Every finding on record at Brookview Healthcare Center

Based on a review of facility policy, observations, and staff interviews, the facility failed to ensure that the central supply closet was free of expired medications. One of one central supply closets observed contained expired medications.Findings include:Review of the facility policy titled, Medication Storage in the Healthcare Centers, revealed that, medications and biologicals are stored safely, securely, and properly following manufacturer recommendations or those of the supplier. Observation of Central Supply Closet on 01/07/26 2:30 PM with Licensed Practical Nurse (LPN)1 revealed the following expired items: Five (5) boxes of Assure Prism Control Solution, each containing two 4 milliliter (mL) vials, expired on 12/27/2025. Three (3) bottles of Nephro Vitamins C and B Complex, each containing 100 tablets, expired on 08/2025. Three (3) bottles of Flush Free Niacin, each containing sixty (60) 500 milligram (mg) capsules, expired on 10/2024. Two (2) bottles of Procure Allergy Relief, each containing 300 tablets at 10 mg per tablet, expired on 08/2025. One (1) bottle of Oyster Shell Calcium, containing 100 tablets at 500 mg per tablet, expired on 11/2025. One (1) bottle of Major Deep Sea Premium Saline Nasal Moisturizer, containing 44 mL (expiration date not listed). One (1) bottle of Liquid Iron Supplement, containing 473 mL, expired on 12/2025. Twelve (12) bottles of Hydrogen Peroxide, each containing 473 mL, expired on 05/2025. Interview with LPN1 on 01/07/26 at 2:30 PM revealed those expired items should have been wasted and not been stored in the central supply room. LPN1 acknowledged expired medications. Interview and observation of expired medications with the Administrator on 01/07/26 between 2:40 PM and 3 PM revealed expired medications should not have been stored in central supply closet. Administrator acknowledged the expired medications and controlled solutions. Administrator revealed she will be disposing of expired medications and controlled solutions.

Based on review of facility policy, interviews and record review, the facility failed to send required notices of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for 1 of three residents, (R)122 reviewed for discharges. Review of the undated facility policy titled Transfer and Discharge Policy stated, The facility permits resident transfers and discharges only in accordance with applicable federal and state regulations and maintains a process to ensure resident rights, safety, and appropriate notice requirements are met. Review of R122's Face Sheet revealed R122 was admitted to the facility on [DATE] and was discharged on 12/18/25 Against Medical Advice (AMA). Review of a facility document titled discharge: Against Medical Advice dated 12/18/25, noted R122 and two staff witnesses signed the AMA release and R122 was discharged from the facility. Review of the facility's December 2025 Nursing Home Transfer and Discharge Notice Spreadsheet sent to the ombudsman on 01/01/26, did not include R122's AMA discharge.During an interview on 01/08/26 at 2:20 PM, the admission Director stated she was unaware that this discharge notification needed to be sent to the ombudsman's office and said it was not done.

Based on a review of facility policy, record review, and interviews, the facility failed to develop a comprehensive, resident-centered care plan for Resident (R)72. Specifically, R72 was not care planned for the use of vaping products. Findings include: Review of the facility policy titled, Vaping Policy in Nursing Home, dated 05/31/23 revealed, Policy Statement: This policy outlines the guidelines and regulations regarding vaping within the premises of the nursing home in compliance with the South Carolina Department of Health and Environmental Control (SCDHEC) and Centers for Medicare and Medicaid Services (CMS) regulations. Review of the facility record titled, Brookview Health Care, Residents that currently vape at facility, identified R72 as a resident who vapes.Review of the facility record titled, Vaping Resident Education, and consent revealed R72 signed education and consent on 02/16/21.Review of R72's care plan on 01/07/26 at 12:00 PM revealed there was not a care plan present related to R72's vaping status.During an interview with R72 on 01/07/26 at 08:40 AM revealed R72 does vape, as the facility does not allow residents to smoke cigarettes. R72 revealed she is not allowed to have a vape in her room, but rather, the nurses will hold onto the vape until she wants to smoke. R72 revealed typically they can smoke their vape whenever they want, as long as the weather is good and it's not dark out. R72 revealed she has not smoked her vape since around Thanksgiving time, but could smoke if she wanted to.During an interview with the Minimum Data Set (MDS) Coordinator (1) on 01/07/26 at 5:40 PM revealed that she primarily serves as the MDS Coordinator and shares responsibility with another MDS nurse for updating resident care plans. She stated that the initial care plan is initiated by the floor nurse upon resident admission. Resident care plans are reassessed at least quarterly and additionally as needed, in response to changes in the resident's condition or care needs. She further stated that residents who use vaping products should have this addressed in their care plans. MDS Nurse states that it is important to have updated and accurate care plans, as care plans are used as guidance for clinical staff to properly care for residents and their unique needs. A subsequent record review was completed with MDS Coordinator 1 of R72's electronic health record (EHR) and confirmed that R72 did not have a care plan addressing the use of vaping products. During an interview with the Administrator on 01/07/26 at 5:50 PM revealed initial care plans are completed with every new admission and should be updated at least quarterly and with any change in condition or with any new concerns that need to be addressed. The Administrator stated residents who use vapes should be care planned for the use of vapes.

