resident #23 reported Saturday mail and packages were not distributed until Monday morning when the Human Resources Director returned to work. They further stated this practice had been occurring for some time.On 07/21/26 at 3:21 PM, during an interview, the Human Resources Director (HRD) stated she had worked at the facility since December 2025. The HRD confirmed the mail carrier delivered mail to the facility on Saturdays, placing letters in the mailbox outside her office door and packages too large for the mailbox on the floor outside her office. The HRD stated she distributed Saturday mail and packages to residents on Monday mornings.Review of the facility's mail distribution process revealed mail delivered on Saturdays was routinely held until Monday because the facility had not assigned staff to distribute resident mail on weekends.On 07/23/26 at 1:32 PM, during an interview, the Administrator stated he was unaware residents were not receiving Saturday mail deliveries until Monday. The Administrator confirmed residents had the right to receive their mail in a timely manner and stated he expected mail delivered to the facility to be distributed to residents as soon as possible.Resident #3A record review of Resident #3's admission Record revealed the facility admitted the resident on 12/19/2025 with diagnoses include Paraplegia, Incomplete.A record review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/2026 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact.Resident #23A record review of Resident #23's admission Record revealed the facility admitted the resident on 08/11/2016 with diagnoses include Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side. A record review of Resident #23's Quarterly MDS with an ARD of 07/08/2026, revealed a BIMS score of 15, indicating cognitively intact.

Based on interviews, record review, and facility policy review, the facility failed to accurately complete the Minimum Data Set (MDS) assessments in accordance with the resident's clinical record for two (2) of (18) residents reviewed for MDS accuracy (Residents #75 and #76). The facility inaccurately coded one resident's discharge status and another resident's discharge date .Findings include: A record of the facility's policy MDS 3.0 Completion with reviewed date of [DATE] revealed . According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI (Resident Assessment Instrument) . Types of OBRA (Omnibus Budget Reconciliation Act) Assessments: . f. Discharge Assessment-completed using the discharge date as the ARD (Assessment Reference Date) . i. Death Tracking i. Complete when a resident expires in the facility. A record review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 [DATE] revealed . 2.5 Assessment Types and Definitions . 2.5 Assessment Types and Definitions . Death in Facility refers to when the resident dies in the facility or dies while on a leave of absence (LOA) (see LOA definition). The facility must complete a Death in Facility tracking record . Discharge refers to the date a resident leaves the facility . A day begins at 12:00 a.m. and ends at 11:59 p.m. Regardless of whether discharge occurs at 12:00 a.m. or 11:59 p.m., this date is considered the actual date of discharge . Discharge Assessment refers to an assessment required on resident discharge from the facility . Resident #76'sA record review of Resident #76's admission Record revealed the facility admitted the resident on [DATE] and discharged on [DATE] with the diagnosis of Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery). A record review of Resident #76's Discharge MDS with an ARD of [DATE] revealed unplanned discharge. Section A2105 Discharge Status revealed 01. Home/Community (e.g., private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements) with return not anticipated. A record review of Resident #76's admission MDS with an ARD of [DATE] revealed Section C revealed a Brief Interview for Mental Status (BIMS) Summary Score of 15, which indicated cognitively intact. A record review of Resident #76's Info Note dated [DATE] from Nurse Practitioner revealed . Nursing staff requested patient be seen today for discharge evaluation. His plan of care and medication regimen was reviewed. However, he left the facility after lunch and did not return. He was subsequently discharged from the facility. A record review of the facility's Release of Responsibility for Leave of Absence revealed Resident #76 signed himself out at 12:00 with a signature of responsible party noted. On [DATE] at 11:50 AM, during an interview with Licensed Practical Nurse (LPN) #1, she explained Resident #76 was admitted with a new amputee and only here for therapy. Resident was noncompliant with all care while he was here. One day resident signed himself out with two friends and never returned to the facility. The social worker tried to call the resident and no answers. On [DATE] at 1:47 PM, during an interview with Social Services #1, she reported that Resident #76 was admitted to the facility, but he left the facility one day and just didn't return. She reported that several attempts were made to call and check on the resident, but the number had been disconnected. On [DATE] at 5:05 PM, during an interview with the Administrator, he reported Resident #76 left with two women, he had a high BIMS and the facility did all that they could. Resident just left against medical advice, but no form was signed because he didn't say anything about not coming back. He reported that the facility's MDS nurse is currently on vacation and unavailable. He expects the MDS to be completed accurately depending on the resident's assessment. Resident #75 A record review of the admission Record revealed Resident #75 was admitted by the facility on [DATE] with diagnoses including Heart Failure. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #75 had a death in the facility. A record review of the facility's Progress Notes, dated [DATE] at 4:30 PM, staff found the Resident #75 difficult to arouse, and that he was lethargic, responded only to a sternal rub, had an oxygen saturation of 62%, and was placed on a non-rebreather mask at 15 liters per minute. At 4:31 PM, emergency medical services was notified. The resident's blood pressure was documented as 64/34, pulse 72, respirations 22, and temperature 97.0 degrees F. Ambulance arrived at 4:45 PM, and the resident was transported to a local hospital. A record review of the facility's Progress Notes dated [DATE] at 7:54 AM, Resident expired, which was two (2) days after being transferred from the facility. On [DATE] at 1:30 PM, during an interview with Registered Nurse (RN) #1 MDS Nurse, the nurse reported she began employment with the facility in [DATE] and was not employed at the time the assessment was completed. The nurse reported that the facility was utilizing a remote agency to complete MDS assessments during that period. On [DATE] at 1:45 PM, during an interview with the Director of Nursing (DON), the DON reported she was not employed by the facility at the time the assessment was completed. The DON stated she expected the facility to complete MDS assessments in accordance with the Resident Assessment Instrument (RAI) Manual. On [DATE] at 2:00 PM, during an interview with the Administrator, he confirmed an outside agency completed the MDS assessment during that time. The Administrator acknowledged the Death MDS was completed inaccurately because the resident died two (2) days after admission to the hospital and did not expire in the facility.

Based on staff interviews, resident interview, record review, and facility policy review, the facility failed to develop and implement a person-centered baseline care plan within 48 hours of admission that included the instructions necessary to meet the resident's immediate needs for one (1) of (1) residents reviewed for baseline care plans. (Resident #79).Findings included:A record review of the facility's policy titled Baseline Care Plan, revised 02/19/26, revealed, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care . Policy Explanation and Compliance Guidelines: 1. Be developed within 48 (forty-eight) hours of a resident's admission .A record review of Resident #79's admission Record revealed the facility admitted the resident on 07/16/26 with diagnoses including Cerebral Infarction, Unspecified, Type 2 Diabetes Mellitus without Complications, Anxiety Disorder, Unspecified, and Epilepsy, Unspecified, Not Intractable, without Status Epilepticus.A record review and staff interview during the survey revealed the facility was unable to provide a baseline care plan for Resident #79 when requested by the State Agency. Review of the medical record failed to identify evidence that a baseline care plan had been developed or implemented within 48 hours of the resident's admission. Further review of the medical record failed to identify documented, individualized instructions for staff regarding Resident #79's immediate care needs, including pain management or follow-up when physician-ordered medications were unavailable.A record review of Resident #79's Order Summary Report, revealed active physician orders including a regular diet with chopped meat texture, start date 7/17/26, blood glucose monitoring four (4) times daily, start date 7/16/26, oxygen at two (2) liters per nasal cannula every shift, start date 7/16/26, Keppra 1000 mg (milligram) twice daily, start date 7/16/26, Lyrica 50 mg twice daily, start date 7/16/26, Novolog 20 units before meals, start date 7/16/26, Percocet 10/325 mg every six (6) hours as needed for pain, start date 7/16/26, and Remeron SolTab 15 mg at bedtime, start date 7/16/26.A record review of Resident #79's Medication Administration Record (MAR) revealed Lyrica was not administered until 07/21/26. Review of the MAR further revealed no administration of physician-ordered Percocet.A record review of Resident #79's Medicare Five-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/22/26 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Review of Section N0415 revealed the resident received antiplatelet, hypoglycemic (including insulin), and anticonvulsant medications.A record review of Resident #79's Progress Note dated 7/19/26 at 11:10 AM revealed nursing staff contacted the pharmacy after determining Resident #79 had not received the physician-ordered pain medications. The pharmacy informed nursing staff the facility had not transmitted the prescriptions for dispensing.On 07/20/26 at 1:47 PM, during an interview and observation, Resident #79 reported she had experienced a stroke and was admitted to the facility for therapy. Resident #79 stated that prior to admission she had been followed by a pain management provider who prescribed Lyrica and oxycodone for pain management. She reported she informed facility staff that if there were any issues obtaining her medications, they should contact her pain management provider. Resident #79 stated she had not received either medication since admission or had not been informed whether the facility had contacted her pain management provider. Resident #79 stated she needed both medications for pain management and wondered whether anyone had contacted her pain management provider.On 07/22/26 at 3:00 PM, during an interview, the Director of Nursing (DON) confirmed the facility had not developed a baseline care plan for Resident #79. The DON stated the purpose of the baseline care plan was to direct the resident's care and provide staff with instructions to meet the resident's immediate needs. The DON further stated that without a baseline care plan, staff did not have documented guidance on how to care for the resident.On 07/22/26 at 5:05 PM, during an interview, the Administrator confirmed the facility was unable to provide a baseline care plan for Resident #79. The Administrator stated the facility's MDS nurse was on vacation and that another nurse hired to complete care plans had not yet started employment.

Based on observation, interviews, record reviews, and the facility's policy review, the facility failed to develop and implement Comprehensive Care Plans regarding the residents that had weight loss, catheterization, and anticoagulant therapy for three (3) of (18) residents sampled. Resident #2, Resident #3, and Resident #13. Findings include: A record review of the facility's Comprehensive Care Plans policy with reviewed date of 02/19/26 revealed . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and All services that are identified in the resident's comprehensive assessment and meet professional stands of quality. Policy Explanation and Compliance Guidelines: . 3. The comprehensive care plan will describe . the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 6. the objectives will be utilized to monitor the resident's progress . Resident #2On 07/20/2026 at 12:10 PM, during an observation of Resident #2, the resident was observed with a catheter patent to bedside drainage. A record review of Resident #2's admission Record revealed the facility admitted the resident on 05/07/2026 with the diagnoses of Other Toxic Encephalopathy, Herpes viral Infection of Perineal Skin and Rectum, and Traumatic Subdural Hemorrhage with Loss of Consciousness Status Unknown. A record review of Resident #2's Order Summary Report revealed orders for . Catheter care every shift. Keep catheter bag below level of bladder. Keep drainage bag covered for privacy at all times. Empty drainage bag and record amount every shift with start date 05/08/2026. A record review of Resident #2's 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/08/2026 revealed section C1000 Cognitive Skills for Daily Decision Making severely impaired. Section H revealed indwelling catheter. A record review of Resident #2's Comprehensive Care Plan revealed only two (2) care plans in place related to requires tube feeding and dependent on staff for meeting emotional, intellectual, physical, and social needs, with no care plan for foley catheter and other nursing concerns. Resident #13A record review of Resident #13's admission Record revealed the facility admitted the resident initially on 02/25/2022 and reentry on 02/21/2024 with the diagnosis of Chronic Systolic (Congestive) Heart Failure. A record review of Resident #13's Quarterly MDS with an ARD of 07/09/2026 revealed a Brief Interview for Mental Status (BIMS) Summary Score of 5, which indicated severely cognitively impaired. Section K0300 revealed weight loss and not on physician-prescribed weight-loss regimen. Section O revealed no hospice. A record review of Resident #13's Comprehensive Care Plan revealed individual care plan with focus concerns, goals and interventions to meet those needs. No care plan was implemented for weight loss after the resident was discharged from Hospice. A record review of Resident #12's Progress Notes dated 06/28/2026 Nutrition/Dietary Note . Reason for Assessment: readmit/general review . Resident had been a hospice patient for some time and was discharged from hospice recently . weight change: current wt. (weight) not available; last wt. 155# (pounds) (2/26); which showed wt. loss. After that hospice patient-no weight Ht. (height) 72 (inches) . A record review of Resident #13's Care Profile revealed weights on 01/06/2026, the resident weighed 167 lbs. (pounds) on 07/02/2026, the resident weighed 147 lbs. which is a -11.98% Loss. On 07/21/2026 at 1:00 PM, during an interview with Licensed Practical Nurse (LPN) #5, she reported that Resident #13 was on hospice for a long time and improved and was discharged . His weight has gone up and down. He is on diuretics, but he eats snack food more than regular food. On 07/22/26 at 3:00 PM, during an interview, the Director of Nursing (DON) confirmed the facility does not have complete comprehensive care plans in place for some residents and no new care plan developed for weight loss after Resident #13 was discharged from hospice services. The DON stated the purpose of the comprehensive care plan was to direct the residents' care and provide staff with instructions to meet the residents' immediate needs. The DON further stated that without a comprehensive care plan, staff did not have documented guidance on how to care for the residents. On 07/22/26 at 5:05 PM, during an interview, the Administrator confirmed the facility was unable to provide comprehensive care plans for Resident's #2, # 3, and #13. The Administrator stated the facility's MDS nurse was on vacation and that another nurse hired to complete care plans had not yet started employment. Resident #3 A record review of Resident #3's admission Record revealed the resident was admitted on [DATE] with diagnoses of Paraplegia, Incomplete, and Anxiety Disorder, Unspecified. A record review of Resident #3's Quarterly MDS with an ARD of 6/18/26 revealed a BIMS Summary Score of 15, which indicated cognitively intact. A record review of Resident #3's Order Summary Report revealed orders for Apixaban Oral Tablet 2.5 MG (milligram) Give 1 tablet by mouth two times a day for blood thinner. A record review of Resident #3's Comprehensive Care Plan revealed no care plan to address anticoagulant therapy with interventions.

Based on interview, record review, and facility policy review, the facility failed to ensure controlled substances were securely stored and accessible only to authorized personnel for one (1) of (4) medication storage areas reviewed (Director of Nursing's office). Narcotic medications were left unsecured in the Director of Nursing's office, allowing an unauthorized maintenance employee to access, remove, and destroy controlled substances. Findings include:A review of the facility's policy, Medication Storage, revised [DATE], revealed, .Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations.Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biological will be stored in locked compartments.b. Only authorized personnel will have access to the keys to locked compartments.2. Narcotics and Controlled Substances: a. Schedule II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key.A record review of the facility's Reportable Incident Form reported by the facility to the State Agency included a Brief description of what happened as On [DATE], 2 members of Nursing Services entered into the Director of Nursing Services (DON) Office to recover some narcotics that were held in a sealed drawer. The 2 Nurses stated they were informed by the former DON of the location of the narcotics. The 2 Nurses stated that when they walked into the office, they found the drawer containing the narcotics, but the seals were broken that had been placed over the drawer. According to the nurses, they immediately called the former DON to verify what the contents of the drawer should be. The former DON informed the nurses there were several bubble packs of narcotics along with 1 bottle of morphine, 2 boxes of fentanyl patches and 20 narcotic administration sheets. According to the 2 nurses, the bubble packs were not in the drawer nor were the bubbles packs accounted for. According to the 2 nurses, after their conversation with the former DON, they went to the Human Resources Manager to initiate an investigation into this matter. The 2 nurses then stated it was discovered that (Proper Name), Maintenance Tech, had been cleaning out the office during the day. Under suspicion (Proper Name) was called into the HR Office to discuss if he had any information concerning the seals being broken on the drawer and possibly having knowledge of the missing bubble packs of narcotics.(Proper Name) stated that he took the drugs out of the sealed drawer across the street to the adjoining office building and destroyed the narcotics and placed them into the garbage dumpster. When asked if he knew that he was not to touch medications of any type, especially narcotics, (Proper Name) said I did not know that wasn't supposed to do that. I was only doing what I was told to do by the former DON.the HR Manager walked over to the dumpster to visually see or physically find any medications that might be in the dumpster. The HR Manager did find medications in the dumpster and retrieved what she could. Some of the medications appeared to have the liquid used to destroy narcotics on them. The number of narcotics that had been thrown into the dumpster is unknown because there is no accounting for them or inventory for them.A record review of a signed statement by Licensed Practical Nurse (LPN) #1, dated [DATE], revealed, At approximately 1330 (1:30 PM) on Wednesday, [DATE].entered the office of former DON.to recover some narcotics that were placed in a secured, sealed drawer in the office per former DON instruction; the medication had either expired, order changed, and or the patient had transitioned.A record review of a handwritten statement from the Maintenance Tech, unsigned and undated, revealed, I.was told to destroy any all medicine that was not any good or that was expired up in the DON office. (Proper name of former DON) was who told me to get rid of it. Not known that a nurse or pharmacy has to be there to look or make sure that it was done.I was told to do it and that was what I did.When I saw the drawer no tape was on it.On [DATE] at 1:14 PM, during an interview the Administrator confirmed narcotic medications were expected to remain secure and accessible only to authorized personnel. The Administrator acknowledged an unauthorized employee gained access to the medications because they were being stored in the DON's office in her desk drawer. He confirmed the facility could not verify that all medications removed from the office had been recovered.On [DATE] at 2:00 PM, during an interview the Human Resources (HR) Director, reported Licensed Practical Nurse (LPN) #1 and LPN #6 notified her that the Director of Nursing (DON) instructed them by text message to retrieve narcotics stored in the bottom drawer of the DON's office and place the medications back to the medication carts. The HR Director reported the nurses discovered the tape seal securing the drawer had been broken and the drawer was unlocked. The HR Director stated the Maintenance Assistant had been cleaning DON's office earlier that day. When questioned, the Maintenance Assistant admitted removing the medications from the drawer and stated the DON instructed him to empty the office and destroy the medications. The HR Director reported the Maintenance Assistant was immediately suspended pending investigation. The HR Director further reported the DON sent a text message to the administrative staff at approximately 6:15 PM on [DATE] notifying them that she had resigned effective immediately.On [DATE] at 2:15 PM, during an interview with LPN #1, the nurse reported she received a text message from the DON instructing her and LPN #6 to retrieve narcotics from the bottom drawer of the DON's office and reconcile the medications to the medication carts. LPN #1 reported upon entering the office they observed the tape seal had been broken and the drawer was unlocked. LPN #1 reported the drawer contained two boxes of fentanyl patches, one bottle of morphine, and approximately (20) narcotic accountability records. LPN #1 stated there were no bubble-packed controlled medications in the drawer. The nurse reported she contacted the DON, who stated there should have been (14) bubble-packed medications stored in the drawer.On [DATE] at 2:30 PM, during an interview with the Business Office Manager (BOM), the BOM reported she and the HR Director searched for the discarded medications. The BOM reported recovering routine medications, narcotic medications, inhalers, vials, liquid medications, and damaged bubble-pack medications that had been saturated with an unidentified cleaning solution. The BOM stated several medication packages were no longer legible and confirmed the facility was unable to determine whether all medications had been recovered.On [DATE] at 2:46 PM, during an interview with LPN #6, the nurse confirmed the DON instructed LPN #1 by text message to retrieve the narcotics from the office and place them to the medication carts. LPN #6 reported when they entered the office, the tape seal on the drawer had been broken and the drawer was unlocked. LPN #6 confirmed the drawer contained only two boxes of fentanyl patches, one bottle of morphine, and approximately (20) narcotic accountability records. The nurse confirmed the bubble-packed medications were missing and reported notifying the HR Director and Administrator immediately. LPN #6 further reported observing the Maintenance Assistant cleaning the DON's office earlier that day.On [DATE] at 3:04 PM, during an interview with the former DON acknowledged controlled substances had been stored in her office and confirmed the Maintenance Assistant was not authorized to access, handle, transport, or destroy narcotic medications. She denied that she had asked him to destroy the medications.On [DATE] at 3:15 PM, during an interview with the Maintenance Tech, he acknowledged removing medications from the DON's office, pouring cleaning solution over the medications, and discarding the medications into the facility dumpster. He stated the DON had asked him to destroy the medications.On [DATE] at 3:45 PM, during an interview with the Consultant Pharmacist, the pharmacist reported controlled substances must remain secured in locked medication storage areas and accessible only to authorized personnel. The pharmacist reported that unauthorized access or destruction of controlled substances placed residents at risk for medication diversion, medication loss, interruption of prescribed therapy, and inability to account for controlled substances.

Based on staff interview and facility policy review, the facility failed to conduct Quality Assurance Performance Improvement (QAPI) meetings in accordance with regulatory standards for four (4) of four (4) quarters reviewed.Findings includeA review of the facility's Quality Assurance and Performance Improvement (QAPI) policy, dated 2/19/26 revealed, .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program.Policy Explanation and Compliance Guidelines: 2.b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program.On 07/24/2026 at 9:45 AM, during an interview with the Administrator, he disclosed that since the current owners of the facility assumed operations there has been no QAPI meeting in the facility. The Administrator noted he is unable to provide QAPI sign-in sheets from the previous facility. The Administrator confirmed that regular QAPI meetings are important to maintain quality care for the residents. The Administrator stated he will have QAPI meetings quarterly and as needed.

Based on staff interview and facility policy review, the facility failed to implement their antibiotic stewardship program for seven (7) of (12) months reviewed.Findings include:A review of the facility's policy, Antibiotic Stewardship Program, dated 2/19/26, revealed, Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program.Policy Explanation and Compliance Guidelines:.4. The program includes antibiotic use protocols and a system to monitor antibiotic use.A review of the facility's Infection Prevention and Control Program revealed there was no documentation indicating the facility was monitoring resident antibiotic usage.On 07/22/2026 at 3:30 PM, during an interview with the facility's Scheduler, she revealed that the facility's Infection Preventionist (IP) left employment with the facility in December of 2025. The facility has not had an IP since then.On 07/22/2026 at 3:35 PM, during an interview the Director of Nursing (DON) confirmed that since the IP left the facility there has not been an official antibiotic stewardship program or documentation. The DON stated the importance of maintaining review of antibiotics is to prevent the misuse or overuse of antibiotics that can mask other problems. The DON affirmed that her expectation is to have antibiotics reviewed regularly by an Infection Preventionist.On 07/23/2026 at 1:45 PM, during an interview with the Administrator revealed that he was made aware of the lapse in the antibiotic stewardship program for the facility. The Administrator confirmed that the importance of having an active antibiotic stewardship program is to ensure effective monitoring of antibiotics for residents in the facility and to prevent the overuse of antibiotics.

Based on staff interview and facility policy review, the facility failed to have a certified Infection Preventionist (IP) for seven (7) out of (12) months reviewed. Findings include:A review of the facility's policy, Infection Preventionist dated 3/23/26, revealed, .Policy: The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program.Policy Explanation and Compliance Guidelines: 1. The facility will designate a qualified individual as Infection Preventionist (IP) whose primary role is to coordinate and be actively accountable for the facility's infection prevention and control program to include the antibiotic stewardship program.On 07/22/2026 at 3:30 PM, during an interview with the Scheduler, she revealed that the facility has not had a certified Infection Preventionist since December of 2025.On 07/22/2026 at 3:35 PM, during an interview with the Director of Nursing (DON), she revealed the facility did not currently have a certified IP nurse and no staff at the facility had an IP training certificate. The DON reported that the importance of having a certified IP is to make sure the infection control program is implemented. The DON affirmed that her expectation is to have a specific person to assume and maintain the role of Infection Preventionist.