Based on observations, interviews and record review the facility failed to revise resident care plans for individual needs and current interventions for two Resident (R)2 and R109 reviewed for Care Plans. Findings include:Review of the undated facility policy titled, Care Planning Policy revealed, Policy Statement: The facility shall develop, implement, and maintain person-centered care plans to meet each resident's assessed needs and preference in accordance with applicable federal and state regulations. Policy: Care plans shall be reviewed and revised as needed based on changes in the resident's condition or needs.Review of R2's Face Sheet revealed R2 was most recently admitted to the facility on [DATE] with diagnoses including but not limited to: dementia, psychosis, insomnia and schizoaffective disorder.Review of R2's Physician Order revealed Memantine 5 milligrams (mgs) once a morning at 9:00 AM, with a start date of 12/13/25 for unspecific dementia.Review of R2's Comprehensive Care Plan with a start date of 02/05/25 revealed, Resident has a diagnosis of dementia with memantine 10 mg BID in place for treatment. 5/21/25 - D/C Memantine 10 mg twice daily; start Memantine 5 mg twice daily on 5/22/25 for two weeks, then start Memantine 5 mg once daily for two weeks. 6/5/25 - Memantine 5 mg once daily for two weeks. 12/13/25 - Start Memantine 5 mg every morning. Approaches with a start date of 02/05/25 state, Memantine 10 mg PO twice a day per MD order. D/C 5/21/25. The care plan was last reviewed/revised on 01/08/26. The care plan approaches/interventions did not reflect the R2's current medication orders.Review of R109's Face Sheet revealed R109 was admitted to the facility on [DATE] with diagnoses including but not limited to: Pressure ulcer of right heel, unstageable, non-pressure chronic ulcer of right ankle, pressure-induced deep tissue damage of left heel and congestive heart failure.Review of R109's Physician Order revealed Lorazepam 1 mg three times a day, with a start date of 12/20/25 for restlessness and agitation.Review of R109's Comprehensive Care Plan with a start date of 09/02/25 revealed, Diagnosis of restlessness and agitation with Lorazepam 1mg PO every eight hours PRN in place for treatment. Approaches included: Administer medication as ordered by medical physician. The care plan did not reflect R109's current medication orders.During an interview on 01/07/26 at 5:40 PM, the MDS Coordinator stated, she primarily serves as the MDS coordinator and has a shared responsibility with another MDS nurse when it comes to updating care plans. Resident care plans are reassessed at least quarterly and additionally as needed in response to any change in the resident's condition or care needs.During an interview on 01/07/26 at 5:50 PM, the Administrator stated, Initial care plans are completed with every new admission and should be updated at least quarterly and with any change in condition or with any new concerns that need to be addressed.During an interview on 01/08/26 at 10:00 AM, Licensed Practical Nurse (LPN)2 stated, Nursing staff did not update care plans and that it was done by the MDS Coordinator.During an interview on 01/08/26 at 10:18 AM, the MDS Coordinator stated, Care plans are reviewed by her and another MDS nurse each morning. MDS nurse then confirmed the incorrect information in the care plans and stated she would have it corrected.

Based on review of the facility policy, record review, observations and interviews, the facility failed to ensure and document that Resident (R)36 received baths on the designated bath dates between 12/19/25-01/03/26 for 1 of 2 residents sampled for activities of daily living.Findings include:During an interview on 01/08/26 at 6:00 PM, the Administrator revealed that the facility does not have a policy on Activities of Daily Living (ADL) care, and the expectation is for staff to follow state and federal regulations.R36 was admitted to the facility on [DATE] with diagnoses including, but not limited to, lack of coordination, muscle weakness, cerebral palsy, dementia, mood disturbance, and anxiety.Review of R36's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/25 revealed that R36 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating that R36 is cognitively intact. The MDS indicated that R36 has upper extremity impairment on one side, lower extremity impairment on both sides, and is dependent for all self-care and mobility needs.Review of R36's Activities of Daily Living (ADL) record did not reflect documentation of a bath or shower provided from 12/19/25-01/03/26.Review of R36's care plan revealed that R36 requires substantial to dependent assistance with most ADLs and requires transfers using a Hoyer lift with two-staff member assistance.Review of R36's progress notes did not reveal documentation of any refusals of activities of daily living care for the six months reviewed.During observations of R36 on 01/06/26 at 9:45 AM and on 01/08/26 at 4:00 PM, R36's hair appeared greasy with multiple areas of dandruff present.During an interview on 01/08/26 at 1:29 PM, Certified Nursing Assistant (CNA)1 revealed that R36 sometimes misses baths due to staffing shortages or issues with the Hoyer lift. R36 requires a two-person assist and sometimes resists turning and repositioning, which makes providing care more difficult when staffing is inadequate. CNA1 further stated that the floor does not have sufficient staff to transport R36 to and from the shower room due to the level of assistance required.During an interview on 01/08/26 at 1:57 PM, Licensed Practical Nurse (LPN)3 revealed that if the floor is short-staffed to assist with the Hoyer lift, R36 may not receive a shower but is always provided a bed bath, including cleansing beneath the breasts, armpits, and perineal area.During an interview on 01/08/26 at 4:45 PM, the Administrator revealed that R36 has gotten baths, but it may not have been documented. It is the expectation for staff to document all baths and showers given to all residents.

Based on review of facility policy, record review, interview and observation, the facility failed to ensure Resident (R)4 was provided appropriate supervision to prevent an elopement from the facility for 1 of 3 resident reviewed.On 09/05/25 at 11:21 AM, the surveyor provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 09/03/25. The IJ was related to 42 CFR 483.25 - Freedom from Accidents Hazards/Supervision/Devices.On 09/05/25, the facility provided an acceptable IJ Removal Plan. On 09/05/25, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the non-compliance. The SA is considering this IJ at Past Non-compliance as of 09/04/25.An Extended Survey was conducted in conjunction with the Complaint Survey for noncompliance at F689, constituting substandard quality of care.Review of the facility policy titled Elopement Response Guidelines with an effective date 05/01/06 states, It is the responsibility of all staff to provide a safe environment for all residents. The following guidelines will be followed in the event that a resident is missing. Responding to an actual elopement: 1. It is the responsibility of all staff, regardless of the department they work in, to respond to activated door alarms and to return residents to their unit . 3. When a resident is determined to be missing: Note the time that the resident is/was determined missing. The staff members assigned to the unit where the resident resides will verify that the resident has not been signed out. Staff members will do a thorough search to locate the resident. If the resident is not located, proceed with the following: The Charge Nurse will notify the Director of Nursing that a resident is missing. Staff members from other departments will search the entire facility and grounds. Prior to beginning the search, the resident's photograph will be viewed by all staff involved in the search.Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE] with diagnoses including but not limited to other seizures (History of), vascular dementia, moderate, with anxiety (History of), and dementia.Review of R4's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/05/25 revealed the assessment is in process.Review of R4's Care Plan with a start date of 08/30/25 revealed, Resident has disorganized thinking or incoherent (rambling or irrelecant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) R/T [related to] dementia diagnosis. This Care Plan directed staff to, Orient to person, place, and time as appropiate [sic]. Protect from injuring self and others during delirious state. provide a quiet, well-lit, calm environment. Surround resident with familiar objects. Remove potentially dangerous objects from environment. Further review of the Care Plan dated 08/30/25 revealed, Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by: verbal and physical threats to staff. This Care Plan directed staff to, Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Maintain a calm environment and approach to the resident.Review of a document titled Addressing Decisional Capacity, signed by the Attending Physician on 09/02/25 revealed, This patient DOES NOT meet all the criteria for decisional capacity, therefor is not able to make healthcare decisions for self . Further review of this document revealed, Criteria not met: Oriented to person place time, Understands the nature of his/her illness, Ability to understand that decisions need to be made, Ability to communicate a decision, Ability to under and use information logically to reach a decision, Ability to be realistic in decision making .Review of R4's Progress Notes, revealed the following notes:08/30/25 at 10:30 AM Resident arrived via stretcher . Resident exit seeking.08/30/25 at 7:07 PM Resident continues to exit seek.08/31/25 at 11:02 AM Resident up this am ambulating . Continues to exit seek pushing on doors.09/01/25 at 2:00 PM Resident continues to exit seek.09/01/25 at 5:57 PM . Noted exit seeking and has made door alarm go off in dining room and long peach hall door .09/01/25 at 6:24 PM Resident attempting to leave this nurse was trying to redirect resident.09/03/25 at 9:00 PM Recorded as late entry on 09/04/25 at 1:59 PM During Shift change this nurse and day shift nurse was counting NARCS. 7P-7a CNA asked where [R4], her resident was. Another CNA spoke up and said she is on Peach unit sitting on the couch. The 7P- 7a CNA went to Peach. Resident was not there. All staff from all units began looking tor [sic] [R4] around 7:15-7:17pm. As the staff was outside looking for the resident [R4]. The kitchen lady pulled up with [R4]. she reported she had seen her at [local grocery store]. She was able to bring her back to the facility in her car .During an interview on 09/04/25 at 2:45 PM, Dietary 1 stated, I have worked here for three years now. I clocked out at 7:20 PM yesterday. I called my daughter to pick me up from work. I told her to bring my wallet with her so I could go to [local grocery store]. As soon as we pulled up at [local grocery store, I saw [R4] standing in front of [local grocery store] holding a bag of chicken. She was standing partially in the road. It was a good thing she didn't get hit by a car. She told me she was there because she had to go pick up her kids. I returned her to the facility. When we arrived, [Licensed Practical Nurse (LPN1)] came out to get her with the other staff.During an interview on 09/04/25 at 2:54 PM, LPN2 stated, I was coming on to my shift. I work 7P to 7A, the nurse before me left early. I counted the narcotics with the other nurse, and as we were counting, I heard the [Certified Nursing Assistant (CNA)1] asking where is my resident. The other CNA said she is on Peach, sitting on the couch. Then she ask again where is my resident. We continued to finish counting the Narcotics. Then we proceed to look for [R4]. We first looked in the building, we didn't see her. When went outside to look for her, we saw the kitchen lady bringing her back to the facility. The kitchen lady told us [R4] was at [local grocery store]. The [local grocery store] is 1.3 miles from [the facility]. [R4] had a little bag of chicken. I wasn't sure if she was given the chicken or if the kitchen lady gave her the chicken. We had a time getting her back in the building. The CNAs are supposed to walk around with each other and get report. Some of the younger CNAs do not round on the residents with the off going CNAs. It is a requirement here at this facility to do rounds at the end of the shift. [R4] is not oriented. She is oriented to self. When she gets out the door all of her orientation seems to come back. We asked her how she got out of the building and she said she went out with a group of Black people. We immediately placed her on 15-minute checks. She then darted to the side door on Dogwood. Those doors, if you lean on them, the door will open up. She sat in the chair and cussed at us. I proceeded to give her medications, then she calmed down. The DON came in to get our statements.During an interview on 09/04/25 at 3:21 PM, Registered Nurse (RN)1 stated, I was called around 7:20 PM by [LPN1] who stated, The resident got out of the building, and they were looking for the resident. They said they were looking for her for about 10 minutes. That is when the lady from the kitchen pulled up and told us she found her at the [local grocery store]. I asked her if she had any injuries and to do a full body audit. Then I called the Administrator. The resident was placed on 15-minute checks. The staff was educated on abuse/neglect and elopement. We are still educating the staff. They called the SC House Calls our on-call group. Staff did not report any issues with the door. She left out of the Dogwood main entrance door. Unsure how she got out of the door. We are still investigating.During an observation on 09/04/25 at 3:33 PM, the surveyor looked at the front door to the Dogwood unit. This surveyor observed a coded keypad on the door. The entry was a double-door exit to get outside. If you hold the lever on the door for 15 seconds, after the countdown down the door opens. A sign on the door states push until alarm sounds door will open in 15 seconds. The audio alarm which was a beeping noise was minimal. The alert sound was not loud.During an interview