Based on observations, and staff interviews, the facility failed to post the required daily nurse staffing information in a prominent location readily accessible to residents, resident representatives, and visitors for one (1) of six (6) survey day observations. This deficient practice had the potential to affect all residents residing in the facility by limiting access to required information regarding the nursing staff available to provide care each day.Findings include:The facility was unable to provide a policy addressing the posting of daily nurse staffing information.On 07/21/26 at 10:00 AM, during the initial tour, the State Agency (SA) observed the facility had not posted the required daily nurse staffing information in the lobby or any other location readily accessible to residents, resident representatives, or visitors.On 07/21/26 at 10:20 AM, during an interview, the Scheduler stated she had not posted the required daily nurse staffing information for approximately three (3) months because she was unaware the information was required to be posted daily.On 07/24/26 at 12:01 PM, continued observations throughout the survey confirmed the required daily nurse staffing information had not been posted at any time during the survey. Following notification by the State Agency, the facility posted the required daily nurse staffing information.On 07/24/26 at 12:45 PM, during an interview, the Director of Nursing (DON) stated she had recently assumed the position and was unaware the daily nurse staffing information had not been posted. The DON stated she expected the required staffing information to be posted each day.On 07/24/26 at 12:53 PM, during an interview, the Administrator acknowledged he was unaware the required daily nurse staffing information had not been posted. The Administrator confirmed he expected the staffing information to be posted daily in accordance with regulatory requirements.

Based on interview, record review, and facility policy review, the facility failed to ensure residents' right to a dignified and comfortable environment by failing to effectively address ongoing disruptive behaviors that interfered with other residents' ability to rest for two (2) of four (4) residents reviewed for resident rights. Resident #2 and Resident #3.Findings include:A review of the facility's policy, Resident Rights, revised 3/10/26, revealed, .Policy: The facility will inform the resident.of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility.Resident rights. The resident has the right to a dignified existence.On 4/29/26 at 4:30 PM, during an interview with Resident #2, she reported that during nighttime hours Resident #1 frequently yelled loudly, which disturbed her sleep. She reported the behavior occurred primarily at night and was not observed during daytime hours. She explained the noise caused difficulty resting and had been ongoing.On 4/30/26 at 10:10 AM, during an interview with Resident #3, she reported her rest was frequently disrupted during nighttime hours by Resident #1 yelling loudly. She reported the behavior typically occurred at night and the environment was generally quiet during the day. She explained the noise interfered with her ability to sleep.On 4/30/26 at 10:30 AM, during an interview with Certified Nurse Aide (CNA) #1, she reported she worked both day and night shifts and was familiar with Resident #1's routine. She reported Resident #1 frequently yelled and screamed at intervals throughout the night. She reported the resident was generally quiet and often slept during the day. She confirmed staff assisted Resident #1 out of bed and into a geri-chair during both day and nighttime hours.On 4/30/26 at 11:15 AM, during an interview with the Director of Nursing (DON), she reported the facility was aware Resident #1 had a pattern of increased yelling during nighttime hours and resting for extended periods during the day. She reported the resident had diagnoses including Dementia and Psychosis, which contributed to the behavior. She reported interventions included monitoring, repositioning, offering care, and attempts at redirection; however, the behaviors continued at intervals throughout the night. She acknowledged the facility had received reports from other residents regarding disrupted sleep due to nighttime yelling and stated the facility must balance individual resident needs with the overall environment.On 4/30/26 at 12:00 PM, during an interview with the Administrator, he reported the facility was aware of concerns related to nighttime noise from Resident #1 affecting other residents' ability to rest. He reported the resident had a history of Dementia with behaviors including yelling at night and sleeping during the day. He reported the facility relocated Resident #1 to a private room in an effort to reduce disturbances and stated staff continued to monitor and provide care and redirection as needed.Resident #1A record review of the admission Record revealed the facility admitted Resident #1 on 3/10/26 with diagnoses including Psychosis and Dementia. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident's cognition was severely impaired. A record review of the Progress Notes revealed on 3/12/26 at 1:54 AM, Resident #1 was observed hollering out, and on 3/13/26 at 1:18 AM, Resident #1 was observed hollering loudly. Resident #2A record review of the admission Record revealed the facility admitted Resident #2 on 12/19/25 with diagnoses including Paraplegia and Type 2 Diabetes Mellitus. A record review of the Quarterly MDS with an ARD of 3/18/26 revealed Resident #2 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #3A record review of the admission Record revealed the facility admitted Resident #3 on 5/4/20 with diagnoses including Waldenstrom Macroglobulinemia. A record review of the Quarterly MDS with an ARD of 3/9/26 revealed Resident #3 had a BIMS score of 15, which indicated the resident was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure residents' rights regarding privacy and confidentiality were maintained related to posting of signage on resident walls that included personal health information for two (2) of four (4) residents reviewed for resident rights. Resident #52 and Resident #15. Findings included: A review of the facility's policy, Resident's Rights, dated 2003, revealed, Each and every resident in this facility has the right to . 12. Be treated at all times courteously, fairly, and with the fullest measure of dignity . 17. Be treated with consideration and respect for their personal privacy . Resident #52 A record review of the Admission Record revealed the facility admitted Resident #52 on 7/15/24 with diagnoses including Dementia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/25 revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated his cognition was severely impaired. On 4/14/25 at 12:07 PM, during an observation, Resident #52 was not in his room. Signage was on the wall above the head of the bed, highlighted in green, indicating, Allergy to Standing Order See Nurse and another sign underneath it for a turn schedule indicating times the resident should be repositioned. On 4/15/25 at 8:30 AM, during a phone interview with Resident #52's sister, she reported she was not aware of the signs and did not know what the green-highlighted sign meant. On 4/16/25 at 9:40 AM, in an observation, the signage was still present above the bed, including information related to an allergy and the turn schedule. On 4/16/25 at 2:00 PM, during an interview with Registered Nurse (RN) #1, she explained that the allergy signs were used to alert nurses not to give standing order medications that residents were allergic to. She confirmed the allergy and turn schedule information was listed in the resident's medical record and care plan, and that signage was not necessary. She stated Resident #52 was able to reposition independently and did not need assistance with turning. On 4/16/25 at 2:10 PM, during an interview and observation with Licensed Practical Nurse (LPN) #1, she confirmed the presence of both signs on Resident #52's wall. She stated the allergy sign was placed due to the resident's allergy to Nitroglycerin. She confirmed that the information was documented in the medical record and that signage was not necessary. She also acknowledged the turn schedule was from a previous resident and Resident #52 had been in the room for over six (6) months. On 4/16/25 at 2:50 PM, during an interview with the Administrator, she stated she was unaware of the signage present in residents' rooms. She explained that some residents and families had requested signage for care needs but acknowledged that some of the signage was placed in rooms of residents with low BIMS scores, who may not have been aware of the signs. She confirmed all signs would be removed the same day and that she expected all staff to always honor resident rights. 37415 Resident #15 A record review of the Admission Record revealed the facility admitted Resident #15 on 1/12/21 with diagnoses including Chronic Respiratory Failure. A record review of the Quarterly MDS with an ARD of 1/31/25 revealed Resident #15 had a BIMS score of 15, which indicated she was cognitively intact. On 4/14/25 at 10:57 AM, during an observation and interview, RN #1 observed signs on Resident #15's wall, including a clock with turn schedule and a sign instructing staff to check water in both oxygen concentrators and BiPAP (Bilevel Positive Airway Pressure) each shift, Do not turn the concentrator off, and Do not put H20 (water) bottle on BiPAP with H20. Bottle of water should only be placed on 02 (Oxygen) concentrator for nasal cannula. RN #1 asked the resident if her husband had placed the sign on the wall, and the resident stated he had not. On 4/17/25 at 8:28 AM, during an interview with the Director of Nursing (DON), she confirmed she did not know who placed the signs on the residents' walls. She explained the turn schedule was placed to remind staff to turn residents but acknowledged that such information could be placed on the care plan instead. She confirmed the signs included personal information that did not need to be posted and was visible to visitors.

Based on interview, record review, and facility policy review, the facility failed to submit the comprehensive Minimum Data Set (MDS) assessment within the required timeframe for one (1) of seventeen (17) sampled residents. Resident #46. Findings included: A review of the facility's policy, MDS 3.0 Completion, undated, revealed, .Residents are assessed, using a comprehensive assessment process, in order to identify care needs and develop an interdisciplinary are plan .Policy Explanation and Compliance Guidelines .2. Types of OBRA (Omnibus Budget Reconciliation Act) assessments .c. Annual Assessment - a comprehensive assessment completed using an ARD no > (greater) 366 days from the most recent prior comprehensive assessment and no >92 days from the most recent quarterly assessment . A record review of the Admission Record revealed the facility admitted Resident #46 on 3/7/22 with diagnoses including Peripheral Vascular Disease. A record review of the most recent MDS submitted for Resident #46 revealed a Quarterly MDS with an Assessment Reference Date (ARD) of 12/10/2024, which is more than 92 days past due. On 4/16/25 at 8:30 AM, during an interview with Registered Nurse (RN) #2, MDS Nurse, she acknowledged the resident's Annual MDS with an ARD of 3/10/25 had not been submitted, causing the MDS to be over 120 days overdue. She confirmed she was responsible for submitting the MDS to CMS. She explained she had become very busy with other duties at the facility which caused her to fall behind on submitting the MDS. She noted that the importance of keeping the MDS record current is to document the care the resident needs and is receiving and to ensure the facility can bill for care. She stated her goal is to ensure submissions are timely in the future. On 4/16/25 at 8:47 AM, during an interview with the Director of Nursing (DON), she affirmed the facility failed to submit the resident's Annual MDS with an ARD of 3/10/25, which was over 120 days overdue. She confirmed the MDS nurse is responsible for submitting the MDS on schedule and noted the MDS nurse was relatively new to the role. She emphasized that timely submission ensures residents receive appropriate care and stated she would continue to educate the MDS nurse. On 4/17/25 at 1:03 PM, during an interview with the Administrator, she acknowledged the late submission for the comprehensive MDS with an ARD of 3/10/25. She confirmed the MDS nurse was responsible for submitting the MDS and stated she would implement additional training to support the MDS nurse's development. She stated her expectation was for MDS submissions to be timely.

Based on observation, interview, record review, and facility policy review, the facility failed to implement care plan interventions related to Enhanced Barrier Precautions (EBP) for one (1) of 17 care plans reviewed. Resident #53 Findings include: A record review of the facility's policy Comprehensive Care Plans, revised 02/06/25, revealed . It is the policy of this facility to .implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .Policy Explanation and Compliance Guidelines .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . A record review of the Care Plan Report for Resident #52 revealed a Focus of Resident is on enhanced barrier precautions r/t (related to) foley. (type of indwelling catheter) Interventions included staff will wear gown, gloves for direct care, foley care. On 04/15/25 at 02:20 PM, during an observation, Certified Nurse Aide (CNA) #1, completed catheter care for Resident #53 and did not don a gown to provide the care. During an interview with CNA #1 on 04/15/25 at 02:50 PM, she confirmed that EBP required the staff to wear a gown and gloves, and she did not wear a gown while providing catheter care for Resident #53. She explained she has access to all resident's care plans on the Kiosk and confirmed, Resident #53 has a care plan intervention indicating enhanced barrier precautions on his plan of care. On 04/16/25 at 04:55 PM, during an interview with Registered Nurse (RN)#3/Care Plan Nurse, she explained the purpose of the care plan is to inform the staff how to provide care for residents. She confirmed Resident #53 had a care plan for EBP. She confirmed that she expected all staff to implement care plan interventions. During an interview with the Director of Nursing (DON) on 04/17/25 at 11:50 AM, she explained she was aware that CNA #1 did not wear a gown while providing catheter care and she expected staff to follow the care plan when providing resident care. A record review of the Order Summary Report revealed Resident #53 had a Physician's Order, dated 4/4/25, for Enhanced Barrier Precautions related to Foley. A record review of the Admission Record revealed the facility admitted Resident #53 on 12/2/2024 and he had current diagnoses including Neuromuscular Dysfunction of Bladder. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Further review revealed the resident had an indwelling catheter.

Complaint # Based on record review, staff interview and policy/procedure review, the facility failed to ensure a resident's rights and wishes were honored related to implementation of Cardiopulmonary Resuscitation (CPR) and Rescue Breathing for one (1) of three (3) residents reviewed with an Advance Directive for full code status. (Resident #3). Resident #3, with intact cognitive status, had a documented consent, dated [DATE], for Cardiopulmonary Resuscitation (CPR) to be performed in the event of emergency. CPR/Rescue Breathing (RB) was not initiated on [DATE] at 5:08 AM, when the facility found the resident with a dislodged [MEDICAL CONDITION] and the resident gasping for air prior to the development of [MEDICAL CONDITION]. After activating the Emergency Medical System (EMS), the facility waited approximately 11 minutes until EMS arrived (5:19AM) to initiate rescue breathing and cardiopulmonary resuscitation. The local hospital admitted Resident #3 with severe Brain Anoxia and Resident #3 was mechanical ventilator dependent. Upon discharge from the hospital, Resident #3 was admitted to a Long Term Acute Care (LTAC) where the resident expired on [DATE] with [MEDICAL CONDITION]. The facility's failure to honor the resident's advanced directive and promptly initiate Rescue Breathing and Cardiopulmonary Resuscitation (CPR) when Resident #3 demonstrated respiratory distress due to [MEDICAL CONDITION] dislodgement resulted in subsequent [MEDICAL CONDITION] due to [MEDICAL CONDITION]. This situation lead to the death of Resident #3 and was likely to cause serious injury, harm, impairment or death to other residents with the potential need for Rescue Breathing with a Full Code status. The situation was determined to be an Immediate Jeopardy (IJ) that began on [DATE]. The facility's administrator was notified of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.10 (b) (4) (8) (F155), was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy, entitled Code Policy, undated, revealed, . in the event that the heart should stop or respirations should cease: Cardiopulmonary Resuscitation will be started (CPR), emergency medication will be administered and an Emergency transfer to the hospital will take place. Unless there is an order for [REDACTED]. Review of the facility's policy, entitled, Policy On Medical Directives, dated [DATE] revealed the resident has the right to make decisions concerning self-determination of medical care. This policy revealed the facility would adhere to the medical directives of residents except where those directives are unacceptable to Administration as a matter of conscience. Review of the 2015 American Heart Association's Cardiopulmonary (CPR) Guidelines for the adult revealed to look for no breathing or only gasping and check pulse (simultaneously). If the adult had no breathing but had a pulse, the guideline read to provide rescue breathing, one breath every ,[DATE] seconds or about ,[DATE] breaths per minute. Activate emergency response system (if not already done) after two minutes. Continue rescue breathing and check pulse about every two minutes. If no pulse, begin CPR (chest compressions). Review of the facility's policy, entitled Required Duties During An Emergency Situation, updated on [DATE], did not address how to assist a resident with a compromised airway who remained responsive. This policy addressed an individual that was unresponsive and did not follow the American Heart Association's (AHA) guidelines for a compromised airway or airway obstruction in a conscious person. The facility provided a copy of, Best Practices, Evidence-Based Nursing Procedures, Second Edition, Lippincott, Williams and Wilkins copyright 2007. Review of this document indicated the following, If the patient's breathing is obstructed-for example, when the tube is blocked with mucus that can't be removed by suctioning or by withdrawing the inner cannula-call the appropriate code, and provide manual resuscitation with a handheld resuscitation bag or reconnect the patient to the ventilator. Don't remove the [MEDICAL CONDITION] entirely because this may allow the airway to close completely. Review of Resident #3's Comprehensive Physician order [REDACTED].#3's code status was listed as FULL CODE. Resident #3 signed the Code Policy on [DATE]. Resident #3 had a Brief Interview for Mental Status (BIMS) of 15 on the latest Minimum Data Set (MDS) that indicated Resident #3 was cognitively intact. A phone interview on [DATE] at 3:55 PM with Registered Nurse (RN) #1 revealed she was caring for Resident #3 on [DATE], the morning Resident #3 had Respiratory Arrest with subsequent [MEDICAL CONDITION]. RN #1 reported she could hear Resident #3 banging loudly on the side rails and she rushed into the room. RN #1 said she found Resident #3's [MEDICAL CONDITION] (trach) Tube was dislodged. RN #1 stated she asked Certified Nursing Assistant (CNA) #1 to stay with Resident #3 while she called the ambulance and got the paperwork ready for transport. RN #1 reported she and Licensed Practical Nurse (LPN) #1 returned to the room with the Emergency Medical Services (EMS) staff, and RN #1 and LPN #1 started CPR on Resident #3 with the EMS staff. In an interview with RN #1 on [DATE] at 9:55 AM, RN #1 confirmed she had a current CPR certification, but no rescue breathing was attempted until EMS arrived. RN #1 stated Resident #3 was very anxious and trying to stand up prior to her leaving her room to call EMS on [DATE]. RN #1 also reported CNA #1 said Resident #3 was restless, thrashing about in the bed. RN #1 stated Resident #3 collapsed when she, LPN #1, and EMS arrived, so they initiated CPR. RN #1 did not identify anxiety, thrashing about, and trying to stand up as an indication that Resident #3 was unable to effectively breath. RN #1, explained, She (Resident #3) was afraid. In an interview with RN #1 on [DATE] at 2:35 PM, RN #1 stated she was aware Resident #3 was a Full Code. RN #1 stated the code status of a resident is found at the end of each chart, on the Face Sheet and on the physician's orders [REDACTED].#1 stated in an emergency, the procedure is to start CPR and call 911. Review of the Healthcare Provider CPR cards from the American Heart Association revealed RN #1's CPR card had an Issue Date of [DATE] and had a Recommended Renewal Date of [DATE] which indicated the card was current on [DATE]. In an interview with CNA #1 on [DATE] at 1:00 PM, CNA #1 stated on the morning Resident #3 coded ([DATE]), she could hear Resident #3 banging on the side rails and she went into the room to see what was happening. She stated she noted Resident #3's [MEDICAL CONDITION] was out, and CNA #1 called for help. CNA #1 stated she stayed the room while RN #1 went to call EMS. CNA #1 reported she could hear Resident #3 gasp for air before the nurses and the Emergency Medical Technicians (EMTs) came into the room. CNA #1 confirmed no one in the facility attempted rescue breathing/CPR until EMS arrived. CNA #1 stated RN #1 and LPN #1 came back into the room at the same time EMS arrived. CNA #1 confirmed she had a current CPR certification. Review of the Healthcare Provider CPR cards from the American Heart Association revealed CNA #1's CPR card had an Issue Date of [DATE] and had a Recommended Renewal Date of ,[DATE] which indicated the card was current on [DATE]. The State Agency (SA) was unable to reach LPN #1 for a phone interview and a message was left. Review of the Healthcare Provider CPR cards from the American Heart Association revealed LPN #1's CPR card had an Issue Date of [DATE] and had a Recommended Renewal Date of ,[DATE] indicating the card was current on [DATE]. In a phone interview with Emergency Medical Technician- Paramedic (EMT-P) #1 on [DATE] at 2:35 PM revealed Resident #3 was in respiratory arrest with her chin occluding her stoma opening on arrival to the facility. EMT-P #1 stated the nursing staff came into the room at the same time as the EMT-P's, and a CNA was at Resident #3's bedside. EMT-P #1 stated no rescue breathing or CPR had been attempted prior to EMS arrival per staff. A Death Certificate revealed Resident #3 was pronounced deceased on [DATE] at 6:30 AM at a Long Term Specialty Care Facility, with [MEDICAL CONDITION] listed as cause of death. Review of the Face Sheet revealed the facility admitted Resident #3 on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with the reference date of [DATE] indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #3 was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance on [DATE] for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy: 1. The facility established and signed a contract for training purposes and services with a Respiratory Therapist on [DATE] at 1:00 PM. The Respiratory Therapist trained the Director of Nurses (DON) on dislodged trachs and Residents experiencing breathing and respiratory difficulties. 2. On [DATE] an in-service was conducted by the DON at 2:00 PM, explaining procedures for a dislodged trach, providing rescue breathing and the reference Manuel of Best Practices Policy and Procedures being available at the Nurses Station with 5 of 10 RNs and 7 of 12 LPNs. The DON placed instructions from the Respiratory Therapist on what to do if [MEDICAL CONDITION] out and resident is not breathing on the RN/LPN communication board on [DATE] at 3:00 PM. 3. At 5:00 PM on [DATE], an emergency quality assessment (QA) meeting was called with the Medical Director, Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. This meeting covered identification, documentation, monitoring residents with respiratory distress; a new policy on providing rescue breathing for Residents with respiratory distress, Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. 4. A second emergency QA meeting was called on [DATE] at 6:40 PM with the Medical Director via phone conference, the Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the addition of an assessment form for identification of risk factors for respiratory distress. This assessment will be performed on new admissions, change in respiratory status, change in code status and quarterly on MDSs. The form was approved 5. On [DATE] at 6:50 PM an audit was conducted to identify residents at risk for respiratory distress with the form that was reviewed in QA meeting and approved by Medical Director on [DATE] 5:00 PM by the MDS Nurse, DON and Corporate Nurse. A 100% assessment of all Residents was conducted in the facility to identify the risk of respiratory distress. The result of the audit identified 13 Residents at risk, (with two being Residents with a trach.) Care plans were reviewed and updated accordingly by the Care Plan Nurse and DON. An inventory of oxygen related equipment and supplies was completed by Maintenance and Central Supply at 5:50 PM. 6. On [DATE] at 5:00 PM, in-services were conducted by a Respiratory Therapist for the QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. Respiratory Therapist trained additional staff on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. During these in-services, staff exhibited proper performance of use of equipment. 9 of 11 RNs, 6 of 11 LPNs, 18 of 32 CNAs and 24 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply were trained. 100% of staff verbalized understanding. No staff will be allowed to work until in-serviced. 7. On [DATE] at 7:00 PM, in-services were conducted by a QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties, procedures for manual resuscitation and rescue breathing. [DATE] -[DATE]: 2 of 2 RNs were in-serviced by QA RN, Trainer RN and Trainer LPN On [DATE] - [DATE]: 4 of 5 LPNs were in-serviced by QA RN, Trainer RN and Trainer RN; 1 of 1 LPN trained via telephone. On [DATE] - [DATE]: 13 of 14 CNAs were in-serviced by QA RN, Trainer RN and Trainer LPN, On [DATE] -[DATE]: 4 of 5 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. There were 2 employees unavailable, 1 Dietary and 1 CNA. No staff will be allowed to work until in-serviced. 8. On [DATE] at 7:00 PM, in-service were conducted by QA RN on Policy changes related to care [MEDICAL CONDITION] and rescue breathing, and performance of manual resuscitation and new code form with 9 of 11 RNs, 7 of 11 LPNs, 16 of 32 CNAs, 23 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. 9. On [DATE] at 8:00 PM, in-service were conducted by QA RN on the new code form, respiratory versus cardiac events and the respiratory assessment form. 9 of 11 RNs, 7 of 11 LPNs, 100 % of staff verbalized understanding. 10. On [DATE] at 7:00 AM, in-service were conducted by DON, Trainer RN #2 and Trainer LPN #2 on the new code form, respiratory versus cardiac events and the respiratory assessment form. 1 of 2 RNs, 2 of 4 LPNs, 8 of 16 CNAs, 3 of 6 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 1 RN, 2 LPNs, 4 CNAs and 1 other were trained by telephone. 100 % of staff verbalized understanding. 4 CNAs and 2 other personnel were unreachable. No staff will be allowed to work until in-serviced. 11. On [DATE] at 5:30 PM, a personnel action form with a written warning was completed for unacceptable work performance for RN #1. RN #1 received counseling by QA RN and was in-serviced on proper procedures for a resident in respiratory distress; RN #1 verbalized understanding. On [DATE], RN #1 was suspended pending additional training and education, competency skill pass and review by an Administrative team. 12. The incident was reported by the DON to the Board of Nursing on [DATE] at 10:35 AM and to the State Department of Health as of [DATE]. 13. [DATE] Facility adopted into orientation procedures: training newly hired employees during orientation on the newly implemented policies and procedures, code forms, risk assessments and audit tools. 14. On [DATE] 10:00 AM, all training exercises were completed. The facility alleged Immediate Jeopardy removed as of [DATE]. On [DATE] the State Survey Agency surveyors validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services done on [DATE] across all disciplines. Interviews included RNs, LPNs, CNAs, Dietary Staff, Housekeeping Staff, Maintenance Supervisor, Bookkeeping/Business Office Staff, Activity Director, Laundry Staff, the Director of Nursing, Social Service Director, the Nurse Consultant and the Administrator. Two (2) RNs, four (4) LPNs, twelve (12) CNAs, two (2) laundry staff, six (6) dietary staff, one (1) Bookkeeping/Business Office Staff, one (1) Activity Director, one (1) Social Service Director, two (2) housekeeping staff and one (1) Maintenance Supervisor verified being in-serviced on emergency procedures for a resident found not breathing and if a [MEDICAL CONDITION] was noted to be dislodged. The Administrator verified being in-serviced on rescue breathing for a resident when the airway is not effective, to include if the [MEDICAL CONDITION] should become dislodged. Record review of RN #1's personnel file confirmed she was suspended and the state board of nursing was notified on [DATE]. RN #1 was suspended pending additional education and training. RN #1 must shadow another RN on the 7AM to 3PM shift for 30 days. Administrative team is to evaluate progress of RN #1 and determine if suspension should be lifted. Review of the Quality Assurance (QA) meeting dated [DATE] at 5:00 PM confirmed the meetings consisted of discussing the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. The meeting also covered identification, documentation, monitoring resident with respiratory distress. The Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. Review of a second Quality Assurance (QA) meeting on [DATE] at 6:40 PM with the Medical Director via phone conference confirmed the meeting to discuss the addition of an assessment form for identification of risk factors for respiratory distress and/or failure. This form was approved and the committee began in-services to all nurses and the facility began assessments of all residents.