on 09/04/25 at 3:35 PM, R4 stated, It is so many doors here I am unsure which door I went out of. I got out good and came back good. I should have gone home. I went to get me something to eat. When I came back they told me to go back to my room, and they were going to get someone to come get me, but no one answered. I am here at the hospital. I have never been in this place. R4 continued to tell this surveyor she is going to get her medicine.During an interview on 09/04/24 at 4:04 PM, CNA1 stated, I look for my people when I come on shift. I pulled up in the parking lot at 6:40 PM. I clocked in at 6:44 PM. I looked at a few rooms and I realized [R4] wasn't in the room. I asked where she was and they said she was on Peach. I walked the long way around through the Dogwood unit. I went back to the desk and asked where is [R4]. She is not in the cafeteria. This is when we found out she wasn't in the building. It was about 7:00 PM or 7:05 PM. That is when I told them she wasn't in the building. We looked in every room, in all of the showers and outside. While we were looking for her, one of the ladies in the kitchen was at [local grocery store] and they brought her back to the facility. She was fighting to come back in the building, but she came back in with me. She was still shaking the doors and trying to get out of the building all night. After she returned, I did 15-minute checks all night. [CNA2] was the CNA who had her for first shift. She told me she was on Peach. That wasn't the first time she tried to get out of the building. She had been admitted for at least 5 to 6 days. Our doors tell you when you can exit after attempting to go out. If you hold it for 15 seconds, they will open. The doors also speaks out loud to tell you when to exit. I was very upset that I couldn't find my resident. She told us she followed a group of Black people out. She was in her street clothes. She doesn't look like a resident unless you know her. She is constantly getting out of the door. She has gotten out before and made it to the parking lot. They don't do a walk-through for the report because a lot of CNAs are pulling double shifts. Shift report consist of the CNAs telling you at the desk that this person is doing this or that. Some of the CNAs don't tell you anything. I've been here for at least a year. The end of shift report was not explained to us in detail in orientation. She is not the only resident who gets out. The re-education I have received was on the elopement process.During an interview on 09/04/25 at 4:41 PM, CNA2 stated, I got a phone call about the last time I saw [R4]. It was around 6:15 PM and 6:30 PM. She had been exit seeking all day. We told her she can't go out, and she cussed us out. I redirected her to the dining area at Peach. She went to the dining hall. She was sitting in a Geri chair. The CNA that came in at 7:00 PM asked me had I seen [R4]. I told her where I last saw her. We walked together looking for her. We called the MD [Medical Director] around 7ish. We went outside looking, and that is when we saw one of our kitchen staff pull up outside with her in the car with a bag of chicken. We assumed she followed someone out of the door. I know she has dementia. She told us I let myself out. I am unsure if she seen the code because we didn't hear any alarms. This incident happened at shift change, so you would think someone would have seen her in the parking lot. She is a very smart lady. The doors have a sign on it that states to hold for 15 seconds, then it will open. We received her from the parking lot and assisted her up the hill. She was fussing at us. She sat in a chair by the door when she returned. She was insisting she needed to go pick up her children. Once she calmed down we slide her away from the door. We notified the DON. [Local grocery store] is about 1.3 miles from here. Today, when I returned I was re-educated on abuse/neglect and elopement. The DON went over the steps of elopement.During an interview on 09/04/25 at 4:54 PM, the Administrator stated, The DON called me to let me know what happened. I came to the facility to do the reportable. We had the resident on 15-minute checks. We did a body audit. There were no injuries. The DON received statements to get a timeline to start the reportable. The Abuse/Neglect in-service was started and she is continuing exit seek today. We have the alarms on scheduled checks. We had someone come out and access all of the doors. The signs are on the door, but I don't think we can take the signs off the door for regulations concerns. I know a dementia resident can read the door. She is on the 15-minute checks currently. The family has not been here to see her yet. The family lives in Rock Hill and [NAME]. I think she was exit seeking because she is not from here. The family is looking to move her closer to home. We have cameras in the parking lot. The only thing we can see on the camera is she exited out of the front door of the Dogwood unit. She walked in the parking lot and around the circle. After that we did not see anything else.During an interview on 09/04/25 at 5:07 PM, the Maintenance Director stated, The video is only outside. We can't see what she did to exit. We don't have many residents who exit a lot. The staff are able to redirect if the resident attempts to open the door to exit. I checked that door and the other doors to check functionality. I pushed on the door to make sure the alarm would go off. We checked the doors weekly. Amplified Electronic is the last company we had check the doors last month. The only door that was loose was the door by the kitchen near the vending machines. I tighten the door. During an interview on 09/05/25 at 12:13 PM, LPN3 stated, The facility does not utilize the Wandergurad system, but there are alarms on the door that will go off when opened. If the handle is held down for about 10 seconds, the door will open. LPN3 finally stated that the alarms are not always able to be heard from a resident's room, but can be heard if you are in the hallway. On 09/05/25, the facility provided an acceptable IJ Removal Plan, which included the following:The immediate action taken for the deficient practice include the following:A body audit was completed on Resident #4 upon return to the facility. No injuries were noted.Resident was immediately placed on 15 minute checks.Staff in service on elopement prevention and CMS guidelines were conducted beginning 09/03/2025 and completed on 09/04/2025.Head count conducted for the entire facility following the elopement. All residents accounted for.Maintenance director checked all doors throughout the building. All doors were noted to be functioning properly.The facility recognizes that all residents have the potential to be affected by this deficient practice. Measures put into place to ensure this deficient practice does not reoccur includes the following:A professional contractor was contacted on 09/04/2025 to complete a facility-wide inspection of all door alarms and perform any necessary corrective work. Scheduled to be completed on 09/09/2025.As part of this inspection, the contractor will also evaluate and adjust alarm volume upward, as needed, to ensure maximum audibility throughout the facility.Elopement risk assessments completed on admission, quarterly and with significant changes.Elopement drill conducted on 09/05/2025.All new hires receive dementia management training. The nursing department receives further education on dementia/wandering residents annually and as needed throughout the year.Monitors to be put in place to ensure the deficient practice does not reoccur include:Door alarm inspections will be increased to daily from weekly by the maintenance staff.Inservice to be provided to staff regarding any issues with the doors/alarms must be reported directly to the Director of Nursing or the Administrator.The facility has set the TELS system, used to document completion of the monitoring, to alert the administrator via email and mobile application that the task was completed.The administrator will take findings to QAPI committee monthly for three months and quarterly thereafter until the issue is deemed to require no further issue.The facility alleges that we were in compliance on 09/04/2025.

Based on review of the facility policy, record review, and interview, the facility failed to protect 1 of 1 resident from sexual abuse. Specifically, Resident (R)2 wandered into R1's room and inappropriately touched R1, this was observed by two staff members. Based on the Reasonable Person Approach, R1 had the potential to suffer severe psychosocial harm. On 02/27/25 at 6:21 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 02/27/25 at 6:21 PM, the Administrator and the Director of Nursing were notified that the failure to protect a resident from sexual abuse constituted Immediate Jeopardy (IJ) at F600. On 02/27/25 at 6:21 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 02/04/25. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 02/28/25 at 1:25 PM, the facility provided an acceptable IJ Removal Plan. On 02/28/25 at 2:16 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D. An extended survey was conducted due to non-compliance at F600, constituting substandard quality of care. Findings include: Review of the undated facility policy titled Abuse and Neglect Prohibition, documented, .each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property . Sexual Abuse - Includes, but is not limited to sexual harassment, sexual coercion, sexual assault . Prevention 2.) Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including, but not limited to: schizoaffective disorder, dementia, with other behavioral disturbance, epilepsy, and anxiety. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/24, revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating R1 had severe cognitive impairment. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including, but not limited to: restlessness and agitation, psychotic disorder with hallucinations due to known physiological condition, Schizoaffective disorder, and Parkinsonism. Review of R2's Quarterly MDS with ARD of 01/17/25, revealed a BIMS score of 10 out of 15, indicating R2 had moderate cognitive impairment. Review of R2's Quarterly Elopement Evaluation dated 01/13/25 at 9:05 AM, documented R2 is ambulatory and/or Independent in wheelchair locomotion. R2 is cognitively impaired, has poor decision-making skills, and/or pertinent diagnosis. R2 has a history of wandering. Resident is at risk for elopement. Review of R2's Progress Note dated 02/04/25 at 1:07 AM, documented, Resident noted being physically aggressive with staff and other residents. Resident noted going into resident's room, pulling off the covers from resident, and screaming at different resident. Resident became physically and verbally combative with staff with staff was attempting to redirect resident. DON notified. EMS called for transport to ER for psych eval. Nursing Review of R1's Progress Note dated 02/05/25 at 11:23 AM, documented, LOA: Per daughter's (RP) request, res transported to CMC ER for exam. Res awake and alert. No s/sx of pain or distress noted. Nursing During a phone interview with R1's Representative (RP) on 02/27/25 at 10:28 AM, revealed that on 02/05/25, between 10:30 AM and 11:00 AM, the Director of Nursing (DON) contacted R1's RP via phone and said on Monday night 02/03/24, going into 02/04/25, a male resident went missing and staff couldn't find him. When facility staff started looking for him, they heard water running from R1's room, and staff went in the room, and found the male resident. R2 was completely naked, and was actively trying to get R1's brief off. The facility staff intervened and removed him from her room. R1's RP stated the DON told her staff assessed the female resident that night, and the next morning, and she didn't have any trauma related to the event. R1's RP stated R1 has severe dementia, and will say yes as her only form of communication, and is non-ambulatory. Staff told her (R1's RP) they didn't think that it was a big enough deal and since they didn't find anything, it was not a reportable offense. The DON told the RP the male resident was sent to the psych ward. R1's RP stated, It killed me when I got the call, I requested them to send my mom to the hospital, because their assessments were not thorough enough in my opinion. R1's RP further stated that R1 went out to the hospital, no abrasions to the body or vaginal area. Police told her that R2 was interviewed and admitted to the police that R2 put it in but not all the way, not enough to make babies. I called the ombudsman, and she gave me the department's information to file a complaint. During an interview with the Attorney General Council for the [Local Hospital] Healthcare System via phone on 02/27/25 at 1:55 PM, revealed that the internet is down and they would not be able to send the hospital information until the internet is available. However, the Attorney General Council revealed R1's HPI (history of present illness) revealed given concerns of potential sexual consult. Review of R1's HPI dated 02/05/25, documented, [R1] is a 77 y.o. a female who presents to the emergency department today given concerns over a potential sexual assault. History somewhat limited as patient does have a history of dementia, I am told by EMS that her care facility reported to the family that another individual with dementia may have exposed himself and had been on top her two days ago, the family had requested that she be transferred to the emergency department for further assessment. She does not have any acute complaints I am told she is mentating at baseline and does again have a known history of dementia, she will intermittently participate in the history and physical exam, and has not had any recent falls or other difficulties. ED Course Notes: SANE (Sexual Assault Nursing Examiners) has completed their evaluation, and was also able to discuss with the daughter. It sounds that the perpetrator of this event is actually not demented, but rather is a known schizophrenic. As a result SANE will contact the police department and has filed appropriate reports, we will continue to maintain patient safety until disposition can be made and we will discuss with the nursing facility prior to any plans to discharge home it sounds that this individual is also not currently at the facility so she would have a safe place to go. Police have evaluated the situation and appropriate reports filed per SANE team, patient safe to return to her care facility. Spoke with nurse at Brookview. She states the report she was given is that the event occurred at 2 am Tuesday morning. The male dementia patient at Brookview was lost for about 10 minutes. The male patient was found fully naked on top of [R1]. [R1] was