Complaint # Based on record review, staff interview, and policy/procedure review, the facility failed to thoroughly investigate and report to the State Agency (SA) when facility staff failed to initiate Rescue Breathing during [MEDICAL CONDITION] dislodgement and subsequent respiratory distress for one (1) of five (5) residents reviewed. (Resident #3). The facility failed to investigate and report an incident when the facility staff failed to initiate Rescue Breathing (RB) on [DATE] at 5:08 AM, when the facility staff found Resident #3's [MEDICAL CONDITION] (trach) Tube out and the resident in respiratory distress prior to the development of [MEDICAL CONDITION]. The facility activated the Emergency Medical System (EMS) on [DATE] at 5:10 AM but did not initiate CPR. When EMS arrived at the facility at 5:19 AM, (11 minutes after the [MEDICAL CONDITION] dislodgement), Resident #3 had no pulse and was unresponsive. Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1, and EMS staff then initiated CPR upon EMS arrival with rescue breathing and chest compressions. Resident #3 was resuscitated at the local hospital. The local hospital admitted Resident #3 with severe Brain Anoxia and Resident #3 was mechanical ventilator dependent. Upon discharge from the hospital, Resident #3 was admitted to a Long Term Acute Care (LTAC) where the resident expired on [DATE] with [MEDICAL CONDITION]. The facility's failure to perform a thorough investigation, protect other [MEDICAL CONDITION] residents, and report the incident caused a situation that was likely to cause serious injury, harm, impairment or death to other residents in the facility. The situation was determined to be an Immediate Jeopardy (IJ) that began on [DATE] when Resident #3 did not receive rescue breathing and CPR by facility staff. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on [DATE]. An acceptable credible Allegation of Compliance was received on [DATE] in which the facility alleged the Immediate Jeopardy was removed on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.13 (c) (1) (ii) (iii) (3) (4) (F225), was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings included: The facility's policy entitled Reporting To State Officials Policy , not dated, revealed the facility would report to the State Agency and the Attorney General's Office any suspected cases of abuse, neglect, exploitation by phone within twenty-four (24) hours and in writing within seventy-two (72) hours. In a review of the facility's policy Abuse and Neglect, updated [DATE] revealed the facility would report to the SA and the Attorney General's (AG) office any event that is unexplainable, determined to be abuse, neglect or exploitation or if the event is of a major nature. Record review of Resident #3's Emergency Medical System (EMS) reports and Departmental Notes revealed Resident #3 had a documented consent, dated [DATE], for Cardiopulmonary Resuscitation (CPR) to be performed in the event of emergency. Review of the facility's incident report and investigation notes of Resident #3's code on [DATE] revealed no documentation of the reporting of the facility's failure to perform rescue breathing/CPR on a full code resident . The report read that the facility concluded the nurse acted appropriately and there was no need to report. According to Departmental Notes Rescue Breathing/CPR was not initiated on [DATE], when the facility found the resident with the [MEDICAL CONDITION] (trach) Tube out and in respiratory distress prior to the development of [MEDICAL CONDITION]. In a phone interview on [DATE] at 3:55 PM with Registered Nurse (RN) #1, who was caring for Resident #3 on [DATE], confirmed she did not initiate rescue breathing/CPR for Resident #3 until she and Licensed Practical Nurse (LPN) #1 returned to the resident's room with Emergency Medical Services (EMS) staff. RN #1 stated she and LPN #1 started CPR on Resident #3 while the EMS intubated her. On [DATE] at 2:35 PM in a phone interview, Emergency Medical Technician- Paramedic (EMT-P) #1 revealed upon arrival to the facility, Resident #3 was in respiratory arrest with her chin occluding her stoma opening ([MEDICAL CONDITION]). EMT-P #1 stated the nursing staff came into the room upon EMS arrival, and a CNA (Certified Nurses Assistant) was at Resident #3's bedside. EMT-P #1 stated no rescue breathing or CPR had been attempted prior to EMS arrival per staff. EMS initiated CPR and transferred the resident to the hospital. Review of hospital reports revealed Resident #3 was admitted to the hospital on [DATE]. Resident #3 was resuscitated at the local hospital with the return of a pulse but with severe brain anoxia (lack of oxygen) and was mechanical ventilator dependent. Resident #3 was discharged to a long-term care facility (LTAC) and expired on [DATE] due to [MEDICAL CONDITION]. Interview with the Quality Assurance (QA) nurse on [DATE] at 3:00 PM revealed the QA committee met immediately after the incident with Resident #3 and deemed no harm. The QA nurse stated the committee concluded the staff acted appropriately so nothing changed. Therefore there was nothing to report. Interview with the Administrator on [DATE] at 10:58 AM revealed she did not report this occurrence to the State Agency (SA) because when it was reviewed by QA it was determined as a [MEDICAL CONDITION] and the staff acted appropriately. The Administrator stated she was unaware Respiratory Distress, from the [MEDICAL CONDITION] becoming dislodged, caused Resident #3's [MEDICAL CONDITION]. We did not fully investigate this incident. We see it now. Record review revealed the facility admitted Resident #3 on [DATE] and readmitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with the reference date of [DATE] indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #3 was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance on [DATE] for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy: 1. The facility established and signed a contract for training purposes and services with a Respiratory Therapist on [DATE] at 1:00 PM. The Respiratory Therapist trained the Director of Nurses (DON) on dislodged trachs and Residents experiencing breathing and respiratory difficulties. 2. On [DATE] an in-service was conducted by the DON at 2:00 PM, explaining procedures for a dislodged trach, providing rescue breathing and the reference Manuel of Best Practices Policy and Procedures being available at the Nurses Station with 5 of 10 RNs and 7 of 12 LPNs. The DON placed instructions from the Respiratory Therapist on what to do if [MEDICAL CONDITION] out and resident is not breathing on the RN/LPN communication board on [DATE] at 3:00 PM. 3. At 5:00 PM on [DATE], an emergency quality assessment (QA) meeting was called with the Medical Director, Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. This meeting covered identification, documentation, monitoring residents with respiratory distress; a new policy on providing rescue breathing for Residents with respiratory distress, Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. 4. A second emergency QA meeting was called on [DATE] at 6:40 PM with the Medical Director via phone conference, the Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the addition of an assessment form for identification of risk factors for respiratory distress. This assessment will be performed on new admissions, change in respiratory status, change in code status and quarterly on MDSs. The form was approved 5. On [DATE] at 6:50 PM an audit was conducted to identify residents at risk for respiratory distress with the form that was reviewed in QA meeting and approved by Medical Director on [DATE] 5:00 PM by the MDS Nurse, DON and Corporate Nurse. A 100% assessment of all Residents was conducted in the facility to identify the risk of respiratory distress. The result of the audit identified 13 Residents at risk, (with two being Residents with a trach.) Care plans were reviewed and updated accordingly by the Care Plan Nurse and DON. An inventory of oxygen related equipment and supplies was completed by Maintenance and Central Supply at 5:50 PM. 6. On [DATE] at 5:00 PM, in-services were conducted by a Respiratory Therapist for the QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. Respiratory Therapist trained additional staff on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. During these in-services, staff exhibited proper performance of use of equipment. 9 of 11 RNs, 6 of 11 LPNs, 18 of 32 CNAs and 24 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply were trained. 100% of staff verbalized understanding. No staff will be allowed to work until in-serviced. 7. On [DATE] at 7:00 PM, in-services were conducted by a QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties, procedures for manual resuscitation and rescue breathing. [DATE] -[DATE]: 2 of 2 RNs were in-serviced by QA RN, Trainer RN and Trainer LPN On [DATE] - [DATE]: 4 of 5 LPNs were in-serviced by QA RN, Trainer RN and Trainer RN; 1 of 1 LPN trained via telephone. On [DATE] - [DATE]: 13 of 14 CNAs were in-serviced by QA RN, Trainer RN and Trainer LPN, On [DATE] -[DATE]: 4 of 5 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. There were 2 employees unavailable, 1 Dietary and 1 CNA. No staff will be allowed to work until in-serviced. 8. On [DATE] at 7:00 PM, in-service were conducted by QA RN on Policy changes related to care [MEDICAL CONDITION] and rescue breathing, and performance of manual resuscitation and new code form with 9 of 11 RNs, 7 of 11 LPNs, 16 of 32 CNAs, 23 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. 9. On [DATE] at 8:00 PM, in-service were conducted by QA RN on the new code form, respiratory versus cardiac events and the respiratory assessment form. 9 of 11 RNs, 7 of 11 LPNs, 100 % of staff verbalized understanding. 10. On [DATE] at 7:00 AM, in-service were conducted by DON, Trainer RN #2 and Trainer LPN #2 on the new code form, respiratory versus cardiac events and the respiratory assessment form. 1 of 2 RNs, 2 of 4 LPNs, 8 of 16 CNAs, 3 of 6 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 1 RN, 2 LPNs, 4 CNAs and 1 other were trained by telephone. 100 % of staff verbalized understanding. 4 CNAs and 2 other personnel were unreachable. No staff will be allowed to work until in-serviced. 11. On [DATE] at 5:30 PM, a personnel action form with a written warning was completed for unacceptable work performance for RN #1. RN #1 received counseling by QA RN and was in-serviced on proper procedures for a resident in respiratory distress; RN #1 verbalized understanding. On [DATE], RN #1 was suspended pending additional training and education, competency skill pass and review by an Administrative team. 12. The incident was reported by the DON to the Board of Nursing on [DATE] at 10:35 AM and to the State Department of Health as of [DATE]. 13. [DATE] Facility adopted into orientation procedures: training newly hired employees during orientation on the newly implemented policies and procedures, code forms, risk assessments and audit tools. 14. On [DATE] 10:00 AM, all training exercises were completed. The facility alleged Immediate Jeopardy removed as of [DATE]. On [DATE] the State Survey Agency surveyors validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services done on [DATE] across all disciplines. Interviews included RNs, LPNs, CNAs, Dietary Staff, Housekeeping Staff, Maintenance Supervisor, Bookkeeping/Business Office Staff, Activity Director, Laundry Staff, the Director of Nursing, Social Service Director, the Nurse Consultant and the Administrator. Two (2) RNs, four (4) LPNs, twelve (12) CNAs, two (2) laundry staff, six (6) dietary staff, one (1) Bookkeeping/Business Office Staff, one (1) Activity Director, one (1) Social Service Director, two (2) housekeeping staff and one (1) Maintenance Supervisor verified being in-serviced on emergency procedures for a resident found not breathing and if a [MEDICAL CONDITION] was noted to be dislodged. The Administrator verified being in-serviced on rescue breathing for a resident when the airway is not effective to include if the [MEDICAL CONDITION] should become dislodged. Record review of RN #1's personnel file confirmed she was suspended and the state board of nursing was notified on [DATE]. RN #1 was suspended pending additional education and training. RN #1 must shadow another RN on the 7AM to 3PM shift for 30 days. Administrative team is to evaluate progress of RN #1 and determine if suspension should be lifted. Review of the Quality Assurance (QA) meeting dated [DATE] at 5:00 PM confirmed the meetings consisted of discussing the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. The meeting also covered identification, documentation, monitoring resident with respiratory distress. The Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. Review of a second Quality Assurance (QA) meeting on [DATE] at 6:40 PM with the Medical Director via phone conference confirmed the meeting to discuss the addition of an assessment form for identification of risk factors for respiratory distress and/or failure. This form was approved and the committee began in-services to all nurses and the facility began assessments of all residents.

Complaint # Based on interviews, record review and facility policy review the facility failed to develop a plan of care for [MEDICAL CONDITION] dislodgement for Resident #3 after previous [MEDICAL CONDITION] dislodgement for one (1) of five (5) residents reviewed with [MEDICAL CONDITION], Resident #3. The facility failed to develop a care plan with interventions for [MEDICAL CONDITION] (trach) dislodgement after Resident #3 had a known history of [MEDICAL CONDITION] dislodged. On [DATE] at 5:08 AM, the facility staff discovered Resident #3 with a [MEDICAL CONDITION] in respiratory distress prior to [MEDICAL CONDITION]. The facility activated the Emergency Medical System (EMS) on [DATE] at 5:10 AM but did not initiate CPR. When EMS arrived in the resident's room at 5:19AM, (11 minutes after [MEDICAL CONDITION]) Resident #3 had no pulse and was unresponsive. EMS initiated CPR with rescue breathing and chest compressions and continued until they arrived at the emergency room (ER). Resident #3 was resuscitated at the local hospital with the return of a pulse, but with severe Brain Anoxia. The hospital admitted Resident #3 and later transferred the resident to another long-term care facility. Resident #3 expired on [DATE] with [MEDICAL CONDITION]. The State Agency identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE] when Resident #3'[MEDICAL CONDITION] again after previous dislodgement. The facility failed to develop a plan of care for [MEDICAL CONDITION] dislodgement for Resident #3. This incident caused serious injury to Resident #3 and placed other residents with tracheostomies in a situation that was likely to cause serious injury, harm, impairment and death. The situation was determined to be an Immediate Jeopardy (IJ) that began on [DATE] with Resident #3'[MEDICAL CONDITION]. The facility's Administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.20 (d) (F279), was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's policy, entitled Comprehensive Care Plans, dated [DATE], revealed the plans of care are to be developed by the interdisciplinary team to coordinate and communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. Review of Resident #3's care plans revealed no care plan interventions for how to handle a [MEDICAL CONDITION] being dislodged. A review of Resident #3's Nurses Notes revealed a history of the [MEDICAL CONDITION] becoming dislodged. According to the notes, Resident #3'[MEDICAL CONDITION] dislodged on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Resident #3'[MEDICAL CONDITION] dislodged on [DATE] that resulted in respiratory distress and Resident #3's subsequent [MEDICAL CONDITION]. In an interview on [DATE] at 9:55 AM with RN #1 revealed, Resident #3's Care Plan did not include interventions for [MEDICAL CONDITION] dislodgement or how to clean it, but stated she was taught in nursing school how to care for it. In an interview with RN #2 on [DATE] at 1:20 PM revealed the Care Plan did not include interventions for when the [MEDICAL CONDITION] became dislodged for Resident #3 who had a history of [REDACTED].#2 stated, we try to include everything,[MEDICAL CONDITION], oxygen, suctioning, pneumonia. In an interview on [DATE] at 1:30 PM, RN #3 stated, It's (interventions) not on the Care Plan for emergency care because everyone knows what to do- they know to call 911 and do CPR. Record review revealed the facility admitted Resident #3 on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with the reference date of [DATE] indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating Resident #3 was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance on [DATE] for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy: 1. The facility established and signed a contract for training purposes and services with a Respiratory Therapist on [DATE] at 1:00 PM. The Respiratory Therapist trained the Director of Nurses (DON) on dislodged trachs and Residents experiencing breathing and respiratory difficulties. 2. On [DATE] an in-service was conducted by the DON at 2:00 PM, explaining procedures for a dislodged trach, providing rescue breathing and the reference Manuel of Best Practices Policy and Procedures being available at the Nurses Station with 5 of 10 RNs and 7 of 12 LPNs. The DON placed instructions from the Respiratory Therapist on what to do if [MEDICAL CONDITION] out and resident is not breathing on the RN/LPN communication board on [DATE] at 3:00 PM. 3. At 5:00 PM on [DATE], an emergency quality assessment (QA) meeting was called with the Medical Director, Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. This meeting covered identification, documentation, monitoring residents with respiratory distress; a new policy on providing rescue breathing for Residents with respiratory distress, Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. 4. A second emergency QA meeting was called on [DATE] at 6:40 PM with the Medical Director via phone conference, the Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the addition of an assessment form for identification of risk factors for respiratory distress. This assessment will be performed on new admissions, change in respiratory status, change in code status and quarterly on MDSs. The form was approved 5. On [DATE] at 6:50 PM an audit was conducted to identify residents at risk for respiratory distress with the form that was reviewed in QA meeting and approved by Medical Director on [DATE] 5:00 PM by the MDS Nurse, DON and Corporate Nurse. A 100% assessment of all Residents was conducted in the facility to identify the risk of respiratory distress. The result of the audit identified 13 Residents at risk, (with two being Residents with a trach.) Care plans were reviewed and updated accordingly by the Care Plan Nurse and DON. An inventory of oxygen related equipment and supplies was completed by Maintenance and Central Supply at 5:50 PM. 6. On [DATE] at 5:00 PM, in-services were conducted by a Respiratory Therapist for the QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. Respiratory Therapist trained additional staff on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. During these in-services, staff exhibited proper performance of use of equipment. 9 of 11 RNs, 6 of 11 LPNs, 18 of 32 CNAs and 24 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply were trained. 100% of staff verbalized understanding. No staff will be allowed to work until in-serviced. 7. On [DATE] at 7:00 PM, in-services were conducted by a QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties, procedures for manual resuscitation and rescue breathing. [DATE] -[DATE]: 2 of 2 RNs were in-serviced by QA RN, Trainer RN and Trainer LPN On [DATE] - [DATE]: 4 of 5 LPNs were in-serviced by QA RN, Trainer RN and Trainer RN; 1 of 1 LPN trained via telephone. On [DATE] - [DATE]: 13 of 14 CNAs were in-serviced by QA RN, Trainer RN and Trainer LPN, On [DATE] -[DATE]: 4 of 5 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. There were 2 employees unavailable, 1 Dietary and 1 CNA. No staff will be allowed to work until in-serviced. 8. On [DATE] at 7:00 PM, in-service were conducted by QA RN on Policy changes related to care [MEDICAL CONDITION] and rescue breathing, and performance of manual resuscitation and new code form with 9 of 11 RNs, 7 of 11 LPNs, 16 of 32 CNAs, 23 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. 9. On [DATE] at 8:00 PM, in-service were conducted by QA RN on the new code form, respiratory versus cardiac events and the respiratory assessment form. 9 of 11 RNs, 7 of 11 LPNs, 100 % of staff verbalized understanding. 10. On [DATE] at 7:00 AM, in-service were conducted by DON, Trainer RN #2 and Trainer LPN #2 on the new code form, respiratory versus cardiac events and the respiratory assessment form. 1 of 2 RNs, 2 of 4 LPNs, 8 of 16 CNAs, 3 of 6 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 1 RN, 2 LPNs, 4 CNAs and 1 other were trained by telephone. 100 % of staff verbalized understanding. 4 CNAs and 2 other personnel were unreachable. No staff will be allowed to work until in-serviced. 11. On [DATE] at 5:30 PM, a personnel action form with a written warning was completed for unacceptable work performance for RN #1. RN #1 received counseling by QA RN and was in-serviced on proper procedures for a resident in respiratory distress; RN #1 verbalized understanding. On [DATE], RN #1 was suspended pending additional training and education, competency skill pass and review by an Administrative team. 12. The incident was reported by the DON to the Board of Nursing on [DATE] at 10:35 AM and to the State Department of Health as of [DATE]. 13. [DATE] Facility adopted into orientation procedures: training newly hired employees during orientation on the newly implemented policies and procedures, code forms, risk assessments and audit tools. 14. On [DATE] 10:00 AM, all training exercises were completed. The facility alleged Immediate Jeopardy removed as of [DATE]. On [DATE] the State Survey Agency surveyors validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services done on [DATE] across all disciplines. Interviews included RNs, LPNs, CNAs, Dietary Staff, Housekeeping Staff, Maintenance Supervisor, Bookkeeping/Business Office Staff, Activity Director, Laundry Staff, the Director of Nursing, Social Service Director, the Nurse Consultant and the Administrator. Two (2) RNs, four (4) LPNs, twelve (12) CNAs, two (2) laundry staff, six (6) dietary staff, one (1) Bookkeeping/Business Office Staff, one (1) Activity Director, one (1) Social Service Director, two (2) housekeeping staff and one (1) Maintenance Supervisor verified being in-serviced on emergency procedures for a resident found not breathing and if a [MEDICAL CONDITION] was noted to be dislodged. The Administrator verified being in-serviced on rescue breathing for a resident when the airway is not effective to include if the [MEDICAL CONDITION] should become dislodged. Record review of RN #1's personnel file confirmed she was suspended and the state board of nursing was notified on [DATE]. RN #1 was suspended pending additional education and training. RN #1 must shadow another RN on the 7AM to 3PM shift for 30 days. Administrative team is to evaluate progress of RN #1 and determine if suspension should be lifted. Review of the Quality Assurance (QA) meeting dated [DATE] at 5:00 PM confirmed the meetings consisted of discussing the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. The meeting also covered identification, documentation, monitoring resident with respiratory distress. The Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. Review of a second Quality Assurance (QA) meeting on [DATE] at 6:40 PM with the Medical Director via phone conference confirmed the meeting to discuss the addition of an assessment form for identification of risk factors for respiratory distress and/or failure. This form was approved and the committee began in-services to all nurses and the facility began assessments of all residents.

Complaint # Based on interviews, record review and facility policy review the facility's Quality Assurance Committee failed to identify deficient practice and implement corrective actions related to training for [MEDICAL CONDITION] dislodgement, resident assessment, and rescue breathing for a resident with a [MEDICAL CONDITION] for one (1) of five (5) residents reviewed, Resident #3. The facility's Quality Assurance Committee failure to identify training issues: inadequate respirations, assessment of respiratory distress, and prompt initiation of Rescue Breathing (Cardiopulmonary Resuscitation) when Resident #3's [MEDICAL CONDITION] became dislodged and resulted in subsequent Resident #3's [MEDICAL CONDITION]. This caused serious harm to Resident #3 and was likely to cause serious injury, harm, impairment or death to other residents with [MEDICAL CONDITION] and other residents with the potential need for Rescue Breathing with a Full Code status. The situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE]. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.75 (o) (F520), was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's Job Description entitled, Quality Assurance Nurse Job Description, not dated, revealed the Quality Assurance (QA) nurse is responsible to coordinate between the resident, the medical record, and facility staff to provide quality care and ensure compliance with state and federal regulations. The facility Administrator and QA RN were unable to provide a QA Committee facility policy. Review of the facility's incident report and investigation for Resident #3's code on [DATE] revealed no documentation of the facility's failure to perform rescue breathing/CPR on a full code resident. The report read the facility concluded the nurse acted appropriately and there was no need to report. According to Departmental Notes by Registered Nurse (RN) #1 Rescue Breathing/CPR was not initiated on [DATE], when the facility found the resident with the [MEDICAL CONDITION] (trach) Tube out and in respiratory distress prior to the development of [MEDICAL CONDITION]. On [DATE] at 3:55 PM, in a phone interview with Registered Nurse (RN) #1, cared for Resident #3 on [DATE], revealed RN #1 did not recognize respiratory distress and initiate rescue breathing/CPR for Resident #3 until she returned to the resident's room with Emergency Medical Services (EMS) staff. RN #1 stated she and LPN #1 started CPR on Resident #3 while the EMS intubated her. Record review revealed the facility held a monthly Quality Assurance (QA) Committee meeting on [DATE] with the Administrator, the Director of Nursing, Medical Director, QA Nurse and nine other staff present. The committee discussed Resident #3's incident on [DATE] during the meeting. Interview with the QA nurse on [DATE] at 3:00 PM revealed the QA Committee met immediately after the incident with Resident #3 and deemed no harm, and stated the staff acted appropriately, so nothing changed. During an interview with the Administrator on [DATE] at 10:58 AM she stated due to the failure to investigate the incident thoroughly, the facility QA Committee was unaware Resident #3's Respiratory Distress caused the resident's [MEDICAL CONDITION]. Record review revealed Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with the reference date of [DATE] indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating Resident #3 was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance on [DATE] for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy: 1. The facility established and signed a contract for training purposes and services with a Respiratory Therapist on [DATE] at 1:00 PM. The Respiratory Therapist trained the Director of Nurses (DON) on dislodged trachs and Residents experiencing breathing and respiratory difficulties. 2. On [DATE] an in-service was conducted by the DON at 2:00 PM, explaining procedures for a dislodged trach, providing rescue breathing and the reference Manuel of Best Practices Policy and Procedures being available at the Nurses Station with 5 of 10 RNs and 7 of 12 LPNs. The DON placed instructions from the Respiratory Therapist on what to do if [MEDICAL CONDITION] out and resident is not breathing on the RN/LPN communication board on [DATE] at 3:00 PM. 3. At 5:00 PM on [DATE], an emergency quality assessment (QA) meeting was called with the Medical Director, Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. This meeting covered identification, documentation, monitoring residents with respiratory distress; a new policy on providing rescue breathing for Residents with respiratory distress, Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. 4. A second emergency QA meeting was called on [DATE] at 6:40 PM with the Medical Director via phone conference, the Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the addition of an assessment form for identification of risk factors for respiratory distress. This assessment will be performed on new admissions, change in respiratory status, change in code status and quarterly on MDSs. The form was approved 5. On [DATE] at 6:50 PM an audit was conducted to identify residents at risk for respiratory distress with the form that was reviewed in QA meeting and approved by Medical Director on [DATE] 5:00 PM by the MDS Nurse, DON and Corporate Nurse. A 100% assessment of all Residents was conducted in the facility to identify the risk of respiratory distress. The result of the audit identified 13 Residents at risk, (with two being Residents with a trach.) Care plans were reviewed and updated accordingly by the Care Plan Nurse and DON. An inventory of oxygen related equipment and supplies was completed by Maintenance and Central Supply at 5:50 PM. 6. On [DATE] at 5:00 PM, in-services were conducted by a Respiratory Therapist for the QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. Respiratory Therapist trained additional staff on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. During these in-services, staff exhibited proper performance of use of equipment. 9 of 11 RNs, 6 of 11 LPNs, 18 of 32 CNAs and 24 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply were trained. 100% of staff verbalized understanding. No staff will be allowed to work until in-serviced. 7. On [DATE] at 7:00 PM, in-services were conducted by a QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties, procedures for manual resuscitation and rescue breathing. [DATE] -[DATE]: 2 of 2 RNs were in-serviced by OA RN, Trainer RN and Trainer LPN On [DATE] - [DATE]: 4 of 5 LPNs were in-serviced by QA RN, Trainer RN and Trainer RN; 1 of 1 LPN trained via telephone. On [DATE] - [DATE]: 13 of 14 CNAs were in-serviced by QA RN, Trainer RN and Trainer LPN, On [DATE] -[DATE]: 4 of 5 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. There were 2 employees unavailable, 1 Dietary and 1 CNA. No staff will be allowed to work until in-serviced. 8. On [DATE] at 7:00 PM, in-service were conducted by QA RN on Policy changes related to care [MEDICAL CONDITION] and rescue breathing, and performance of manual resuscitation and new code form with 9 of 11 RNs, 7 of 11 LPNs, 16 of 32 CNAs, 23 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. 9. On [DATE] at 8:00 PM, in-service were conducted by QA RN on the new code form, respiratory versus cardiac events and the respiratory assessment form. 9 of 11 RNs, 7 of 11 LPNs, 100 % of staff verbalized understanding. 10. On [DATE] at 7:00 AM, in-service were conducted by DON, Trainer RN #2 and Trainer LPN #2 on the new code form, respiratory versus cardiac events and the respiratory assessment form. 1 of 2 RNs, 2 of 4 LPNs, 8 of 16 CNAs, 3 of 6 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 1 RN, 2 LPNs, 4 CNAs and 1 other were trained by telephone. 100 % of staff verbalized understanding. 4 CNAs and 2 other personnel were unreachable. No staff will be allowed to work until in-serviced. 11. On [DATE] at 5:30 PM, a personnel action form with a written warning was completed for unacceptable work performance for RN #1. RN #1 received counseling by QA RN and was in-serviced on proper procedures for a resident in respiratory distress; RN #1 verbalized understanding. On [DATE], RN #1 was suspended pending additional training and education, competency skill pass and review by an Administrative team. 12. The incident was reported by the DON to the Board of Nursing on [DATE] at 10:35 AM and to the State Department of Health as of [DATE]. 13. [DATE] Facility adopted into orientation procedures: training newly hired employees during orientation on the newly implemented policies and procedures, code forms, risk assessments and audit tools. 14. On [DATE] 10:00 AM, all training exercises were completed. The facility alleged Immediate Jeopardy removed as of [DATE]. On [DATE] the State Survey Agency surveyors validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services done on [DATE] across all disciplines. Interviews included RNs, LPNs, CNAs, Dietary Staff, Housekeeping Staff, Maintenance Supervisor, Bookkeeping/Business Office Staff, Activity Director, Laundry Staff, the Director of Nursing, Social Service Director, the Nurse Consultant and the Administrator. Two (2) RNs, four (4) LPNs, twelve (12) CNAs, two (2) laundry staff, six (6) dietary staff, one (1) Bookkeeping/Business Office Staff, one (1) Activity Director, one (1) Social Service Director, two (2) housekeeping staff and one (1) Maintenance Supervisor verified being in-serviced on emergency procedures for a resident found not breathing and if a [MEDICAL CONDITION] was noted to be dislodged. The Administrator verified being in-serviced on rescue breathing for a resident when the airway is not effective to include if the [MEDICAL CONDITION] should become dislodged. Record review of RN #1's personnel file confirmed she was suspended and the state board of nursing was notified on [DATE]. RN #1 was suspended pending additional education and training. RN #1 must shadow another RN on the 7AM to 3PM shift for 30 days. Administrative team is to evaluate progress of RN #1 and determine if suspension should be lifted. Review of the Quality Assurance (QA) meeting dated [DATE] at 5:00 PM confirmed the meetings consisted of discussing the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. The meeting also covered identification, documentation, monitoring resident with respiratory distress. The Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. Review of a second Quality Assurance (QA) meeting on [DATE] at 6:40 PM with the Medical Director via phone conference confirmed the meeting to discuss the addition of an assessment form for identification of risk factors for respiratory distress and/or failure. This form was approved and the committee began in-services to all nurses and the facility began assessments of all residents.

Complaint # Based on interviews, record review, review of standards of practice, professional literature review, and American Heart Association guidance review, the facility failed to provide care in a manner that met professional standards of care by failure to assess, determine distress, and provide rescue breathing for Resident #3 when the residents [MEDICAL CONDITION] became dislodged for one (1) of five (5) residents reviewed. Resident #3, with intact cognitive status, had a documented consent, dated [DATE], for Cardiopulmonary Resuscitation (CPR) to be performed in the event of emergency. CPR/Rescue Breathing (RB) was not initiated on [DATE] at 5:08 AM, when the facility found the resident with a dislodged [MEDICAL CONDITION] and the resident gasping for air prior to the development of [MEDICAL CONDITION]. After activating the Emergency Medical System (EMS), the facility waited approximately 11 minutes until EMS arrived to initiate rescue breathing and cardiopulmonary resuscitation. The local hospital admitted Resident #3 with severe Brain Anoxia and Resident #3 was mechanical ventilator dependent. Upon discharge from the hospital, Resident #3 was admitted to a Long Term Acute Care (LTAC) where the resident expired on [DATE] with [MEDICAL CONDITION]. The facility's failure to identify, follow professional standards of care, and promptly initiate Rescue Breathing/Cardiopulmonary Resuscitation (CPR) when Resident #3's [MEDICAL CONDITION] (trach) tube became dislodged resulting in lack of oxygen and subsequent [MEDICAL CONDITION] caused a situation that was likely to cause serious injury, harm, impairment, or death to other residents with [MEDICAL CONDITION]. The situation was determined to be an Immediate Jeopardy (IJ) on [DATE] that began on [DATE]. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on [DATE]. The State Agency validated and determined the Immediate Jeopardy was removed on [DATE] prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.20(k)(3)(i) (F281), was lowered to an D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of Best Practices, Evidence-Based Nursing Procedures, Second Edition, Lippincott, Williams and Wilkins copyright 2007, provided by the facility, indicated Consult the physician about first-aid measures you can use for your [MEDICAL CONDITION] patient should an emergency occur. Follow your facility's policy regarding procedure if a [MEDICAL CONDITION] is expelled or if the outer cannula becomes blocked. If the patient's breathing is obstructed-for example, when the tube is blocked with mucus that can't be removed by suctioning or by withdrawing the inner cannula-call the appropriate code, and provide manual resuscitation with a handheld resuscitation bag or reconnect the patient to the ventilator. Don't remove the [MEDICAL CONDITION] entirely because this may allow the airway to close completely. The 2015 American Heart Association's Cardiopulmonary (CPR) Guidelines for the adult revealed to, look for no breathing or only gasping and check pulse (simultaneously). Is pulse definitely felt within ten seconds? If yes, and the adult has no breathing but has a pulse, provide rescue breathing, one breath every ,[DATE] seconds or about ,[DATE] breaths per minute. Activate emergency response system (if not already done) after two minutes. Continue rescue breathing and check pulse about every two minutes. If no pulse, begin CPR (chest compressions). During a phone interview with Registered Nurse (RN) #1 on [DATE] at 3:55 PM, RN #1 revealed on [DATE] Resident #3 called her name and when entering the room, Resident #3 pointed at her [MEDICAL CONDITION] (trach) and pointed to the clock and indicated she wanted her to do [MEDICAL CONDITION]. RN #1 revealed she informed Resident #3 she would be right back, and when she walked down the hall, she heard banging on the side rails and went in Resident #3's room and found Resident #3 with [MEDICAL CONDITION] dislodged. RN #1 stated she then told Certified Nurse Assistant (CNA) #1 (who also responded to the banging) to remain in the room with Resident #3 while RN #1 went to call the Emergency Medical Services (EMS). RN #1 stated Resident #3 was anxious and thrashing about in bed and trying to get up but stated she could not tell if Resident #3 was having difficulty breathing. RN #1 stated she, along with Licensed Practical Nurse (LPN) #1 returned to the room at the same time the EMS staff arrived. RN #1 stated upon her entering the room, Resident #3 became unresponsive and both she and LPN #1 with the EMS staff began CPR. During an interview with Registered Nurse (RN) #1 on [DATE] at 9:55 AM, RN #1 again confirmed Resident #3 was anxious and trying to stand up and thrashing about in bed. RN #1 stated she believed Resident #3 was anxious and was thrashing about in bed because, She was afraid. RN #1 revealed Certified Nursing Assistant (CNA) #1 reported to her Resident #3 was restless and thrashing about while RN #1 was not in room. RN #1 reported when she and Licensed Practical Nurse (LPN) #1 went into Resident #3's room, at the same time the Emergency Medical Service (EMS) personnel arrived, Resident #3 was unresponsive and Cardiopulmonary Resuscitation (CPR) was initiated. RN #1 confirmed no CPR or rescue breathing had been done prior to EMS arrival. In an interview with RN #1 on [DATE] at 2:35 PM confirmed the late entry documentation dated [DATE] regarding the emergency events for Resident #3 on [DATE] was an estimated time. RN #1 confirmed she requested CNA #1 to stay in the room with Resident #3 when her tracheotomy tube became dislodged while she went to call 911 (EMS). RN #1 revealed she also had to go into the computer to print Resident #3's Face Sheet then go to the end of the hall by the front offices where the printer was to retrieve it to give to EMS once they arrived. RN #1 stated, I'm sure it took (name of the ambulance service) more than two (2) minutes to arrive. The State Board of Nursing position statement for Delegation read, Some tasks, due to their complexity and the accompanying assessment and evaluation skills required, may not be delegated to unlicensed persons. In an interview on [DATE] at 1:00 PM, CNA #1 stated she heard banging on the side rails and went into Resident #3's room (on [DATE]) and found Resident #3 with her [MEDICAL CONDITION] out. CNA #1 reported she called for help and RN #1 arrived and instructed CNA #1 to stay at the bedside while RN #1 called EMS and filled out the paperwork for transfer. CNA #1 stated no one returned to Resident #3's bedside until the EMS arrived(10 minutes later), and that is when RN #1 and LPN #1 came back into the room. CNA #1 reported she could hear Resident #3 gasp for air before the nurses and the Emergency Medical Technicians (EMTs) came into the room. CNA #1 said, I couldn't tell if Resident #3 was breathing. CNA #1 confirmed no rescue breathing had been attempted until EMS arrived. CNA #1 verified she had a current CPR certification. During a phone interview with Emergency Medical Technician- Paramedic (EMT-P) #1 on [DATE] at 2:35 PM, revealed he remembered the incident regarding Resident #3's [MEDICAL CONDITION] becoming dislodged. EMT-P #1 stated upon arrival to the facility, Resident #3 was in respiratory arrest with her chin occluding her stoma opening. EMT-P #1 stated the EMS arrived at Resident #3's room at the same time the nursing staff. EMT-P #1 stated a CNA was the only person at Resident #3's bedside when they arrived and no rescue breathing or CPR had been attempted prior to EMS arrival per staff. EMT-P #1 stated Resident #3's legs were hanging off the bed when EMS arrived. EMT-P stated and when he connected Resident #3 to the cardiac monitor, the resident's heart was in Pulseless Electrical Activity (electrical activity but no pulse because the heart is not pumping enough blood to cause a pulse). EMT-P #1 stated he intubated (put a tube down the airway to provide rescue breathing) Resident #3. EMT-P #1 stated he believed the lack of pulse was caused by hypoxemia (lack of oxygen) because [MEDICAL CONDITION] out and she was not breathing. EMT-P #1 also stated It could have been a mucus plug or anything stopping up [MEDICAL CONDITION] her not to breath. EMT-P stated it took ten (10) minutes for the 911 call till they arrived at Resident #3's bedside and start CPR. Review of the Treatment Administration Record (TAR) and nurses notes for the night of [DATE] - [DATE] revealed the facility had not performed any as needed suctioning for Resident #3. Review of the February 2015 TAR revealed on [DATE] routine every eight hour suctioning was discontinued and as needed suctioning continued. Review of the April TAR revealed facility nursing staff had suctioned Resident #3 one time on [DATE]. Review of the [DATE] local hospital Hospitalist History & Physical for Resident #3 revealed reported to the hospital that Resident #3 was found in full arrest with [MEDICAL CONDITION] and presented to the hospital with jerking movements concerning for [MEDICAL CONDITIONS]. Review of the hospital Discharge Summary for Resident #3 dated [DATE] revealed resident was discharged from the hospital to a specialty hospital with [MEDICAL CONDITION] and on a ventilator with a dense infiltrate on chest X-ray. The summary read upon discharge, Resident #3 was only responsive to painful stimuli. In an interview on [DATE] at 2:35 PM, RN #1 stated she had received no training at the facility related to resident care with [MEDICAL CONDITION]. Review of the personal records revealed RN #1 received a license to practice as a Registered Nurse on [DATE]. The records indicated prior to becoming an RN, she was a Certified Nurses Assistant (CNA) from 1994 to 1999 and a Licensed Practical Nurse (LPN) from 1999 until 2014. Review of RN #1's Healthcare Provider CPR card from the American Heart Association had an Issue Date of [DATE] and had a Recommended Renewal Date of [DATE] which indicated the card was current on [DATE]. Interview on [DATE] at 4:03 PM with CNA #1 revealed CNA #1 stated she had not received any training [MEDICAL CONDITION] prior to the incident on [DATE] with Resident #3. Review of personal records revealed the state issued CNA #1 a certification on [DATE]. Review of CNA #1's Healthcare Provider CPR card from the American Heart Association had an Issue Date of [DATE] and had a Recommended Renewal Date of ,[DATE] which indicated the card was current on [DATE]. A phone interview with LPN #1 was attempted but unsuccessful by the State Agency (SA). Review of personal records revealed the state issued LPN #1 a license on [DATE]. Review of LPN #1's Healthcare Provider CPR card from the American Heart Association had an Issue Date of [DATE] and had a Recommended Renewal Date of ,[DATE] which indicated the card was current on [DATE]. Record review revealed the facility originally admitted Resident #3 on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #3 was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance on [DATE] for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy: 1. The facility established and signed a contract for training purposes and services with a Respiratory Therapist on [DATE] at 1:00 PM. The Respiratory Therapist trained the Director of Nurses (DON) on dislodged trachs and Residents experiencing breathing and respiratory difficulties. 2. On [DATE] an in-service was conducted by the DON at 2:00 PM, explaining procedures for a dislodged trach, providing rescue breathing and the reference Manuel of Best Practices Policy and Procedures being available at the Nurses Station with 5 of 10 RNs and 7 of 12 LPNs. The DON placed instructions from the Respiratory Therapist on what to do if [MEDICAL CONDITION] out and resident is not breathing on the RN/LPN communication board on [DATE] at 3:00 PM. 3. At 5:00 PM on [DATE], an emergency quality assessment (QA) meeting was called with the Medical Director, Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. This meeting covered identification, documentation, monitoring residents with respiratory distress; a new policy on providing rescue breathing for Residents with respiratory distress, Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. 4. A second emergency QA meeting was called on [DATE] at 6:40 PM with the Medical Director via phone conference, the Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the addition of an assessment form for identification of risk factors for respiratory distress. This assessment will be performed on new admissions, change in respiratory status, change in code status and quarterly on MDSs. The form was approved 5. On [DATE] at 6:50 PM an audit was conducted to identify residents at risk for respiratory distress with the form that was reviewed in QA meeting and approved by Medical Director on [DATE] 5:00 PM by the MDS Nurse, DON and Corporate Nurse. A 100% assessment of all Residents was conducted in the facility to identify the risk of respiratory distress. The result of the audit identified 13 Residents at risk, (with two being Residents with a trach.) Care plans were reviewed and updated accordingly by the Care Plan Nurse and DON. An inventory of oxygen related equipment and supplies was completed by Maintenance and Central Supply at 5:50 PM. 6. On [DATE] at 5:00 PM, in-services were conducted by a Respiratory Therapist for the QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. Respiratory Therapist trained additional staff on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. During these in-services, staff exhibited proper performance of use of equipment. 9 of 11 RNs, 6 of 11 LPNs, 18 of 32 CNAs and 24 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply were trained. 100% of staff verbalized understanding. No staff will be allowed to work until in-serviced. 7. On [DATE] at 7:00 PM, in-services were conducted by a QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties, procedures for manual resuscitation and rescue breathing. [DATE] -[DATE]: 2 of 2 RNs were in-serviced by QA RN, Trainer RN and Trainer LPN On [DATE] - [DATE]: 4 of 5 LPNs were in-serviced by QA RN, Trainer RN and Trainer RN; 1 of 1 LPN trained via telephone. On [DATE] - [DATE]: 13 of 14 CNAs were in-serviced by QA RN, Trainer RN and Trainer LPN, On [DATE] -[DATE]: 4 of 5 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. There were 2 employees unavailable, 1 Dietary and 1 CNA. No staff will be allowed to work until in-serviced. 8. On [DATE] at 7:00 PM, in-service were conducted by QA RN on Policy changes related to care [MEDICAL CONDITION] and rescue breathing, and performance of manual resuscitation and new code form with 9 of 11 RNs, 7 of 11 LPNs, 16 of 32 CNAs, 23 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. 9. On [DATE] at 8:00 PM, in-service were conducted by QA RN on the new code form, respiratory versus cardiac events and the respiratory assessment form. 9 of 11 RNs, 7 of 11 LPNs, 100 % of staff verbalized understanding. 10. On [DATE] at 7:00 AM, in-service were conducted by DON, Trainer RN #2 and Trainer LPN #2 on the new code form, respiratory versus cardiac events and the respiratory assessment form. 1 of 2 RNs, 2 of 4 LPNs, 8 of 16 CNAs, 3 of 6 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 1 RN, 2 LPNs, 4 CNAs and 1 other were trained by telephone. 100 % of staff verbalized understanding. 4 CNAs and 2 other personnel were unreachable. No staff will be allowed to work until in-serviced. 11. On [DATE] at 5:30 PM, a personnel action form with a written warning was completed for unacceptable work performance for RN #1. RN #1 received counseling by QA RN and was in-serviced on proper procedures for a resident in respiratory distress; RN #1 verbalized understanding. On [DATE], RN #1 was suspended pending additional training and education, competency skill pass and review by an Administrative team. 12. The incident was reported by the DON to the Board of Nursing on [DATE] at 10:35 AM and to the State Department of Health as of [DATE]. 13. [DATE] Facility adopted into orientation procedures: training newly hired employees during orientation on the newly implemented policies and procedures, code forms, risk assessments and audit tools. 14. On [DATE] 10:00 AM, all training exercises were completed. The facility alleged Immediate Jeopardy removed as of [DATE]. On [DATE] the State Survey Agency surveyors validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services done on [DATE] across all disciplines. Interviews included RNs, LPNs, CNAs, Dietary Staff, Housekeeping Staff, Maintenance Supervisor, Bookkeeping/Business Office Staff, Activity Director, Laundry Staff, the Director of Nursing, Social Service Director, the Nurse Consultant and the Administrator. Two (2) RNs, four (4) LPNs, twelve (12) CNAs, two (2) laundry staff, six (6) dietary staff, one (1) Bookkeeping/Business Office Staff, one (1) Activity Director, one (1) Social Service Director, two (2) housekeeping staff and one (1) Maintenance Supervisor verified being in-serviced on emergency procedures for a resident found not breathing and if a [MEDICAL CONDITION] was noted to be dislodged. The Administrator verified being in-serviced on rescue breathing for a resident when the airway is not effective to include if the [MEDICAL CONDITION] should become dislodged. Record review of RN #1's personnel file confirmed she was suspended and the state board of nursing was notified on [DATE]. RN #1 was suspended pending additional education and training. RN #1 must shadow another RN on the 7AM to 3PM shift for 30 days. Administrative team is to evaluate progress of RN #1 and determine if suspension should be lifted. Review of the Quality Assurance (QA) meeting dated [DATE] at 5:00 PM confirmed the meetings consisted of discussing the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. The meeting also covered identification, documentation, monitoring resident with respiratory distress. The Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. Review of a second Quality Assurance (QA) meeting on [DATE] at 6:40 PM with the Medical Director via phone conference confirmed the meeting to discuss the addition of an assessment form for identification of risk factors for respiratory distress and/or failure. This form was approved and the committee began in-services to all nurses and the facility began assessments of all residents.