also naked other than a diaper when found. Nurse states [R1's] diaper was pulled to the side and male was attempting to take it off. Nurse states unsure if there was penetration. Bed Confined-Unable to ambulate, unable to get out of bed without assistance, unable to safely sit up in a wheelchair. Review of R2's HPI dated 02/04/25, documented, PT to ED via EMS from Brookview. Facility states pt had Aggressive behaviors. Pt is pleasant in triage. [R2] is a 56 y.o male sent from Brookview with aggressive behavior. According to EMS, the patient was being aggressive towards other occupants at the facility. Patients denies this and state he just want to smoke. Unable to perform ROS (Review of Symptoms), Psychiatric disorder. Additional MDM and Provider Notes: [AGE] year-old male brought in by EMS from Brookstone for reported aggressive behavior towards other occupants of the facility. Patient has no knowledge of this and has very tangential thoughts. He has no complaints. CBC showed no leukocytosis, mild anemia. CMP shows reassuring electrolytes, normal renal function and liver function. UDS negative. Ethanol undetectable. Urinalysis not suggestive of a urinary tract infection. Awaiting telepsychiatrist recommendations. Patient signed out to the day team. Spoke with case management regarding the patient no longer being accepted at BrookView due to sexual assault against another [NAME] of BrookView. Case management will look at the patient for placement, however, the patient will not be able to have placement at a facility with pending charges. Dr.notified. Review of an Employee Statement Form written by Certified Nursing Aide (CNA)1 dated 02/04/25 at 1:00 AM stated, On 2/4/2025 at 1AM, I noticed [R2] was missing from the nurse's desk for a few minutes. I got up, I went to his room and he was not in his room. I went to Dogwood, I asked the staff if they had seen [R2], and they stated they heard him playing the piano in the dining room. [Registered Nurse (RN)2] got up, we went to the courtyard, and he was not in the courtyard. We went to the dining room, he was not in the dining room. We looked outside of the dining room, called his name, and he was not outside of the dining room. We came down the hall, I told [Licensed Practical Nurse (LPN)1] that i could not find [R2]. I went into 150 thinking he may have gone in there to look for a radio. I heard [RN2] say he was in 157. I walked back up the hall into 157, I saw [R2] putting on his shirt, and [LPN1] walked in at that time. [RN1] told [LPN1] about what was happening. I walked with [R2] back to the nurse's desk on the peach and waited on EMS to come and get him. Review of the Employee Statement Form written by LPN1 on 02/04/25 at 1:00 AM, documented, On 2/4/25 at around 1 AM, [R2] was sitting at the nurse's desk on the couch. [R2] got up and walked down the hall. [CNA1] asked if [R2] was still sitting on the couch. This nurse said no, he walked down the hall. [CNA1] went to find the resident. [CNA1] walked over on the Dogwood unit and asked the Dogwood staff if the resident had walked by, and Dogwood staff said not recently. Dogwood staff went with [CNA1] to help locate the resident. [CNA1] came back to Peach nursing desk and informed this nurse and another cna that [R2] was not located in the initial search. This nurse and [CNA2] went to Peach Short Hall, looking in rooms, the kitchen, and the laundry room. While walking back to the peach unit, this nurse heard [RN2] talking while coming on to peach unit via long hall. Staff was noted in room [ROOM NUMBER]. Particularly 157A in [R1's] room. This nurse noted [R2] standing beside of 157A'a bed with no pants on. [R2] was yelling at staff and being aggressive. [RN1] explained she saw [R2] on top of [R1] when she entered the room then [R2] got up and got dressed. This nurse took [R2] to the nurses desk. This nurse notified the DON and called EMS to transport resident to the hospital. [CNA] stayed with [R2] while this nurse went back to 157A's room to assess [R1]. [R1] was laying in bed on back. Upon inspection, resident noted to have brief intact, still adhered to both sides. The brief was pulled up the front, with the brief creating a thong like appearance, within the labia majoria. This nurse removed the brief. No redness, injuries, or bruising noted to the vulva or vagina area. Resident denied pain to that area. EMS arrived and escorted [R2] to ER. During an interview, via phone, with LPN1 on 02/27/25 at 2:24 PM, LPN1 confirmed her statement. LPN1 stated she is familiar with both residents. LPN1 stated she spoke to the DON, she and another nurse, and since her brief was intact, they didn't believe she was penetrated, or sexually assaulted which is why she was not sent to the hospital. LPN1 stated she spoke to the DON first, and informed she would take care of it all the following morning. LPN1 stated she did not notify R1's family. LPN1 stated the assessments were visual. No documentation was filled out. Typically it should have been done on paper, and filled out to its entirety. Review of an undated Employee Statement Form written by RN1, states, I was sitting at Dogwood desk working when [CNA1] from peach asked if I saw [R2]. I told her not in the last little bit, but I heard him playing the piano about 15 minutes ago. I went to help [CNA] look for the resident. After looking on Dogwood and in the dining room, the cna went to see if the other staff had seen the resident. Upon walking onto Peach Unit, I heard water running in 157 and knew neither resident could turn it on. When I opened the door the water in the sink was on and about to over flow. I then saw [R2] naked on top of [R1] 157A. I told him to get off of her right now. [R1] was laying flat in bed with cover pulled off, Gown pulled up and brief slightly pulled to the side. At this time, other staff was in the room. This nurse asked [R1] if she was okay and she just looked at me and finally said yes. [LPN1] took [R2] out of the room to the desk. [LPN1] then called DON and EMS. Attempt to interview, via phone, CNA1 on 02/27/25 at 1:05 PM, was unsuccessful and unable to leave a voicemail. Attempt to interview, via phone, RN1 on 02/27/25 at 3:19 PM, was unsuccessful. During an interview with the Director of Nursing (DON) on 02/27/25 at 12:19 PM, the DON she is aware of a situation between two residents, R1 and R2. LPN1 called her on 02/04/25 at 1 AM stating R2 walked out of [LPN] and [CNA's] sight and they got up and started looking for him down the hall. They walked around the building to ensure he didn't make it out of the building. Dogwood