Complaint # Based on interviews, record review, care plan review, and facility policy review the facility failed to follow a resident's care plan related to Advance Directive Code Status and [MEDICAL CONDITION] Care for one (1) of three (3) resident care plans reviewed, Resident #3. The facility failed to follow Resident #3's care plans for [MEDICAL CONDITION] (trach) care and code status when Resident #3's [MEDICAL CONDITION] became dislodged causing respiratory distress leading to [MEDICAL CONDITION] caused by lack of oxygen. This situation caused serious harm to Resident #3 and was likely to cause serious injury, harm, impairment or death to other residents with [MEDICAL CONDITION] and a full code status. The situation was determined to be an Immediate Jeopardy (IJ) that began on [DATE] when Resident #3's [MEDICAL CONDITION] became dislodged causing respiratory distress. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.20 (k) (3) (ii) (F282), was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's policy, entitled Comprehensive Care Plans, dated [DATE], revealed the facility would provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being based on the comprehensive assessment of each resident. The care plan was to include the desires and rights of each resident. Review of Resident #3's care plan revealed a care plan dated [DATE] for [MEDICAL CONDITION] in place recurrent resp. (respiratory) failure d/t (due to) aspiration pneumonia, sleep apnea. The goal for this care plan was Trach will be intact without resp. distress, s/s (signs/symptoms) infection qd (every day) for 90 days. Interventions included to observe for s/s resp distress, sob (shortness of breath), wheezing, [MEDICAL CONDITION] (lack of oxygen). During a phone interview on [DATE] at 3:55 PM, Registered Nurse (RN) #1 revealed on [DATE] (5:00 AM), Resident #3 called her name and when RN #1 entered the room, Resident #3 pointed at her [MEDICAL CONDITION] (trach) and pointed to the clock. RN #1 stated this indicated the resident [MEDICAL CONDITION] performed. RN #1 revealed she informed Resident #3 she would be right back, and when she walked down the hall, she heard banging on the side rails and went in Resident #3's room and found Resident #3 with [MEDICAL CONDITION] dislodged. RN #1 stated Resident #3 was anxious and thrashing about in bed and trying to get up but stated she could not tell Resident #3 was having difficulty breathing. RN #1 stated she left the resident attended by Certified Nurses Assistant (CNA) #1 while she notified Emergency Medical Services (EMS). Upon returning to the room with Licensed Practical Nurse (LPN) #1 and the EMS staff, RN #1 stated Resident #3 became unresponsive and both she and LPN #1 with the EMS staff began Cardiopulmonary Resuscitation (CPR). On [DATE] at 9:55 in an interview, Registered Nurse (RN) #1 confirmed Resident #3 was anxious and trying to stand up, thrashing about in bed before she left the room to call EMS. She stated Certified Nursing Assistant (CNA) #1 reported to her Resident #3 was restless and thrashing about in bed while she was out of the resident's room. RN #1 stated she thought the resident was afraid and that was why Resident #3 was anxious and thrashing about in bed. RN #1 did not identify these as signs/ symptoms of [MEDICAL CONDITION]. Review of Resident #3's care plan also revealed plan of care, dated [DATE], for Resident is a full code with an intervention to honor resident's wishes at all times. Resident #3 signed Consent for Cardiopulmonary Resuscitation on [DATE]. This consent indicated Resident #3 should have CPR in the event of an emergency. This was Resident #3's Advanced Directive for code status. In a phone interview with Registered Nurse (RN) #1 on [DATE] at 3:55 PM, RN #1 revealed the morning Resident #3 was transferred to the emergency room , no rescue breathing was done prior to Resident #3 developing [MEDICAL CONDITION]. RN #1 stated CPR (chest compressions and rescue breathing) was initiated with staff assistance when the EMS arrived. In an interview with Registered Nurse (RN) #1 on [DATE] at 9:55 AM, RN #1 confirmed Resident #3 was a Full Code. RN #1 revealed she did not refer to the resident's care plan. She stated, I know if [MEDICAL CONDITION] out to go ahead and call the ambulance (proper name) ASAP (as soon as possible). Record review revealed the facility admitted Resident #3 on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with the reference date of [DATE] indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #3 was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance on [DATE] for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy: 1. The facility established and signed a contract for training purposes and services with a Respiratory Therapist on [DATE] at 1:00 PM. The Respiratory Therapist trained the Director of Nurses (DON) on dislodged trachs and Residents experiencing breathing and respiratory difficulties. 2. On [DATE] an in-service was conducted by the DON at 2:00 PM, explaining procedures for a dislodged trach, providing rescue breathing and the reference Manuel of Best Practices Policy and Procedures being available at the Nurses Station with 5 of 10 RNs and 7 of 12 LPNs. The DON placed instructions from the Respiratory Therapist on what to do if [MEDICAL CONDITION] out and resident is not breathing on the RN/LPN communication board on [DATE] at 3:00 PM. 3. At 5:00 PM on [DATE], an emergency quality assessment (QA) meeting was called with the Medical Director, Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. This meeting covered identification, documentation, monitoring residents with respiratory distress; a new policy on providing rescue breathing for Residents with respiratory distress, Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. 4. A second emergency QA meeting was called on [DATE] at 6:40 PM with the Medical Director via phone conference, the Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the addition of an assessment form for identification of risk factors for respiratory distress. This assessment will be performed on new admissions, change in respiratory status, change in code status and quarterly on MDSs. The form was approved 5. On [DATE] at 6:50 PM an audit was conducted to identify residents at risk for respiratory distress with the form that was reviewed in QA meeting and approved by Medical Director on [DATE] 5:00 PM by the MDS Nurse, DON and Corporate Nurse. A 100% assessment of all Residents was conducted in the facility to identify the risk of respiratory distress. The result of the audit identified 13 Residents at risk, (with two being Residents with a trach.) Care plans were reviewed and updated accordingly by the Care Plan Nurse and DON. An inventory of oxygen related equipment and supplies was completed by Maintenance and Central Supply at 5:50 PM. 6. On [DATE] at 5:00 PM, in-services were conducted by a Respiratory Therapist for the QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. Respiratory Therapist trained additional staff on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. During these in-services, staff exhibited proper performance of use of equipment. 9 of 11 RNs, 6 of 11 LPNs, 18 of 32 CNAs and 24 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply were trained. 100% of staff verbalized understanding. No staff will be allowed to work until in-serviced. 7. On [DATE] at 7:00 PM, in-services were conducted by a QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties, procedures for manual resuscitation and rescue breathing. [DATE] -[DATE]: 2 of 2 RNs were in-serviced by QA RN, Trainer RN and Trainer LPN On [DATE] - [DATE]: 4 of 5 LPNs were in-serviced by QA RN, Trainer RN and Trainer RN; 1 of 1 LPN trained via telephone. On [DATE] - [DATE]: 13 of 14 CNAs were in-serviced by QA RN, Trainer RN and Trainer LPN, On [DATE] -[DATE]: 4 of 5 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. There were 2 employees unavailable, 1 Dietary and 1 CNA. No staff will be allowed to work until in-serviced. 8. On [DATE] at 7:00 PM, in-service were conducted by QA RN on Policy changes related to care [MEDICAL CONDITION] and rescue breathing, and performance of manual resuscitation and new code form with 9 of 11 RNs, 7 of 11 LPNs, 16 of 32 CNAs, 23 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. 9. On [DATE] at 8:00 PM, in-service were conducted by QA RN on the new code form, respiratory versus cardiac events and the respiratory assessment form. 9 of 11 RNs, 7 of 11 LPNs, 100 % of staff verbalized understanding. 10. On [DATE] at 7:00 AM, in-service were conducted by DON, Trainer RN #2 and Trainer LPN #2 on the new code form, respiratory versus cardiac events and the respiratory assessment form. 1 of 2 RNs, 2 of 4 LPNs, 8 of 16 CNAs, 3 of 6 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 1 RN, 2 LPNs, 4 CNAs and 1 other were trained by telephone. 100 % of staff verbalized understanding. 4 CNAs and 2 other personnel were unreachable. No staff will be allowed to work until in-serviced. 11. On [DATE] at 5:30 PM, a personnel action form with a written warning was completed for unacceptable work performance for RN #1. RN #1 received counseling by QA RN and was in-serviced on proper procedures for a resident in respiratory distress; RN #1 verbalized understanding. On [DATE], RN #1 was suspended pending additional training and education, competency skill pass and review by an Administrative team. 12. The incident was reported by the DON to the Board of Nursing on [DATE] at 10:35 AM and to the State Department of Health as of [DATE]. 13. [DATE] Facility adopted into orientation procedures: training newly hired employees during orientation on the newly implemented policies and procedures, code forms, risk assessments and audit tools. 14. On [DATE] 10:00 AM, all training exercises were completed. The facility alleged Immediate Jeopardy removed as of [DATE]. On [DATE] the State Survey Agency surveyors validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services done on [DATE] across all disciplines. Interviews included RNs, LPNs, CNAs, Dietary Staff, Housekeeping Staff, Maintenance Supervisor, Bookkeeping/Business Office Staff, Activity Director, Laundry Staff, the Director of Nursing, Social Service Director, the Nurse Consultant and the Administrator. Two (2) RNs, four (4) LPNs, twelve (12) CNAs, two (2) laundry staff, six (6) dietary staff, one (1) Bookkeeping/Business Office Staff, one (1) Activity Director, one (1) Social Service Director, two (2) housekeeping staff and one (1) Maintenance Supervisor verified being in-serviced on emergency procedures for a resident found not breathing and if a [MEDICAL CONDITION] was noted to be dislodged. The Administrator verified being in-serviced on rescue breathing for a resident when the airway is not effective to include if the [MEDICAL CONDITION] should become dislodged. Record review of RN #1's personnel file confirmed she was suspended and the state board of nursing was notified on [DATE]. RN #1 was suspended pending additional education and training. RN #1 must shadow another RN on the 7AM to 3PM shift for 30 days. Administrative team is to evaluate progress of RN #1 and determine if suspension should be lifted. Review of the Quality Assurance (QA) meeting dated [DATE] at 5:00 PM confirmed the meetings consisted of discussing the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. The meeting also covered identification, documentation, monitoring resident with respiratory distress. The Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. Review of a second Quality Assurance (QA) meeting on [DATE] at 6:40 PM with the Medical Director via phone conference confirmed the meeting to discuss the addition of an assessment form for identification of risk factors for respiratory distress and/or failure. This form was approved and the committee began in-services to all nurses and the facility began assessments of all residents.

Complaint # Based on interviews, record review, hospital reports, professional literature review, and facility policy review, the facility failed to ensure staff were trained and knowledgeable in the care and treatment during emergency procedures for a resident with a [MEDICAL CONDITION] for one (1) of five (5) residents reviewed, Resident #3. The facility failed to ensure staff were able to recognize a resident's signs of [MEDICAL CONDITION] (lack of oxygen) such as restlessness, agitation, and dyspnea; and use professional standards of practice to respond to Resident #3's [MEDICAL CONDITION] becoming dislodged on 4/25/15. This situation caused serious harm to Resident #3 and was likely to cause serious injury, harm, impairment or death to other residents with [MEDICAL CONDITION]. The situation was determined to be an Immediate Jeopardy (IJ) that began on 4/25/15. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on 9/29/15. The State Survey Agency determined the Immediate Jeopardy was removed on 10/3/15 prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.25 (k) (4) (F328), was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: In a review of the facility's copy of, Best Practices, Evidence-Based Nursing Procedures, Second Edition, Lippincott, Williams and Wilkins copyright 2007, indicated Consult the physician about first-aid measures you can use for your [MEDICAL CONDITION] patient should an emergency occur. Follow your facility's policy regarding procedure if a [MEDICAL CONDITION] is expelled or if the outer cannula becomes blocked. If the patient's breathing is obstructed-for example, when the tube is blocked with mucus that can't be removed by suctioning or by withdrawing the inner cannula-call the appropriate code, and provide manual resuscitation with a handheld resuscitation bag or reconnect the patient to the ventilator. Don't remove the [MEDICAL CONDITION] entirely because this may allow the airway to close completely. Review of facility policies revealed the emergency policy for [MEDICAL CONDITION] Dislodgement was developed 6/1/15 after Resident #3's incident on 4/25/15. In an interview with the Director of Nursing (DON) on 9/29/15 at 12:55 PM confirmed the facility had two (2) nurses trained to replace [MEDICAL CONDITION], so there was not enough nurses trained to cover all shifts. The DON stated she posted a training notice at the nurse's station in June 2015 for the staff to read and sign regarding [MEDICAL CONDITION] Dislodgement and what to do should one become dislodged. The DON stated the nurses had to go to a local Ear, Nose and Throat doctor to be trained because the Respiratory Therapist did not feel comfortable training the nurses to provide [MEDICAL CONDITION] replacement. Review of the notice posted by the facility's DON revealed a note dated 6/1/15 (over a month after the incident of Resident #3 on 4/25/15) at the nurses station for education purposes regarding what to do in the event a [MEDICAL CONDITION] (trach) becomes dislodged. The notice indicated: 1. If in respiratory distress or loss of respirations, [MEDICAL CONDITION] and gives breaths with high oxygen per bag. Call, proper name (the local ambulance service), for emergency response. 2. If in no distress notify, proper name (the local ambulance service), for emergency response. Always inform EMS that [MEDICAL CONDITION] out and resident is in distress or potential distress. The DON signed the note and dated 6/1/15. An interview with the Director of Nursing (DON) on 10/20/15 at 1:48 PM confirmed the facility's policy for [MEDICAL CONDITION] Dislodgement from June 2015, had not been reviewed or signed by the Quality Assurance Committee or the Medical Director. In a phone interview with Registered Nurse (RN) #1 on 9/28/15 at 3:55 PM Resident #3 requested [MEDICAL CONDITION] care on the morning of 4/25/15. RN #1 stated she told Resident #3 she would return in a few minutes. RN #1 then stated she heard banging on the side rails and went into Resident #3's room and found her with [MEDICAL CONDITION] dislodged. RN #1 confirmed she told CNA #1 to stay in the room with Resident #3 while she left to call EMS, but denied she checked to see if Resident #3 was breathing without difficulty. In an interview with Registered Nurse (RN) #1 on 9/30/15 at 9:55 AM, RN #1 confirmed Resident #3 was anxious and trying to stand up, thrashing about in bed. She stated Certified Nursing Assistant (CNA) #1 reported to her Resident #3 was restless and thrashing about in bed. RN #1 did not identify these as signs/symptoms of an obstructed airway or a need for suctioning due to [MEDICAL CONDITION]. In an interview with Certified Nurses Assistant (CNA) #1 on 9/29/15 at 1:00 PM she stated she heard banging on the side rails and went into Resident #3's room and found Resident #3 with her [MEDICAL CONDITION] out. CNA #1 stated Resident #3 was thrashing about, attempting to get out of bed. CNA #1 reported she could hear Resident #3 gasp for air before the nurses and the Emergency Medical Service (EMS) came into the room. CNA #1 stated she could not tell if Resident #3 was breathing. Record review of the facility's Nurses Notes revealed Resident #3's Tracheotomy Tube had become dislodged on 12/2/11, 8/3/12, 8/23/12, 11/9/14, 11/15/14 and 2/4/15 prior to 4/25/15. In an interview on 9/29/15 at 12:55 PM with the Director of Nursing (DON), the DON confirmed at the time of Resident #3's incident on 4/25/15, the facility had two (2) nurses trained to replace [MEDICAL CONDITION] and there was not enough nurses trained to cover all shifts. The DON stated the facility had a Respiratory Therapist on call only for any questions. The DON stated the Respiratory Therapist did not feel comfortable training the nurses to provide [MEDICAL CONDITION] replacement so the facility sent the nurses to a local Ear, Nose and Throat (ENT) physician to be trained. The DON confirmed RN #1 was not trained on replacement of a dislodged [MEDICAL CONDITION] and neither of the two nurses trained were on schedule at the time of the incident. Review of the Working Schedule for 4/25/15 revealed neither of the nurses trained for [MEDICAL CONDITION] replacement were working during Resident #3'[MEDICAL CONDITION] on 4/25/15. An interview with the DON on 10/20/15 at 6:10 PM revealed, the physician who used to train staff on replacing and changing the [MEDICAL CONDITION] in the facility, had received legal advice not to provide any more training to facility staff on replacing or changing [MEDICAL CONDITION] because of liability concerns. The Respiratory Therapist said the same thing. He did not feel comfortable training the staff to replace the [MEDICAL CONDITION] until he works with us more. The DON confirmed there was no policy approved by QA and signed by the QA members for what to do in the event a [MEDICAL CONDITION] became dislodged. The DON was unable to produce any in-services given for staff, regarding interventions for [MEDICAL CONDITION] dislodgement prior to 4/25/15. Interview on 9/29/15 at 5:00 PM with the Respiratory Therapist revealed he was the facility's resource person for RT (Respiratory Therapy). The Respiratory Therapist stated he could not recall any specific training for rescue breathing, and confirmed it was his understanding only two nurses were trained in the facility to replace a [MEDICAL CONDITION]. He stated he felt very uncomfortable about training the staff to reinsert a [MEDICAL CONDITION]. On 10/20/15 at 2:35 PM, in an interview with RN #1, she confirmed she had received no training at the facility related to resident care with a [MEDICAL CONDITION]. Interview with Licensed Practical Nurse (LPN) #2 on 9/28/15 at 6:06 PM revealed LPN #2 was not sure when the last inservice [MEDICAL CONDITION] occurred prior to the incident on 4/25/15 with Resident #3. LPN #2 stated she learned how to suction [MEDICAL CONDITION] nursing school. Interview with LPN #3 on 9/28/15 at 6:15 PM revealed that she learned in nursing school what to do if a [MEDICAL CONDITION] became dislodged. Review of the Hospitalist History & Physical from the local hospital for Resident #3 dated 4/25/15 revealed Resident #3 was found in full arrest with [MEDICAL CONDITION] and presented with jerking movements concerning for [MEDICAL CONDITIONS]. Review of the hospital Discharge Summary for Resident #3 dated 5/9/15 revealed resident was discharged from the hospital to a specialty hospital with [MEDICAL CONDITION] and on a ventilator with a dense infiltrate on chest X-ray. The summary read upon discharge, Resident #3 was only responsive to painful stimuli. Record review revealed the facility initially admitted Resident #3 on 6/14/11 and readmitted Resident #3 on 8/12/14 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with the reference date of 2/12/15 indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating Resident #3 was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance on 10/2/15 for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy: 1. The facility established and signed a contract for training purposes and services with a Respiratory Therapist on 6/1/15 at 1:00 PM. The Respiratory Therapist trained the Director of Nurses (DON) on dislodged trachs and Residents experiencing breathing and respiratory difficulties. 2. On 6/1/15 an in-service was conducted by the DON at 2:00 PM, explaining procedures for a dislodged trach, providing rescue breathing and the reference Manuel of Best Practices Policy and Procedures being available at the Nurses Station with 5 of 10 RNs and 7 of 12 LPNs. The DON placed instructions from the Respiratory Therapist on what to do if [MEDICAL CONDITION] out and resident is not breathing on the RN/LPN communication board on 6/1/2015 at 3:00 PM. 3. At 5:00 PM on 10/1/15, an emergency quality assessment (QA) meeting was called with the Medical Director, Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. This meeting covered identification, documentation, monitoring residents with respiratory distress; a new policy on providing rescue breathing for Residents with respiratory distress, Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. 4. A second emergency QA meeting was called on 10/1/2015 at 6:40 PM with the Medical Director via phone conference, the Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the addition of an assessment form for identification of risk factors for respiratory distress. This assessment will be performed on new admissions, change in respiratory status, change in code status and quarterly on MDSs. The form was approved 5. On 10/1/2015 at 6:50 PM an audit was conducted to identify residents at risk for respiratory distress with the form that was reviewed in QA meeting and approved by Medical Director on 10/1/15 5:00 PM by the MDS Nurse, DON and Corporate Nurse. A 100% assessment of all Residents was conducted in the facility to identify the risk of respiratory distress. The result of the audit identified 13 Residents at risk, (with two being Residents with a trach.) Care plans were reviewed and updated accordingly by the Care Plan Nurse and DON. An inventory of oxygen related equipment and supplies was completed by Maintenance and Central Supply at 5:50 PM. 6. On 9/29/2015 at 5:00 PM, in-services were conducted by a Respiratory Therapist for the QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. Respiratory Therapist trained additional staff on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. During these in-services, staff exhibited proper performance of use of equipment. 9 of 11 RNs, 6 of 11 LPNs, 18 of 32 CNAs and 24 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply were trained. 100% of staff verbalized understanding. No staff will be allowed to work until in-serviced. 7. On 9/29/15 at 7:00 PM, in-services were conducted by a QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties, procedures for manual resuscitation and rescue breathing. 9/29/15 -9/30/15: 2 of 2 RNs were in-serviced by QA RN, Trainer RN and Trainer LPN On 9/29/15 - 9/30/15: 4 of 5 LPNs were in-serviced by QA RN, Trainer RN and Trainer RN; 1 of 1 LPN trained via telephone. On 9/29/15 - 9/30/15: 13 of 14 CNAs were in-serviced by QA RN, Trainer RN and Trainer LPN, On 9/29/15 -9/30/15: 4 of 5 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. There were 2 employees unavailable, 1 Dietary and 1 CNA. No staff will be allowed to work until in-serviced. 8. On 10/1/2015 at 7:00 PM, in-service were conducted by QA RN on Policy changes related to care [MEDICAL CONDITION] and rescue breathing, and performance of manual resuscitation and new code form with 9 of 11 RNs, 7 of 11 LPNs, 16 of 32 CNAs, 23 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. 9. On 10/1/2015 at 8:00 PM, in-service were conducted by QA RN on the new code form, respiratory versus cardiac events and the respiratory assessment form. 9 of 11 RNs, 7 of 11 LPNs, 100 % of staff verbalized understanding. 10. On 10/2/2015 at 7:00 AM, in-service were conducted by DON, Trainer RN #2 and Trainer LPN #2 on the new code form, respiratory versus cardiac events and the respiratory assessment form. 1 of 2 RNs, 2 of 4 LPNs, 8 of 16 CNAs, 3 of 6 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 1 RN, 2 LPNs, 4 CNAs and 1 other were trained by telephone. 100 % of staff verbalized understanding. 4 CNAs and 2 other personnel were unreachable. No staff will be allowed to work until in-serviced. 11. On 10/1/2015 at 5:30 PM, a personnel action form with a written warning was completed for unacceptable work performance for RN #1. RN #1 received counseling by QA RN and was in-serviced on proper procedures for a resident in respiratory distress; RN #1 verbalized understanding. On 10/2/15, RN #1 was suspended pending additional training and education, competency skill pass and review by an Administrative team. 12. The incident was reported by the DON to the Board of Nursing on 10/2/2015 at 10:35 AM and to the State Department of Health as of 10/2/2015. 13. 10/1/15 Facility adopted into orientation procedures: training newly hired employees during orientation on the newly implemented policies and procedures, code forms, risk assessments and audit tools. 14. On 10/2/15 10:00 AM, all training exercises were completed. The facility alleged Immediate Jeopardy removed as of 10/3/2015. On 10/3/15 the State Survey Agency surveyors validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services done on 10/2/15 across all disciplines. Interviews included RNs, LPNs, CNAs, Dietary Staff, Housekeeping Staff, Maintenance Supervisor, Bookkeeping/Business Office Staff, Activity Director, Laundry Staff, the Director of Nursing, Social Service Director, the Nurse Consultant and the Administrator. Two (2) RNs, four (4) LPNs, twelve (12) CNAs, two (2) laundry staff, six (6) dietary staff, one (1) Bookkeeping/Business Office Staff, one (1) Activity Director, one (1) Social Service Director, two (2) housekeeping staff and one (1) Maintenance Supervisor verified being in-serviced on emergency procedures for a resident found not breathing and if a [MEDICAL CONDITION] was noted to be dislodged. The Administrator verified being in-serviced on rescue breathing for a resident when the airway is not effective to include if the [MEDICAL CONDITION] should become dislodged. Record review of RN #1's personnel file confirmed she was suspended and the state board of nursing was notified on 10/2/15. RN #1 was suspended pending additional education and training. RN #1 must shadow another RN on the 7AM to 3PM shift for 30 days. Administrative team is to evaluate progress of RN #1 and determine if suspension should be lifted. Review of the Quality Assurance (QA) meeting dated 10/1/15 at 5:00 PM confirmed the meetings consisted of discussing the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. The meeting also covered identification, documentation, monitoring resident with respiratory distress. The Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. Review of a second Quality Assurance (QA) meeting on 10/1/15 at 6:40 PM with the Medical Director via phone conference confirmed the meeting to discuss the addition of an assessment form for identification of risk factors for respiratory distress and/or failure. This form was approved and the committee began in-services to all nurses and the facility began assessments of all residents.

Complaint # Based on interviews, record reviews, job description review, and facility policy review, the facility failed to be administered in a manner to maintain the highest practicable physical well-being of residents as evidenced by failure to ensure staff training and shift coverage to provide emergency care for residents with [MEDICAL CONDITION] for one (1) of five (5) residents reviewed, Resident #3. The facility's Administration failed to train staff in care of [MEDICAL CONDITION] residents and ensure coverage for all three (3) shifts to provide emergency [MEDICAL CONDITION] replacement. There was two (2) RNs trained to replace [MEDICAL CONDITION] and neither nurse worked ,[DATE] shift. The facility had a Respiratory Therapist contracted on an 'as needed' basis by phone, and was not in the facility when Resident #3's [MEDICAL CONDITION] became dislodged. This caused a situation that was likely to cause serious injury, harm, impairment or death to other residents with [MEDICAL CONDITION]. The situation was determined to be an Immediate Jeopardy (IJ) that began on [DATE]. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.75 (F490), was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's job description, entitled Job Description Administrator dated and signed by the Administrator on [DATE], revealed, It is the duties and responsibilities of the Administrator to plan, organize, staff, direct and coordinate the facility to ensure quality of care for the residents; be knowledgeable of and implement federal, state and local laws and regulations applicable to the facility and residents, personnel and physical plant. The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. Review of the facility's Accident/Incident report revealed a statement dated [DATE] at 5:00 AM that read on [DATE] RN #1 heard Resident #3 calling her name and when entering the room, Resident #3 pointed at her [MEDICAL CONDITION] (trach) and pointed to the clock. RN #1 informed Resident #3 she would be right back. The documentation read,[MEDICAL CONDITION] intact with no resp (respiratory) distress. Resident smiled and shook head ok. RN #1 continued with her medication pass then she heard banging on the side rails. Entered room and [MEDICAL CONDITION], and Resident #3 anxious. Documentation read RN #1 asked Certified Nurse Assistant (CNA#1) to remain in the room with Resident #3 while she went to call (name of ambulance service). (Ambulance Service) notified. Other nurse paged for assistance to do paperwork. (Ambulance Service) arrived . (Ambulance Service) intubated Res (resident) while chest compressions continued. Review of the Emergency Medical Services (EMS) record dated [DATE] revealed documentation that Resident #3 was unresponsive with no respirations and no pulse upon EMS arrival in room at 5:12AM. During a phone interview with Emergency Medical Technician- Paramedic (EMT-P) #1 on [DATE] at 2:35 PM, EMT-P #1 stated based on his assessment, Resident #3's lack of pulse was caused by hypoxemia (lack of oxygen) because [MEDICAL CONDITION] out and she was not breathing. EMT-P #1 also stated It could have been a mucus plug or anything stopping up [MEDICAL CONDITION] her not to breath. EMT-P stated it took ten (10) minutes for the 911 call till they arrived at Resident #3's bedside and start CPR. During an interview with the Administrator on [DATE] at 10:58 AM, the Administrator confirmed she was aware there had been only two (2) nurses trained to replace [MEDICAL CONDITION] and confirmed there was not a nurse on every shift that was trained to replace them should they need it or if it came out. The Administrator stated she knew about the incident on [DATE] with Resident #3, but she was unaware Respiratory Distress caused Resident #3's [MEDICAL CONDITION], because the facility failed to fully investigate the incident. The facility's Administrator confirmed the Respiratory Therapist was on call on an 'as needed' basis, and was available to answer questions by phone for the staff if they had any questions. Additional limited training for nursing staff on emergency [MEDICAL CONDITION] replacement or interventions was not provided until [DATE], (over a month after the incident with Resident #3) on [DATE]. This training was in the form of a note posted at the nurses station for education purposes regarding what to do in the event a [MEDICAL CONDITION] (trach) becomes dislodged. All staff were not trained at that time, leaving other residents at risk in the event of Respiratory distress. Record review revealed Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with the reference date of [DATE] indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating Resident #3 was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance on [DATE] for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy: 1. The facility established and signed a contract for training purposes and services with a Respiratory Therapist on [DATE] at 1:00 PM. The Respiratory Therapist trained the Director of Nurses (DON) on dislodged trachs and Residents experiencing breathing and respiratory difficulties. 2. On [DATE] an in-service was conducted by the DON at 2:00 PM, explaining procedures for a dislodged trach, providing rescue breathing and the reference Manuel of Best Practices Policy and Procedures being available at the Nurses Station with 5 of 10 RNs and 7 of 12 LPNs. The DON placed instructions from the Respiratory Therapist on what to do if [MEDICAL CONDITION] out and resident is not breathing on the RN/LPN communication board on [DATE] at 3:00 PM. 3. At 5:00 PM on [DATE], an emergency quality assessment (QA) meeting was called with the Medical Director, Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. This meeting covered identification, documentation, monitoring residents with respiratory distress; a new policy on providing rescue breathing for Residents with respiratory distress, Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. 4. A second emergency QA meeting was called on [DATE] at 6:40 PM with the Medical Director via phone conference, the Administrator, Director of Nursing, Quality Assessment Nurse, Corporate Nurse, Social Services, Activity Director, MDS and Care Plan Nurses present to discuss the addition of an assessment form for identification of risk factors for respiratory distress. This assessment will be performed on new admissions, change in respiratory status, change in code status and quarterly on MDSs. The form was approved 5. On [DATE] at 6:50 PM an audit was conducted to identify residents at risk for respiratory distress with the form that was reviewed in QA meeting and approved by Medical Director on [DATE] 5:00 PM by the MDS Nurse, DON and Corporate Nurse. A 100% assessment of all Residents was conducted in the facility to identify the risk of respiratory distress. The result of the audit identified 13 Residents at risk, (with two being Residents with a trach.) Care plans were reviewed and updated accordingly by the Care Plan Nurse and DON. An inventory of oxygen related equipment and supplies was completed by Maintenance and Central Supply at 5:50 PM. 6. On [DATE] at 5:00 PM, in-services were conducted by a Respiratory Therapist for the QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. Respiratory Therapist trained additional staff on dislodged trachs and Residents experiencing respiratory difficulties; procedures for manual resuscitation and rescue breathing. During these in-services, staff exhibited proper performance of use of equipment. 9 of 11 RNs, 6 of 11 LPNs, 18 of 32 CNAs and 24 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply were trained. 100% of staff verbalized understanding. No staff will be allowed to work until in-serviced. 7. On [DATE] at 7:00 PM, in-services were conducted by a QA RN, Trainer RN and Trainer LPN on dislodged trachs and Residents experiencing respiratory difficulties, procedures for manual resuscitation and rescue breathing. [DATE] -[DATE]: 2 of 2 RNs were in-serviced by QA RN, Trainer RN and Trainer LPN On [DATE] - [DATE]: 4 of 5 LPNs were in-serviced by QA RN, Trainer RN and Trainer RN; 1 of 1 LPN trained via telephone. On [DATE] - [DATE]: 13 of 14 CNAs were in-serviced by QA RN, Trainer RN and Trainer LPN, On [DATE] -[DATE]: 4 of 5 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. There were 2 employees unavailable, 1 Dietary and 1 CNA. No staff will be allowed to work until in-serviced. 8. On [DATE] at 7:00 PM, in-service were conducted by QA RN on Policy changes related to care [MEDICAL CONDITION] and rescue breathing, and performance of manual resuscitation and new code form with 9 of 11 RNs, 7 of 11 LPNs, 16 of 32 CNAs, 23 of 29 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 100 % of staff verbalized understanding. 9. On [DATE] at 8:00 PM, in-service were conducted by QA RN on the new code form, respiratory versus cardiac events and the respiratory assessment form. 9 of 11 RNs, 7 of 11 LPNs, 100 % of staff verbalized understanding. 10. On [DATE] at 7:00 AM, in-service were conducted by DON, Trainer RN #2 and Trainer LPN #2 on the new code form, respiratory versus cardiac events and the respiratory assessment form. 1 of 2 RNs, 2 of 4 LPNs, 8 of 16 CNAs, 3 of 6 other employees that include dietary, housekeeping, laundry, maintenance, medical records, bookkeeping, Activities, Social Services, and Central Supply, were trained. 1 RN, 2 LPNs, 4 CNAs and 1 other were trained by telephone. 100 % of staff verbalized understanding. 4 CNAs and 2 other personnel were unreachable. No staff will be allowed to work until in-serviced. 11. On [DATE] at 5:30 PM, a personnel action form with a written warning was completed for unacceptable work performance for RN #1. RN #1 received counseling by QA RN and was in-serviced on proper procedures for a resident in respiratory distress; RN #1 verbalized understanding. On [DATE], RN #1 was suspended pending additional training and education, competency skill pass and review by an Administrative team. 12. The incident was reported by the DON to the Board of Nursing on [DATE] at 10:35 AM and to the State Department of Health as of [DATE]. 13. [DATE] Facility adopted into orientation procedures: training newly hired employees during orientation on the newly implemented policies and procedures, code forms, risk assessments and audit tools. 14. On [DATE] 10:00 AM, all training exercises were completed. The facility alleged Immediate Jeopardy removed as of [DATE]. On [DATE] the State Survey Agency surveyors validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services done on [DATE] across all disciplines. Interviews included RNs, LPNs, CNAs, Dietary Staff, Housekeeping Staff, Maintenance Supervisor, Bookkeeping/Business Office Staff, Activity Director, Laundry Staff, the Director of Nursing, Social Service Director, the Nurse Consultant and the Administrator. Two (2) RNs, four (4) LPNs, twelve (12) CNAs, two (2) laundry staff, six (6) dietary staff, one (1) Bookkeeping/Business Office Staff, one (1) Activity Director, one (1) Social Service Director, two (2) housekeeping staff and one (1) Maintenance Supervisor verified being in-serviced on emergency procedures for a resident found not breathing and if a [MEDICAL CONDITION] was noted to be dislodged. The Administrator verified being in-serviced on rescue breathing for a resident when the airway is not effective to include if the [MEDICAL CONDITION] should become dislodged. Record review of RN #1's personnel file confirmed she was suspended and the state board of nursing was notified on [DATE]. RN #1 was suspended pending additional education and training. RN #1 must shadow another RN on the 7AM to 3PM shift for 30 days. Administrative team is to evaluate progress of RN #1 and determine if suspension should be lifted. Review of the Quality Assurance (QA) meeting dated [DATE] at 5:00 PM confirmed the meetings consisted of discussing the Immediate Jeopardy status of the facility and the plan of correcting the deficient practice in order to achieve and sustain compliance. The meeting also covered identification, documentation, monitoring resident with respiratory distress. The Respiratory Therapist provided clinical performance evaluation forms for training staff and a full code form. Review of a second Quality Assurance (QA) meeting on [DATE] at 6:40 PM with the Medical Director via phone conference confirmed the meeting to discuss the addition of an assessment form for identification of risk factors for respiratory distress and/or failure. This form was approved and the committee began in-services to all nurses and the facility began assessments of all residents.

Based on observation, record review, staff interview and policy review, the facility failed to provide social services in a manner to maintain Residents highest practicable well being for two (2) of fifteen (15) records reviewed (Resident #10 and Resident #11). This was evident by the failure of Social Services (SS) #1 to report an incident of Resident to Resident sexual abuse that occurred on 05/07/13. The IJ was not removed upon exit from the facility on 08/01/13, and is considered ongoing. Findings include: Review of the facility's policy entitled "Social Services", with no date noted, stated "POLICY: The facility, regardless of its size will provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. POLICY EXPLANATION and COMPLIANCE GUIDELINES: 1. The social worker, or social service designee, will complete an initial and quarterly assessment of each resident, identifying any need for medically-related social services of the resident. Any need for medically-related social services will be documented in the medical record. through the assessment and care planning process, identifying and seeking ways to support residents' individual needs." Record review of Resident #10 on 07/30/13 at 10:30 a.m., documentation dated 05/07/13 (no time noted) in the Social Services (SS) Progress Notes written by SS #1, revealed "It was reported to me that (Resident #10) has been putting his hand up and down between a female resident's legs (Resident #11) and running his hand up and down and there had been several incidents in the past week. It was observed that this man also ran his hand down (another) lady (leg) at the table on several occasions. (Resident #10) was talked to and explained that this behavior would not be tolerated and he should never touch ladies like this. (Resident #10) will be placed at another table and his behavior monitored and he will be watched closely in group events, etc." Interview with Social Services (SS) #1 on 07/30/13 at 10:30 a.m., revealed the following: SS #1 stated, "They (Certified Nursing Assistant) came to get me and I went in there and I moved (Resident #10) him away from the table and talked to him, I called his daughter and we were just monitoring him. No, I didn't report it to anybody, because I had taken care of it and moved him. We found out from daughter that (Resident #10) had a prior history (sexual abuse) on 11/04/12 she said that he had abused his son's mentally handicapped daughter. We didn't know it when we admitted him, but he's much better now than when we admitted him." Social Services #1 confirmed that she was made aware of Resident #10 history of sexual behaviors on 11/04/12 and that she failed to report that as an area of concern that should be monitored and placed in the Resident's care plan at that time, of 11/04/12, when she was made aware of this from Resident #10's responsible party (RP). Interview with Social Services (SS) #1 on 08/01/13 at 4:50 p.m., stated "I can't remember last time I had an in-service here on abuse and neglect, I ain't gonna lie to you about it." Social Service #1 confirmed that she failed to report 05/07/13 incident of sexual abuse and protect Resident #11 from further episodes of abuse and neglect. Interview with Office Manager on 08/01/13 at 5:00 p.m. confirmed that she was not able to locate an inservice on abuse/neglect that SS #1 had taken. The Office Manager also confirmed that employees are screened and trained upon hire and are given abuse/neglect policies at that time but any further inservices are provided by Administration and Nursing. The Office Manger further confirmed that SS #1 has been employed at the facility for over [AGE] years. Review of Resident #10 SS note dated 11/04/12 stated, "Daughter told me that her father (Resident #10) had molested his granddaughter and that his son had not spoken to him in years. Daughter was ashamed of this and I assured her that we did not hold it against her. We will monitor (Resident #10) and watch for any signs and symptoms of behavior or other aggressive behavior. " Review of Resident #10 care plan dated 08/30/12 through 12/05/12 revealed no care plan was initiated to address Resident #10 history of inappropriate sexual behaviors. Review of Resident #10 SS note dated 07/25/13 stated, "At present, we will have him (Resident #10) eat meals in his room for a couple of days and plan on moving him to a new hall where the residents are more alert and can tell if something goes wrong." Resident #11 A record review for Resident #11 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11 Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/28/13, revealed a Brief Interview of Mental Status (BIMS) summary score was 99, which reflects Resident #11 was unable to complete this interview. Staff assessment of cognitive skills for daily decision making revealed a score of 3, indicating Resident #11 has severely impaired cognitive skills. Record Review of Resident #10 on 07/30/13 at 10:30 a.m., documentation dated 05/07/13 (no time noted) in the Social Services (SS) Progress Notes written by SS #1, revealed " It was reported to me that (Resident #10) has been putting his hand up and down between a female resident's legs (Resident #11) and running his hand up and down and there had been several incidents in the past week. It was observed that this man also ran his hand down (another) lady (leg) at the table on several occasions. (Resident #10) was talked to and explained that this behavior would not be tolerated and he should never touch ladies like this. (Resident #10) will be placed at another table and his behavior monitored and he will be watched closely in group events, etc. " Review of the facility policy and through confirmation of SS #1 interviews, SS #1 failed to identify and seek ways to meet and support Resident #11's emotional and psychological needs that may arise after the incident that occurred on 05/07/13 by not reporting it to Administration and Nursing staff.

Based on record review and staff interview, the facility failed to document information and maintain complete and accurate medical records for two (2) of seventeen (17) records reviewed (Resident #10 and Resident #11). This was evident by the lack of documentation of an incident report for the incidents that occurred on 05/07/13; and, lack of documentation to indicate that Resident #10 and Resident #11 were monitored after the sexual inappropriate touching incident that occurred on 05/07/13 and 07/25/13. The IJ was not removed upon exit from the facility on 08/01/13, and is considered ongoing. Findings include: Resident #11 A record review for Resident # 11 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11 Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/28/13, revealed a Brief Interview of Mental Status (BIMS) summary score was 99, which reflected Resident #11 was unable to complete this interview. Staff assessment of cognitive skills for daily decision making revealed a score of 3, indicating Resident #11 has severely impaired cognitive skills. Review of Resident #11 clinical records, dated 07/30/13 (incident of sexual abuse occurred on 07/25/13) as problem onset stated, "Resident was touched inappropriately by another resident: GOAL; Resident will show no S/S mental distress, crying, restlessness, every day x 90 days. APPROACHES; Monitor, document, report S/S mental distress, crying, yelling, frowning, restlessness. Check every 30 minutes. If S/S present report to nurse any sexual abusive behavior with resident from male resident." Record review of Resident #11 records on 07/29/13 through 08/01/13, revealed there was no documentation found to show that Resident #11 was checked every 30 minutes as stated. Record review of Resident #11's records on 07/29/13 through 08/01/13, revealed no documentation to indicate that Resident #11 was assessed after incident occurred on 07/25/13. Resident #10 Record review of Resident #10 revealed, he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10 Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/30/13, revealed Resident #10 Brief interview of Mental Status (BIMS) summary score was an 11, which reflects Resident #10 was cognitively intact. Review of incident report on 07/30/13 typed by the Director of Nursing (DON), signed and dated 07/26/13 (incident of sexual abuse occurred on 07/25/13), revealed, "DON received allegation of male touching female in hall this Friday. Allegation in way of written and verbal report by nurse. Incident report completed by nurse. DON, ADM, SS met and developed plan of care: 1. Plan to protect resident's with room change to 75B away from concern; 2. Plan to have meals at male table or to eat in room and supervised during in hall or activities. 3. MD notified and examined (Resident #10). (Resident #10) very upset and informed MD that they made him do it by shaking their butt in his face. Told MD that he is guilty as charged and that the devil made him do it. Resident expressed no remorse for incident. 4. Emergency care plan team meeting was placed and plan of care altered to meet concerns. MD and DON met resident (Res #10) and went over POC (Plan of Care) agreement Friday and resident approved measures. 5. Administration, SS, Nursing reviewed tape. Incident is clearly observed. Female does not appear in distress and nursing immediate response to situations during rounds. 6. Administrator filed report of incident with AG (Attorney General) and state department of health. Review of Departmental notes (Nursing) on 07/30/13 revealed a Nursing Progress Note for Resident #10 dated 07/26/13 at 1:42 p.m. stated, "Dr (Name) visited and examined resident this am. Resident in room [ROOM NUMBER] bed B with room change related to resident recent behavior. Inappropriate touching of a female resident who has severe Alzheimer's. No new orders. Continue current POC (Plan of Care) change with supervision. Interview on 08/01/13 at 4:00 p.m. with Registered Nurse (RN) Charge Nurse #2 stated, "She (RN Charge Nurse #3) told me what he had done, but I was not given any instructions to follow. The DON brought me the MD order and just told me to monitor him, but we were not given any specific orders to monitor him every hour or anything." When asked if they moved Resident #10 to another room she stated, "I asked ADON and she said we weren't gonna move him tonight (07/25/13) because we didn't have enough staff to move him." RN Charge Nurse #2 reviewed the Daily Assignment Sheet for 07/25/13 and confirmed that on 07/25/13 it was not noted to monitor Resident #10 or Resident #11 or have them on one to one supervision. Record review of Resident #10's records on 07/29/13 through 08/01/13 revealed no documentation to show that Resident #10 was monitored initially after incident occurred.