nurse, located him in R1's room, completely naked, on top of female resident. Female residents covers were pushed back, brief still on. The DON stated LPN1 yelled at him to get off her, and yelled for back up, and another nurse came in to assist the RN. LPN1 told me she assessed the resident. There was no evidence that he penetrated her. No redness, no discharge, no bruises. Female resident has dementia, and is not cognitive enough to say what would have happened to her. Male resident has psychosis issues, he had behavioral issues, however, not sexual, physical and verbal. The DON stated she hadn't had any issues with R2. The DON stated it was her decision to not send R1 to the hospital because R1 did not have redness, or injury. The DON stated her fear was that if R2 tried to do it and wasn't successful, he would try that with somebody else and didn't want him back at the facility. The DON stated R1's niece, who is a nurse in the facility and works on that unit messaged her on the following night, it was on 02/04/24, and she found out upon getting the report. She asked me if R1's daughter had been notified, and the nurse confirmed she hadn't called. The DON stated she would notify her the following day on 02/05/25. The DON further stated on 02/05/25, she called the daughter and apologized in regards to her not being notified the day it happened. The DON told the daughter, R2 walked in R1's room, had gotten in bed with R1, and her brief was still on. The DON stated R1's daughter requested R1 to be sent out. The DON stated she told the daughter that she was assessed twice by facility staff and there were no injuries and that the male resident was sent out that night. The daughter still wanted her mother to get sent out. During an interview with the Administrator on 02/27/25 at 3:40 PM, revealed she is familiar with both residents. The Administrator stated the DON told her that R2 went into R1 room. R2 wandered off from LPN1's sight and ended up in R1's room. R2 was found naked, at R1's bedside. The Administrator stated he was removed from the room. R2 was sent out to the hospital for further evaluation. R1 did not go, there was no indication it occurred. She was fine. She didn't remember anything having happened. On 02/28/25 at 1:25 PM, the facility provided an acceptable IJ Removal Plan, which included the following: - Resident #2 was sent to the Hospital Psychiatric Unit. - Resident #1 was checked for any signs and symptoms of abuse. She was sent to hospital for further evaluation. - Resident #1 did not recall the incident occurring. - All staff will receive additional training on Sexual Abuse by the Staff Development Coordinator starting 2/28/25 and will be completed by March 3, 2025. - The DON was provided with additional training on reportable incidents by the Administrator on 02/27/25. - The Administrator will be notified in addition to the Director of Nursing of all unusual occurrences involving two residents. - All staff will be educated to the update of this procedure by the Staff Development starting 02/28/25 and will be completed by March 3, 2025. - All incident reports will be brought to the Morning Meeting for review. - The Administrator will monitor these incidents to ensure that any resident/resident incidents were reported to her. Administrator will take findings of this monitoring tool to the QAPI committee monthly for three months and quarterly thereafter until the issue is deemed to require no further review. The facility alleges that we were in compliance on 02/28/25.

Based on review of the facility policy, record review, and interview, the facility failed to report to the State Survey Agency (SSA) an alleged incident involving sexual abuse, that occurred on 02/04/25. Findings include: Review of the undated facility policy titled Abuse and Neglect Prohibition, documented, Prevention 2.) Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring. The facility will report allegations and substantiated occurrences of abuse, neglect and misappropriation of resident property to the state agency and law enforcement officials designated by state law. The facility will report to the company management and legal departments in accordance with company reporting procedures. The facility will report any occurrences of abuse by registered or certified staff to the State Board as required by state law. Policies and facility procedure will be analyzed and modified as necessary by the QA&A Committee so as to meet the full intent of the law. Review of R1's HPI (History of Present Illness) dated 02/05/25, documented, [R1] is a 77 y.o. a female who presents to the emergency department today given concerns over a potential sexual assault. History somewhat limited as patient does have a history of dementia, I am told by EMS that her care facility reported to the family that another individual with dementia may have exposed himself and had been on top her two days ago, the family had requested that she be transferred to the emergency department for further assessment . Review of R2's HPI dated 02/04/25, documented, PT to ED via EMS from Brookview. Facility states pt had Aggressive behaviors. Spoke with case management regarding the patient no longer being accepted at BrookView due to sexual assault against another [NAME] of BrookView. Review of the Employee Statement Form written by Licensed Practical Nurse (LPN)1 on 02/04/25 at 1:00 AM, documented, On 2/4/25 at around 1 AM, . Staff was noted in room [ROOM NUMBER]. Particularly 157A in [R1's] room. This nurse noted [R2] standing beside of 157A'a bed with no pants on. [Registered Nurse (RN)1] explained she saw [R2] on top of [R1] when she entered the room then [R2] got up and got dressed. This nurse notified the DON and called EMS to transport resident to the hospital. [R1] was laying in bed on back. Upon inspection, resident noted to have brief intact, still adhered to both sides. The brief was pulled up the front, with the brief creating a thong like appearance, within the labia majoria. This nurse removed the brief. No redness, injuries, or bruising noted to the vulva or vagina area. Resident denied pain to that area. EMS arrived and escorted [R2] to ER. Review of an undated Employee Statement Form written by RN1, documented, Upon walking onto Peach Unit, I heard water running in 157 and knew neither resident could turn it on. When I opened the door the water in the sink was on and about to over flow. I then saw [R2] naked on top of [R1]. I told him to get off of her right now. [R1] was laying flat in bed with cover pulled off, gown pulled up and