Based on the survey results dated 8/1/13, the facility failed to protect a cognitively impaired resident, Resident #11, from sexual abuse by Resident #10. Resident #10 was observed by staff in the dining room on 5/7/13 with his hand between Resident #11 legs, rubbing her private area. Resident #10 was observed again on 7/25/13 by staff with his hands between cognitively impaired Resident #11 legs, rubbing her private area. This was for one (1) of three (3) residents reviewed for abuse and neglect (Resident #11). This was deemed an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 7/30/13 at 4:00 p.m. A revisit was conducted on 8/20-21/13 to validate the Allegation of Compliance (AoC). The IJ which began on 5/7/13 was determined to be removed on 8/14/13. The facility provided an Allegation of Compliance (AoC) that was accepted by CMS on 8/19/13. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, staff interview and record review. The facility provided evidence that the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 8/14/13. The facility remained out of compliance at a scope and severity of "D", isolated deficiencies that constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. Findings include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired, Resident #11, from sexual abuse by Resident #10. Resident #10 was observed by staff in the dining room on 5/7/13 with his hand between Resident #11 legs, rubbing her private area. Resident #10 was observed again on 7/25/13 by staff with his hands between cognitively impaired Resident #11 legs, rubbing her private area. The facility provided an Allegation of Compliance (AoC) that was accepted by CMS on 8/19/13. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy. Information contained in the Credible AoC, submitted by the facility, alleged removal as of 8/14/13. The following information was validated related to Resident #10: On 7/25/13, the Director of Nursing (DON) notified the Medical Director of the incident between Resident #10 and Resident #11. On 7/25/13, the Medical Director, who is the Attending Physician for Resident #10, gave the following orders for Resident #10: To remain in the room unless supervised by staff; May attend activities and for to the dining room with supervision; Report and intervene signs and symptoms of sexually suggestive behavior; Transport to areas with staff beside resident; Meals/activities in room this weekend. On 7/25/13, Resident #10 agreed to eat meals in his room and have a room change. On 7/25/13, the Social Worker notified Resident #10's family of the incident involving the inappropriate touching of a female. On 7/25/13, the Social Worker attempted to contact the Sheriff in (local) County, and left a message. The Sheriff returned the phone call, and was notified by the Social Worker of Resident #10's inappropriate sexual contact with Resident #11. On 7/25/13, Registered Nurse (RN) #2 updated the Certified Nursing Assistant's "Resident ADL Record & Care Plan" stating, "In Room except during supervision." Resident #10's care plan was updated on 7/25/13 to address the resident's inappropriate touching of a female. On 7/26/13, Resident #10 was moved to room [ROOM NUMBER] B in another section of the facility away from Resident #11's room. On 7/26/13 the Director of Nursing (DON) documented, "DON responded to resident who was loud and cursing. Wanted to sit at same table with female. Very aggressive. Threatening facility and stated that he lied for the facility when State was in this morning. I finally got resident to go to a private area away from other residents in the dining room. Resident was very angry and stated that it was their fault that he has been persecuted after saying he was sorry. DON explained that the State was next door and he could visit at will but he could not sit at the table with female and the staff would assist back and forward. Stated that he would not eat and returned to room. Refused to have tray in room or go to the table where all male residents were. Reported to MD. Psych to evaluation for admission." The Medical Director visited with Resident #10 on 7/26/13 and counseled Resident #10 concerning the inappropriate touching of a female resident. On 7/29/13, Resident #10's ADL care plan was updated to include an approach of eating in Dining Room at a table with males. On 7/29/13 the Social Worker documented, "He became very hostile and cussing. You could not reason with him. I tried on several occasions to calm him down and he refused. His behavior became so bad that he was cussing at everyone and telling that he never did anything wrong. He just kept cussing. Due to this behavior, I called (local Geri Psych Unit (GPU)) and ask for a Screen. He was screened and they will accept him for placement in the AM." physician's orders [REDACTED]." physician's orders [REDACTED]." The Social Worker's notes revealed that Resident #10 was transferred to (local hospital) in Newton, MS on 7/30/13. The following information was validated for Resident #11: The Social Worker notified Resident #11's family of the incident between Resident #11 and Resident #10 on 7/25/13. Resident #11 was being monitored every shift by licensed nurses for signs and symptoms of depression with targeted behaviors such as [MEDICAL CONDITION] and restlessness. On 7/25/13 at 3:40 p.m., Resident #11's care plan was reviewed by the Interdisciplinary Care Plan Team. The Interdisciplinary Care Plan Team decided that no changes were required since Resident #11 was already being monitored by the nurses for signs and symptoms of depression. On 7/28/13, Registered Nurse (RN) #4 performed a body audit on Resident #11 with no abrasions to perineal area noted. On 7/30/13 at 7:00 p.m., the Certified Nursing Assistants initiated every thirty minute visual monitoring of Resident #11. On 7/31/13 at 8:00 p.m., the Licensed Nurses initiated hourly visual monitoring of Resident #11. A Psychiatric Nurse Practitioner evaluated Resident #11 on 8/6/13 and noted no behavior disturbances. The Nurse Practitioner wrote an order on 8/6/13 stating, "D/C intensive monitoring program." The following facility practices were validated: On 7/30/13 at 6:00 p.m., a Quality Assurance Registered Nurse began in-servicing all staff on the definition of abuse, screening new hires, prevention of abuse, identification of events that could be abuse, investigation, protection from abuse, training, and reporting of abuse. No employee was allowed to work until the in-service had been completed. On 7/30/13, an in-service was given to all department heads on abuse. The staff included in this inservice were Social Services, Director of Nursing (DON), Quality Assurance Nurse, and Assistant Director of Nursing, Care Plan Nurse, Medical Records, Maintenance Supervisor, Administrative Assistant, Billing, Bookkeeper, and Activity Director. The in-service covered the seven components of abuse: screening, training, prevention, protection, identification of abuse, investigation and reporting. The instructor was a Registered Nurse from an outside entity. The facility policy addressing Abuse was revised on 7/30/13 to cover Resident to Resident abuse. The Director of Nursing notified the Medical Director on 7/30/13 at 4:30 p.m. to inform of the policy change and verbal approval by the Medical Director was obtained. The Medical Director reviewed the revised policy on 7/31/13, and approved the revision. On 7/30/13, the facility initiated a policy for admission requirements which included screening potential admissions by checking the Sex Offender Registry prior to approval for admission. The procedure for screening for admissions was revised on 7/30/13 to include checking the Sex Offender Registry prior to accepting a resident for admission. On 7/30/13 the DON, Assistant Director of Nursing (ADON), Quality Assurance Registered Nurse (QA RN), Registered Nurse (RN) #1, Activity Director (AD), and Medical Records Staff (MR) #1 reviewed the medical records of residents who had a history of [REDACTED]. The census in the facility was 66, during this review. Of the 66 residents reviewed, 28 were identified as having a history of behaviors. Review of the facility's "Personnel Action Form" for Social Services confirmed on 7/30/13, Social Services was reprimanded and suspended without pay then given 90 day probation. A poster was placed on the bulletin board in the main hallway on 7/31/13. The poster included definitions of abuse, neglect, and exploitation; informed how to report and who to report to, and discussed the investigation process. The poster is to inform staff, families, and other visitors of the facts about abuse. The facility initiated a new form for reporting abuse on 7/30/13 to provide a written report of any allegation of abuse. The form may be completed by anyone wishing to report any allegation of abuse or neglect. All allegations of abuse, neglect, or exploitation will be reported to the Director of Nursing and/or the Administrator at the time. The written report will be presented at the morning stand up meeting of department heads and the problem will be discussed as a team. The facility initiated the use of the Hand in Hand Training Series on 7/30/13, at 7:00 a.m. The first session "What is Dementia?" was covered and the second session "What is Abuse?" remained in progress. Module Two had been reviewed by all but three employees. Training will continue until all staff have completed it. Module Three was started on 8/12/13. The trainer was a Registered nurse. Review of facility documentation revealed, a new assessment tool was initiated on 8/2/13, to assist with identifying residents at risk for abusing others. This tool, "At Risk for the Potential to Abuse Other Residents Assessment" and "Quarterly Review of Abuse Potential" were designed to be used with new admissions and in conjunction with the Minimum Data Set (MDS) assessments. On 8/2/13, all residents were assessed for the potential to abuse others and 18 residents were identified as being at risk to abuse others. These residents were placed on every 30 minute visual monitoring by the Nurses and Certified Nurse Aides. The residents identified were: Resident #4, Resident #6, Resident #9, Resident #11, Resident #12, Resident #15, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, and Resident #29. These assessments were verified through record review of each of the 18 residents. An in-service was conducted on 8/2/13 by the Nurse Consultant, who is a Registered Nurse with over [AGE] years of experience in Long Term Care. The in-service addressed abuse including a definition of abuse with examples cited and the seven components to the abuse policy. The employees were allowed to ask questions throughout the in-service. A written test was given to the employees following the in-service. Another session of this in-service was done on 8/5/13 for employees who were not present on 8/2/13. Employees from all departments were present at the in-service. The aforementioned in-services were conducted on the following dates: 7/30/13, 7/31/13, 8/1/13, 8/2/13, 8/5/13 and 8/13/13. The risk assessment tool, "At Risk for the Potential to Abuse Other Residents Assessment", was revised on 8/6/13 to include the risk potential of High, Moderate, or Low. This was verified through review. On 8/6/13, the Psychiatric Nurse Practitioner visited the facility and assessed each of the 18 residents identified as at risk to abuse others. This was verified by documentation, dated 8/6/13, by Psychiatric Nurse Practitioner on each of the 18 residents identified (Resident #4, Resident #6, Resident #9, Resident #11, Resident #12, Resident #15, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, and Resident #29). Corresponding orders from Psychiatric Nurse Practitioner's recommendations from the assessment was also noted during record review. Based on the Psychiatric Nurse Practitioner's assessment on 8/6/13, 12 residents were removed from intensive monitoring, (Resident #11, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #25, Resident #26, Resident #27, Resident #28 and Resident #29) and six (6) residents (Resident #4, Resident #6, Resident #9, Resident #12, Resident #15, and Resident #24)remained on intensive monitoring (every 30 minute visual checks) after 8/6/13 assessment. Review of the "Personnel Action form dated 8/10/13 revealed Social Services was terminated due to failure to obey rules, regulations, policies and/or procedures and unacceptable work performance. Resident #4 was reassessed on 8/13/13, per Psychiatric Nurse Practitioners recommendations', and intensive monitoring was discontinued on 8/14/13. Resident #6, Resident #9, Resident #12, Resident #15 and Resident #24 were verified as still being on intensive monitoring, through one hour or 30 minute visual monitoring, during validation of Allegation of Compliance (AOC) on 8/20/13 and 8/21/13. This was validated through record review of each of the 18 residents. Visual monitoring documentation dated from 8/20/13 until 8/21/13 was validated, along with implementation of recommendations for each resident made by Psychiatric Nurse Practitioner during assessment on 8/6/13. Care plans for each of the 18 residents reflected the identification of risk to abuse others, and the implementation of intensive monitoring as well as the discontinuation of the visual monitoring for 13 of the 18 residents. The facility initiated a process where all resident behaviors and incidents will be listed each shift on the report book for shift to shift communication by the licensed nurses when the behaviors occur. The charge nurse will review the report book for the past 24 hours. The residents involved will be reviewed to ensure proper interventions are in place to protect all residents. The Quality Assessment Committee will meet in a stand up meeting every morning Monday through Friday except Holidays. The committee will discuss the incident and determine what interventions are needed. The care plan will be revised at the meeting to address the interventions that have been initiated. Incidents that occur on weekends or Holidays will be reviewed on the next work day by the Quality Assessment committee. An interdisciplinary Care Plan Team in-service was given by the Quality Assessment Nurse, who is a Licensed Administrator, on 8/13/13. The in-service addressed the facility care plan policy which included care planning acute situations in a timely manner. Interview with 40 staff members from all 3 shifts on 8/20/13 and 8/21/13 verified that the facility had conducted in-services regarding the different types of abuse/neglect, reporting, protection, identification, screening, prevention, training, Resident/Resident abuse, and to whom to report incidents. Policies were updated and revised, and staff were in-serviced on the revisions. Staff members included CNAs, Nurses, the Administrator, the Maintenance Director, Social Services, the Dietary Manager, the Activities Director, Housekeeping, and the DON. Based on verification of the facility's corrective actions that was validated by staff interview, observation, record review and inservices review, the Immediate Jeopardy was removed and the scope and severity was lowered on 8/14/13 to a "D" level, which constituted no actual harm with the potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility' Quality Assurance Committee.

Based on observation, record review, staff interview and policy review, the facility failed to screen, prevent, identify, investigate, protect and report an incident of Resident on Resident sexual abuse for one (1) of three (3) residents reviewed for abuse and neglect (Resident #11). The IJ was not removed upon exit from the facility on 08/01/13, and is considered ongoing. Findings include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #11) from sexual abuse by Resident #10. Resident #10 was observed by staff with his right hand between Resident #11 legs and moving his fingers around. Interview with Administrator on 07/30/13 at 12:30 p.m. revealed that the current facility policy addressing abuse and neglect does not require that the facility "do a background check on them (new admissions) for prior sex offense", but confirmed that they will review the abuse and neglect policy and the admission policy with the Medical Director and make revisions to "run them (new admissions) through the sex offenders data base". Interview with Administrator on 07/31/13 at 12:30 p.m., confirmed that the admission policy does not address "checking the data base for sex offenders, but we will plan to meet with the medical director and review that." Administrator confirms that the facility policy will be reviewed and revised with the medical director to address this issue.

Based on observation, record review, staff interview and policy review, the facility failed to report and properly investigate allegations of sexual abuse to the State Agency, for one (1) of three (3) residents reviewed for abuse and neglect (Resident #11). The IJ was not removed upon exit from the facility on 08/01/13, and is considered ongoing. Findings include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #11) from sexual abuse by Resident #10. Resident #10 was observed by staff with his right hand between Resident #11 legs and moving his fingers around. Interview with Social Services (SS) #1 on 07/30/13 at 10:30 a.m., revealed the following: SS #1 stated, that she didn't report the 05/07/13 incident of sexual abuse of resident #11 to anybody, because she "had taken care of it and moved him". Interview with Administrator and Director of Nursing (DON) on 07/30/13 at 4:10 p.m., revealed a confirmation that they were not aware of Resident #10 history of sexual abuse and that Administrator and DON had no knowledge of incident on 05/07/13 in dining room until 07/30/13 when facility was notified of the immediate jeopardy. When asked if there was an incident report Administrator stated, "I don't have one on it, I'll have to check with (Quality Assurance) she might have one." On 7/30/13 when immediate jeopardy was identified to the facility, the Administrator confirmed that she would begin immediate investigation of the incident of sexual abuse that occurred on 05/07/13. Interview with Quality Assurance Registered Nurse (QA RN) on 07/30/13 at 4:25 p.m., stated, "I don't have an incident report on him (Resident #10) from that note (SS) in May."

Based on observation, record review, staff interview, and facility policy review, the facility failed to implement and provide training of the Abuse and Neglect policy to staff, and monitor residents to prohibit occurrences of abuse and neglect for one (1) of three (3) residents reviewed (Resident #11). The IJ was not removed upon exit from the facility on 08/01/13, and is considered ongoing. Findings include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #11) from sexual abuse by Resident #10. Resident #10 was observed by staff with his right hand between Resident #11 legs and moving his fingers around. Review of the facility's in-services on Abuse and Neglect revealed that the last time Registered Nurse Charge Nurse #3 was in-serviced on Abuse and Neglect was 03/31/11, and there was no record of a documented in-service on Abuse and Neglect for Licensed Practical Nurse (LPN) #1. Interview with Social Services (SS) #1 on 08/01/13 at 4:50 p.m., stated "I can't remember last time I had an in-service here on abuse and neglect, I ain't gonna lie to you about it." Social Service #1 confirmed that she failed to report 05/07/13 incident of sexual abuse and protect Resident #11 from further episodes of abuse and neglect. Interview with Office Manager on 08/01/13 at 5:00 p.m. confirmed that she was not able to locate an inservice on abuse/neglect that SS #1 had taken. The Office Manager also confirmed that employees are screened and trained upon hire and are given abuse/neglect policies at that time but any further inservices are provided by Administration and Nursing. The Office Manger further confirmed that SS #1 has been employed at the facility for over [AGE] years. Interview with Office Manager on 08/01/13 at 5:00 p.m. confirmed these inservices, and also confirmed that employees are trained upon hire and are given abuse/neglect policies at that time. Any further inservices are provided by Administration and Nursing.

Based on observation, record review, staff interview and policy review, the facility failed to protect a cognitively impaired, Resident #11, from sexual abuse by Resident #10. Resident #10 was observed by staff in the dining room on 05/07/13 with his hand between Resident #11 legs, rubbing her private area. Resident #10 was observed again on 07/25/13 by staff with his hands between cognitively impaired Resident #11 legs, rubbing her private area. This was for one (1) of three (3) residents reviewed for abuse and neglect (Resident #11). The IJ was not removed upon exit from the facility on 08/01/13, and is considered ongoing. Findings include: Resident #11 Review of the facility's policy entitled "Abuse/Neglect", with no date observed, documented "Purpose: To prohibit mistreatment, neglect and abuse of residents and misappropriation of residents' property. Scope: Staff, visitors, family, consultants, volunteers and other residents. Abuse: The willful inflection of injury, unreasonable confinement, intimidation, or cruel punishment resulting in physical harm, pain, or mental anguish by a caregiver. Abuse shall not mean conduct which is a part of the treatment and care of, and is furtherance of the health and safety of resident. Procedure or discussion: The following measures will be instituted for abuse prevention: V. IN THE EVENT OF AN ACTUAL OCCURRENCE, place the resident one-on-one monitoring until physician intervention or the resident is no longer exhibiting aggressive behaviors. The facility shall then complete a report form, contact the resident's physician, contact the responsible party, update the care plan and follow reporting procedures. IX. PROTECTION OF THE RESIDENT DURING INVESTIGATION OF RESIDENT ON RESIDENT ABUSE: All resident will be protected during the investigation; The residents will be kept apart during the investigation process; One on One monitoring will be initiated if any incident of abuse occurs until physician intervention occurs or the Resident is no longer exhibiting aggressive behavior; Any resident who abuses another resident will be evaluated for possible medication changes and possible need for psychiatric evaluation. X. REPORTING TO THE APPROPRIATE AUTHORITIES the complaint must be reported to the State Department of Health and the Medicaid Fraud Control Unit (Attorney General) by phone within 24 hours of discovery excluding Saturday, Sunday, and Holidays and in writing within 72 hours of discovery. TRAINING OF EMPLOYEES: will be conducted at the time of hire prior to contact with the residents. The training shall include review of all policies on abuse. The employee will sign acknowledging understanding of the abuse policy. This will be filed in the individual employee's file. In-services will be conducted on an ongoing basis as will as are mandatory for all employees." A record review for Resident #11 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11 Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/28/13, revealed a Brief Interview of Mental Status (BIMS) summary score was 99, which reflected Resident #11 was unable to complete this interview. Staff assessment of cognitive skills for daily decision making revealed a score of 3, indicating Resident #11 has severely impaired cognitive skills. Record review of Resident #10 on 07/30/13 at 10:30 a.m., documentation dated 05/07/13 (no time noted) in the Social Services (SS) Progress Notes written by SS #1, revealed "It was reported to me that (Resident #10) has been putting his hand up and down between a female resident's legs (Resident #11) and running his hand up and down and there had been several incidents in the past week. It was observed that this man also ran his hand down (another) lady (leg) at the table on several occasions. (Resident #10) was talked to and explained that this behavior would not be tolerated and he should never touch ladies like this. (Resident #10) will be placed at another table and his behavior monitored and he will be watched closely in group events, etc." Review of Resident #10 records on 07/30/13 revealed that a care plan was not initiated immediately to address Resident #10 inappropriate touching of a female resident on 05/07/13. Care plan with a problem onset date of 05/14/13, "inappropriate touching of female resident," revealed "Goal: No inappropriate touching of other resident x 30 day through 06/14/13," "Approaches: redirect when inappropriate behavior, remove from situation as directed, resident moved to another table with male resident and oriented female resident, no further inappropriate behavior." Interview with Social Services (SS) #1 on 07/30/13 at 10:30 a.m., revealed the following: SS #1 stated, "They (Certified Nursing Assistant) came to get me and I went in there and I moved (Resident #10) him away from the table and talked to him, I called his daughter and we were just monitoring him. No, I didn't report it to anybody, because I had taken care of it and moved him. We found out from daughter that (Resident #10) had a prior history (sexual abuse) on 11/04/12 she said that he had abused his son's mentally handicapped daughter. We didn't know it when we admitted him, but he's much better now than when we admitted him." Review of Resident #10 SS note dated 11/04/12 stated, "Daughter told me that her father (Resident #10) had molested his granddaughter and that his son had not spoken to him in years. Daughter was ashamed of this and I assured her that we did not hold it against her. We will monitor (Resident #10) and watch for any signs and symptoms of behavior or other aggressive behavior." Review of Resident #10 care plan dated 08/30/12 through 12/05/12 revealed no care plan was initiated to address Resident #10 history of inappropriate sexual behaviors. Interview with Administrator and Director of Nursing (DON) on 07/30/13 at 4:10 p.m., revealed a confirmation that they were not aware of Resident #10 history of sexual abuse and that Administrator and DON had no knowledge of incident on 05/07/13 in dining room and when asked if there was an incident report Administrator stated, "I don't have one on it, I'll have to check with (Quality Assurance) she might have one." Interview with Quality Assurance Registered Nurse (QA RN) on 07/30/13 at 4:25 p.m., stated, "I don't have an incident report on him (Resident #10) from that note (SS) in May." Review of Resident #11 care plan dated 07/30/13 (incident occurred 07/25/13) as problem onset stated, "Resident was touched inappropriately by another resident: GOAL; Resident will show no S/S mental distress, crying, restlessness, every day x 90 days. APPROACHES; Monitor, document, report S/S mental distress, crying, yelling, frowning, restlessness. Check every 30 minutes. If S/S present report to nurse any sexual abusive behavior with resident from male resident." Resident #10 Record review of Resident #10 revealed, he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10 Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/30/13, revealed Resident #10 Brief interview of Mental Status (BIMS) summary score was an 11, which reflected Resident #10 was cognitively intact. Observation during initial tour of the facility on 07/29/13 between 11:40 a.m. and 12:20 p.m., with Assistant Director of Nursing (ADON), Resident #10 was observed sitting in his wheelchair alone in his room (75B). ADON stated, "He was moved from room [ROOM NUMBER]B to 75B recently for touching a female resident." When ADON was questioned about the measures taken by the facility when this incident occurred, she stated, "He was monitored for the first 24 hours, Resident was separated, and he has been on watch. (Resident #10) will be escorted to and from activities with supervision." When asked if Resident #10 was sent for a geriatric psych evaluation she stated, "No, he wasn't." A review of a Complaint/Grievance report dated 07/25/13 with no time noted, revealed "Resident in room [ROOM NUMBER]A (Resident #10) had his right hand between Resident 6A (Resident #11) legs moving them around. Notified Director of Nursing." Signed by (NAME RN). Review of Physician orders [REDACTED].) Act with supervision (2.) Dining room with supervision; Report-intervene with signs and symptoms sexually suggestive behaviors (3.) Psych F/U; Transport to areas by staff beside resident." Signed by (DON). Review of Resident #10 records on 07/30/13 revealed there was a note made to the care plan dated with problem onset of 06/14/13 that stated, "7/25 incident today of inappropriately touching female resident; Goal: No inappropriate touching of other resident x 90 days; Approaches: meals in room x1 day 07/29 may eat in dining room table with males, speak to resident about behavior being unacceptable, remove from area when behavior inappropriate." Review of incident report on 07/30/13 typed by the Director of Nursing, signed and dated 07/26/13 (incident occurred 07/25/13) revealed, "DON received allegation of male touching female in hall this Friday. Allegation in way of written and verbal report by nurse. Incident report completed by nurse. DON, Administrator, Social services met and developed plan of care: 1. Plan to protect resident's with room change to 75B away from concern; 2. Plan to have meals at male table or to eat in room and supervised during in hall or activities. 3. MD notified and examined (Resident #10). Resident (Resident #10) very upset and informed MD that they made him do it by shaking their butt in his face. Told MD that he is guilty as charged and that the devil made him do it. Resident expressed no remorse for incident. 4. Emergency care plan team meeting was placed and plan of care altered to meet concerns. MD and DON met resident (Resident #10) and went over POC (Plan of Care) agreement Friday and resident approved measures. 5. Administration, SS, Nursing reviewed tape. Incident is clearly observed. Female does not appear in distress and nursing immediate response to situations during rounds. 6. Administrator filed report of incident with AG (Attorney General) and state department of health." Review of Departmental notes (Nursing) on 07/30/13 revealed a Nursing Progress Note for Resident #10 dated 07/26/13 at 1:42 p.m. stated, "Dr (Name) visited and examined resident this am. Resident in room [ROOM NUMBER] bed B with room change related to resident recent behavior. Inappropriate touching of a female resident who has severe Alzheimer's. No new orders. Continue current POC (Plan of Care) change with supervision." Interview on 08/01/13 at 10:45 a.m. with Licensed Practical Nurse (LPN) #1 that intervened and filed incident report related to Resident #10 inappropriate sexual behavior on 07/25/13 stated, "Around 1:15 p.m. I came out of another residents room and I saw him (Resident #10) had pulled his wheelchair up next to her (Resident #11) in hallway and his hands were between her legs in her private area and he (Resident #10) was moving his fingers, I said, what are you doing, you can't do that, and I got the back of his wheelchair and pushed him onto his room. He was laughing about it. I left out of his room and came up the hall to look for somebody to report it to. I asked the ADON if I needed to report it to her and she said lets go to the DON office, so I did and reported it to her and filled out an event report. The Administrator came into the DON's office while I was in there and the DON said come in here and listen to this, so I told the ADM what had happened and her mouth just fell open. The ADM said, well he needs to come to DON's office. So when I left out of her (DON) office they were talking about it. I went down to his (Resident #10) room and he was in the bathroom and I told him the DON wanted to see him and he said well she's gonna have to wait a minute, I'm in the bathroom. So I went back up the hall to DON office and told her what he said and the DON said well make sure he comes to my office immediately. I went back to the nurses' desk and I could still see down the hallway to his door and he was still in his room, and I could still see her (Resident #11) sitting in her chair in the hallway. Another CNA (Certified Nursing Assistant) was walking down the hall so I told her to go get him (Resident #10) and bring him to DON office. She (CNA) went down there and he said he wasn't going any damn where, so I went back down there and he was in the bed, so I told him that they needed to see him in the Administrator's office, cause by this time they (ADM, DON, SS) had went in there because they kept calling the nurses' desk (phone) and wanting to know where he was at. Later I saw him come on around the corner and go to the ADM office. It was probably about 45 minutes later from the time it happened until he was going to ADM office." LPN #1 was asked if at any time she was given instructions to follow or told to assess Resident #11 she stated, "No." LPN #1 was asked if Administrator, Director of Nursing or Social Services came to investigate or assess Resident #11 and she stated, "No, they stayed in their offices and he (Resident #10) was in there when I left at 3:02 p.m." Interview on 08/01/13 at 1:30 p.m. with Registered Nurse (RN) #3 Charge Nurse revealed, "They (ADM, DON) kept wanting him (Resident #10) to come to the office but he kept saying no, they (ADM, DON) kept calling the phone at the nurses' desk. At 2:30 p.m. he (Resident #10) was just then going to their office. I had went outside on break and when I was coming back in the door at 2:45 p.m. and he was in the hallway outside the Administrator's door waiting to talk to them, so when I got to the nurses' desk I called them on the phone and let them know he was in the hallway waiting." RN Charge Nurse #3 was asked if she was given instructions to follow or instructions to monitor Resident #10 or Resident #11 to do an assessment on Resident #11 and she stated, "No." RN Charge Nurse #3 also confirmed that they (ADM, DON) did not come out of office to investigate or assess Resident #10 and Resident #11. Interview on 07/31/13 at 10:30 a.m. concerning Resident #10 with Medical Director stated, "When I went to see the patient on Friday (07/26/13) morning, he was hostile, inappropriate and denying it." Medical Director was asked by state agency surveyor why Resident #10 was not sent outside of facility for a psychiatric evaluation after the incident and Medical Director stated, "It was not an emergency, someone (psych consult) would come into the facility and see him and evaluate his mental status (at a later time). Then at that point I told them to send him to geri-psych." Interview on 08/01/13 at 4:00 p.m. with Registered Nurse (RN) Charge Nurse #2 stated, "She (RN Charge Nurse #3) told me what he had done, but I was not given any instructions to follow. The DON brought me the MD order and just told me to monitor him, but we were not given any specific orders to monitor him every hour or anything." When asked if they moved Resident #10 to another room she stated, "I asked ADON and she said we weren't gonna move him tonight (07/25/13) because we didn't have enough staff to move him." RN charge nurse #2 reviewed the Daily Assignment Sheet for 07/25/13 and confirmed that on 07/25/13 it was not noted to monitor Resident #10 or Resident #11 or have them on one to one supervision. Based on review of the facility's in-services on Abuse and Neglect, revealed that the last time Registered Nurse (RN) #3 was in-serviced on Abuse and Neglect was 03/31/11. There was no record of a documented in-service on Abuse and Neglect for Licensed Practical Nurse (LPN) #1. In an interview with the Office Manager on 08/01/13 at 5:00 p.m., revealed these inservices, and confirmed that employees are screened and trained upon hire and are given abuse/neglect policies at that time. Further inservices are provided by Administration and Nursing.

Based on the survey results dated 8/1/13, the facility failed to report and properly investigate allegations of sexual abuse to the State Agency, for one (1) of three (3) residents reviewed for abuse and neglect (Resident #11). This was deemed an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 7/30/13 at 4:00 p.m. A revisit was conducted on 8/20-21/13 to validate the Allegation of Compliance (AoC). The IJ which began on 5/7/13 was determined to be removed on 8/14/13. The facility provided an Allegation of Compliance (AoC) that was accepted by CMS on 8/19/13. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, staff interview and record review. The facility provided evidence that the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 8/14/13. The facility remained out of compliance at a scope and severity of "D", isolated deficiencies that constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. Findings include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired, Resident #11, from sexual abuse by Resident #10. Resident #10 was observed by staff in the dining room on 05/07/13 with his hand between Resident #11 legs, rubbing her private area. Resident #10 was observed again on 07/25/13 by staff with his hands between cognitively impaired Resident #11 legs, rubbing her private area. This was for one (1) of three (3) residents reviewed for abuse and neglect (Resident #11). Information contained in the Credible AoC, submitted by the facility, alleged removal as of 8/14/13. The following information was validated related to Resident #11: The Social Worker attempted to contact the Sheriff in (local) County and left a message on 7/25/13 following the 7/25/13 abuse incident involving Resident #10. The Sheriff returned the phone call, and was notified by the Social Worker of Resident #10's inappropriate sexual contact with Resident #11. The following facility practices were validated: The Quality Assurance Registered Nurse began on 7/30/13 at 6:00 p.m. in-servicing all staff on the definition of abuse, screening new hires, prevention of abuse, identification of events that could be abuse, investigation, protection from abuse, training, and reporting of abuse. No employees were allowed to work until the in-service had been completed. All department heads were inserviced on 7/30/13 on abuse by a Registered Nurse from an outside entity. The staff included in this inservice were Social Services, Director of Nursing (DON), Assistant Director of Nursing (ADON), Quality Assurance Nurse, Care Plan Nurse, Medical Records, Maintenance Supervisor, Administrative Assistant, Billing, Bookkeeper, and Activity Director. The in-service covered the seven components of abuse: screening, training, prevention, protection, identification of abuse, investigation and reporting. A poster which informed how to report abuse and to whom to report abuse was placed on the bulletin board in the main hallway on 7/31/13. The poster included definitions of abuse, neglect, and exploitation and discussed the investigation process. The poster was to inform staff, families, and other visitors of the facts about abuse. On 7/30/13, the facility initiated a new form for reporting abuse to provide written documentation of any allegation of abuse. The form may be completed by anyone wishing to report any allegation of abuse or neglect. All allegations of abuse, neglect, or exploitation will be reported to the Director of Nursing and/or the Administrator at the time. The written report will be presented at the morning stand up meeting of department heads and the problem will be discussed as a team. The Nurse Consultant, who is a Registered Nurse with over [AGE] years of experience in Long Term Care, conducted an inservice on 8/2/13. The inservice addressed abuse including a definition of abuse with examples cited and the seven components to the abuse policy. The employees were allowed to ask questions throughout the in-service. A written test was given to the employees following the in-service. Another session of this in-service was done on 08/05/13 for employees who were not present on 8/2/13. Employees from all departments were present at the in-service. The aforementioned in-services were conducted on the following dates: 7/30/13, 7/31/13, 8/1/13, 8/2/13, 8/5/13 and 8/13/13. The facility began a report book where all resident behaviors and incidents will be listed each shift for shift to shift communication by the licensed nurses when the behaviors occur. The charge nurse will review the report book for the past 24 hours. Interview with 40 staff members from all 3 shifts on 8/20/13 and 8/21/13 verified that the facility had conducted in-services regarding the different types of abuse/neglect, reporting, protection, identification, screening, prevention, training, Resident/Resident abuse, and to whom to report incidents. Policies were updated and revised, and staff were in-serviced on the revisions. Staff members included CNAs, Nurses, the Administrator, the Maintenance Director, Social Services, the Dietary Manager, the Activities Director, Housekeeping, and the DON. Based on verification of the facility's corrective actions that was validated by staff interview, observation, record review and inservices review, the Immediate Jeopardy was removed and the scope and severity was lowered on 8/14/13 to a "D" level, which constituted no actual harm with the potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility' Quality Assurance Committee.

Based on the survey results dated 8/1/13, the facility failed to provide social services in a manner to maintain Residents highest practicable well being for two (2) of fifteen (15) records reviewed (Resident #10 and Resident #11). This was evident by the failure of Social Services (SS) #1 to report an incident of Resident to Resident sexual abuse that occurred on 5/7/13. This was deemed an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 7/30/13 at 4:00 p.m. A revisit was conducted on 8/20-21/13 to validate the Allegation of Compliance (AoC). The IJ which began on 5/7/13 was determined to be removed on 8/14/13. The facility provided an Allegation of Compliance (AoC) that was accepted by CMS on 8/19/13. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, staff interview and record review. The facility provided evidence that the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 8/14/13. The facility remained out of compliance at a scope and severity of "D", isolated deficiencies that constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. Findings include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired, Resident #11, from sexual abuse by Resident #10. Resident #10 was observed by staff in the dining room on 05/07/13 with his hand between Resident #11 legs, rubbing her private area. Resident #10 was observed again on 07/25/13 by staff with his hands between cognitively impaired Resident #11 legs, rubbing her private area. This was for one (1) of three (3) residents reviewed for abuse and neglect (Resident #11). Information contained in the Credible AoC, submitted by the facility, alleged removal as of 8/14/13. The following information was validated related to Resident #10: On 7/25/13, the Social Worker notified Resident #10's family of the incident involving the inappropriate touching of a female. On 7/25/13, the Social Worker attempted to contact the Sheriff in (local) County, and left a message. The Sheriff returned the phone call, and was notified by the Social Worker of Resident #10's inappropriate sexual contact with Resident #11. On 7/29/13 the Social Worker documented, "He became very hostile and cussing. You could not reason with him. I tried on several occasions to calm him down and he refused. His behavior became so bad that he was cussing at everyone and telling that he never did anything wrong. He just kept cussing. Due to this behavior, I called (local Geri Psych Unit (GPU)) and ask for a Screen. He was screened and they will accept him for placement in the AM." The Social Worker's notes revealed that Resident #10 was transferred to (local hospital) in Newton, MS on 7/30/13. The following information was validated for Resident #11: The Social Worker notified Resident #11's family of the incident between Resident #11 and Resident #10 on 7/25/13. The following facility practices were validated: Review of the facility's "Personnel Action Form" for Social Services confirmed on 7/30/13, Social Services was reprimanded and suspended without pay then given 90 day probation. Review of the "Personnel Action form dated 8/10/13 revealed Social Services was terminated due to failure to obey rules, regulations, policies and/or procedures and unacceptable work performance. Based on verification of the facility's corrective actions that was validated by staff interview, observation, record review and inservices review, the Immediate Jeopardy was removed and the scope and severity was lowered on 8/14/13 to a "D" level, which constituted no actual harm with the potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility' Quality Assurance Committee.

Based on observation, record review, staff interview and policy review, the facility failed to develop and implement care plans for Resident #10 and for Resident #11. This is for two (2) of fifteen (15) records reviewed (Resident #10 and Resident #11). An Immediate Jeopardy (IJ) was not removed upon exit from the facility on 08/01/13, and is considered ongoing. Findings include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired Resident (Resident #11) from sexual abuse by Resident #10. Resident #10 was observed by staff with his right hand between Resident #11 legs and moving his fingers around. Review of the facility's policy entitled "MDS, RAPS, and Care plan Documentation" stated, "POLICY: It is the policy of Queen City Nursing Center, Inc. to provide documentation in the medical record for MDS, RAPS, and Care Planning purposes. 6. The care plan will be updated on an ongoing basis with significant changes in interventions." Review of Resident #10's SS note dated 05/07/13 revealed SS #1 was aware of incident of sexual abuse and careplan revealed date of 05/14/13 indicating care plan was not developed until seven (7) days after the incident occurred. Review of Resident #10 records on 07/30/13 revealed that a care plan was not initiated immediately to address Resident #10 inappropriate touching of a female resident on 05/07/13. Care plan dated with problem onset date of 05/14/13 (incident occurred on 05/07/13), Titled, "inappropriate touching of female resident," revealed "Goal: No inappropriate touching of other resident x 30 day through 06/14/13," "Approaches: redirect when inappropriate behavior, remove from situation as directed, resident moved to another table with male resident and oriented female resident, no further inappropriate behavior." Treatment Assessment Record (TAR) indicated that Resident was to be monitored every shift for these behaviors of inappropriate touching. Review of Resident #11 careplan records revealed that a plan of care had not been developed to address the psychological or emotional needs. Review of the facility policy and through confirmation of SS #1 interviews, SS #1 failed to identify and seek ways to meet and support Resident #11's needs that may arise after the incident that occurred on 05/07/13 by not reporting it to Administration and Nursing staff.

Based on the survey results dated 8/1/13, the facility failed to develop and implement care plans for Resident #10 and for Resident #11. This is for two (2) of fifteen (15) records reviewed (Resident #10 and Resident #11). This was deemed an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 7/30/13 at 4:00 p.m. A revisit was conducted on 8/20-21/13 to validate the Allegation of Compliance (AoC). The IJ which began on 5/7/13 was determined to be removed on 8/14/13. The facility provided an Allegation of Compliance (AoC) that was accepted by CMS on 8/19/13. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, staff interview and record review. The facility provided evidence that the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 8/14/13. The facility remained out of compliance at a scope and severity of "D", isolated deficiencies that constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. Findings include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired, Resident #11, from sexual abuse by Resident #10. Resident #10 was observed by staff in the dining room on 05/07/13 with his hand between Resident #11 legs, rubbing her private area. Resident #10 was observed again on 07/25/13 by staff with his hands between cognitively impaired Resident #11 legs, rubbing her private area. This was for one (1) of three (3) residents reviewed for abuse and neglect (Resident #11). Information contained in the Credible AoC, submitted by the facility, alleged removal as of 8/14/13. The following information was validated related to Resident #10: On 7/25/13, Registered Nurse (RN) #2 updated the Certified Nursing Assistant's "Resident ADL Record & Care Plan" stating, "In Room except during supervision." Resident #10's care plan was updated on 7/25/13 to address the resident's inappropriate touching of a female. On 7/29/13, Resident #10's ADL care plan was updated to include an approach of eating in Dining Room at a table with males. The following information was validated for Resident #11: On 7/25/13 at 3:40 p.m., Resident #11's care plan was reviewed by the Interdisciplinary Care Plan Team. The Interdisciplinary Care Plan Team decided that no changes were required since Resident #11 was already being monitored by the nurses for signs and symptoms of depression. The following facility practices were validated: Care plans for each of the 18 residents reflected that the assessment tool for identification of risk to abuse others, and the implementation of intensive monitoring as well as the discontinuation of the visual monitoring for 13 of the 18 residents. The facility initiated a process where all resident behaviors and incidents will be listed each shift on the report book for shift to shift communication by the licensed nurses when the behaviors occur. The charge nurse will review the report book for the past 24 hours. The residents involved will be reviewed to ensure proper interventions are in place to protect all residents. The Quality Assessment Committee will meet in a stand up meeting every morning Monday through Friday except Holidays. The committee will discuss the incident and determine what interventions are needed. The care plan will be revised at the meeting to address the interventions that have been initiated. Incidents that occur on weekends or Holidays will be reviewed on the next work day by the Quality Assessment committee. An interdisciplinary Care Plan Team in-service was given by the Quality Assessment Nurse on 8/13/13. This Quality Assessment Nurse was a Licensed Administrator. The in-service addressed the facility care plan policy which included care planning acute situations in a timely manner. Based on verification of the facility's corrective actions that was validated by staff interview, observation, record review and inservices review, the Immediate Jeopardy was removed and the scope and severity was lowered on 8/14/13 to a "D" level, which constituted no actual harm with the potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility' Quality Assurance Committee.

Based on the survey results dated 8/1/13, the facility failed to document information and maintain complete and accurate medical records for two (2) of seventeen (17) records reviewed (Resident #10 and Resident #11). This was evident by the lack of documentation of an incident report for the incidents that occurred on 5/7/13; and, lack of documentation to indicate that Resident #10 and Resident #11 were monitored after the sexual inappropriate touching incident that occurred on 5/7/13 and 7/25/13. This was deemed an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 7/30/13 at 4:00 p.m. A revisit was conducted on 8/20-21/13 to validate the Allegation of Compliance (AoC). The IJ which began on 5/7/13 was determined to be removed on 8/14/13. The facility provided an Allegation of Compliance (AoC) that was accepted by CMS on 8/19/13. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, staff interview and record review. The facility provided evidence that the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 8/14/13. The facility remained out of compliance at a scope and severity of "D", isolated deficiencies that constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. Findings include: Cross refer to tag F-223 for the facility's failure to protect a cognitively impaired, Resident #11, from sexual abuse by Resident #10. Resident #10 was observed by staff in the dining room on 05/07/13 with his hand between Resident #11 legs, rubbing her private area. Resident #10 was observed again on 07/25/13 by staff with his hands between cognitively impaired Resident #11 legs, rubbing her private area. This was for one (1) of three (3) residents reviewed for abuse and neglect (Resident #11). The following facility practices were validated: On 7/30/13 the DON, Assistant Director of Nursing (ADON), Quality Assurance Registered Nurse (QA RN), Registered Nurse (RN) #1, Activity Director (AD), and Medical Records Staff (MR) #1 reviewed the medical records of residents who had a history of [REDACTED]. The census in the facility was 66, during this review. Of the 66 residents reviewed, 28 were identified as having a history of behaviors. The facility initiated a new form for reporting abuse on 7/30/13 to provide a written report of any allegation of abuse. The form may be completed by anyone wishing to report any allegation of abuse or neglect. All allegations of abuse, neglect, or exploitation will be reported to the Director of Nursing and/or the Administrator at the time. The written report will be presented at the morning stand up meeting of department heads and the problem will be discussed as a team. Interview with 40 staff members from all 3 shifts on 8/20/13 and 8/21/13 verified that the facility had conducted in-services regarding the different types of abuse/neglect, reporting, protection, identification, screening, prevention, training, Resident/Resident abuse, and to whom to report incidents. Policies were updated and revised, and staff were in-serviced on the revisions. Staff members included CNAs, Nurses, the Administrator, the Maintenance Director, Social Services, the Dietary Manager, the Activities Director, Housekeeping, and the DON. Based on verification of the facility's corrective actions that was validated by staff interview, observation, record review and inservices review, the Immediate Jeopardy was removed and the scope and severity was lowered on 8/14/13 to a "D" level, which constituted no actual harm with the potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility' Quality Assurance Committee.