brief slightly pulled to the side. [LPN1] then called the DON and EMS. During a phone interview with the Ombudsman on 02/27/25 at 10:34 AM, revealed she is aware of the complaint involving Resident R1 and R2. The Ombudsman stated that R1's daughter had contacted her to make a complaint and told her that the police were investigating the complaint. The Ombudsman stated she could not recall the exact date; however, it was February 2025. The Ombudsman stated she came to the facility on [DATE], and no one at the facility reported anything to her regarding the incident that occurred between R1 and R2. The Ombudsman also stated she gave R1's daughter the department's information to submit an online submission. During a phone interview with R1's Representative (RP) on 02/27/25 at 10:28 AM, revealed that on 02/05/25, between 10:30 AM and 11:00 AM, the Director of Nursing (DON) contacted R1's RP via phone and said on Monday night 02/03/24, going into 02/04/25, R2 was completely naked, and was actively trying to get R1's brief off. The facility staff intervened and removed him from her room. Staff told her (R1's RP) they didn't think that it was a big enough deal and since they didn't find anything, it was not a reportable offense. During an interview, via phone, with LPN1 on 02/27/25 at 2:24 PM, LPN1 confirmed her statement. LPN1 stated she spoke to the DON, she and another nurse, and since her brief was intact, they didn't believe she was penetrated, or sexually assaulted which is why she was not sent to the hospital. LPN1 stated she spoke to the DON first, and informed she would take care of it all the following morning. LPN1 stated she did not notify R1's family. During an interview with the Director of Nursing (DON) on 02/27/25 at 12:19 PM, the DON stated she is aware of a situation between two residents, R1 and R2. LPN1 called her on 02/04/25 at 1:00 AM, stating RN1 located R2 in R1's room, completely naked, on top of the female resident. The female residents covers were pushed back, brief still on. There was no evidence that he penetrated her, no redness, no discharge, no bruises. The DON stated on 02/05/25, she called the daughter and apologized in regards to her not being notified the day it happened. During an interview with the Administrator on 02/27/25 at 3:40 PM, the Administrator stated the DON told her that R2 went into R1 rooms, R2 was found naked, at R1's bedside. The Administrator stated the DON is responsible for reporting, and this incident should have been reported, and is unsure as to why the DON did not.

Based on review of the facility policy, record review, and interviews, the facility failed to provide appropriate supervision to prevent Resident (R)1's elopement from the facility. Resident (R)1 had a successful elopement from the facility on 01/25/2025 and was without supervision for a period of time. R1 was last seen ambulating in the hall around 6:00 PM by a Certified Nursing Assistant (CNA). Approximately around 7:00 PM, CNA1 noticed that R1 was not in her room and alerted a nurse. The unit and facility was searched, R1 was not found to not be on the premises. R1 obtained a ride from college students located at the neighboring apartment and went to her friend's house. R1 was returned to the facility by local police with a bruise to her right eye, right hand, and right arm. On 01/29/2025 at approximately 5:34 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 01/29/2025 at 5:52 PM, the Administrator was notified that the allegation of elopement for R1 constituted Immediate Jeopardy (IJ) at F689 and the IJ template was presented. On 01/29/2025 at 7:07 PM, the facility provided acceptable plans of removal for the IJs. Review of the facility's removal plan and verification of implementation determined the facility had corrected their own deficiency, related to the IJ being identified as Past-noncompliance. An extended survey was completed on 01/31/2025 due to the failure constituting substandard quality of care. Findings include: Review of the facility's policy titled, Elopement Response Guidelines, effective date 05/01/2006 stated, It is the responsibility of all staff to provide a safe environment for all residents. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: generalized anxiety disorder, vascular dementia, and unspecified dementia with other behavioral disturbance. Review of R1's Elopement Evaluation dated 01/23/2025 revealed R1 had no elopement risk factors, and an elopement care plan was not required. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date of 11/02/2024 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive impairment. Further review of the MDS revealed there were no wandering behaviors exhibited. Review of R1's Progress Note dated 01/25/2025 at 9:00 PM revealed, Resident noted to be upset about a dress that belonged to another resident. Resident was last seen by this nurse on the peach unit around 5:30 pm - 6:00 pm talking to staff. At 7:00 pm, certified nursing assistant (CNA) alerted staff that she was unable to find resident. Staff immediately searched all rooms and the entire facility. Upon searching staff noticed resident's walker on the hill, next to apartment buildings. While staff continued to search, some college students stated they had seen the resident and gave her a ride to her preferred address. Resident's family was updated throughout the process. Director of Nursing (DON) and administrator notified. DON notified provider staff. Review of R1's Progress Note dated 01/25/2025 at 9:41 PM revealed Resident returned to facility in the custody of local police authorities. Resident returned with bruising around eye, bruising noted to back of right hand and right forearm, and a kerlix wrapped around her left forearm. DON present during this time and is aware. DON walked resident to her room and spoke with resident outside of her room in the hallway prior to leaving facility for the night. Resident took her medications whole without difficulty, vital signs stable. No complaints of pain or discomfort noted. Notified responsible party of patient return. Review of Blue Ridge Palmetto Elopement Event Sheet dated 01/25/2025 revealed, Resident left the facility. Contributing factors: Dementia and Anxiety Disorder. Yes, was selected to there being recent events, trauma, new diagnosis, or other stressors/losses. Description given; resident was upset about a dress that does not belong to her. During an interview on 01/29/2025 at 1:17 PM, Licensed Practical Nurse (LPN)1 revealed, I am familiar with the incident. It was my first time on that unit. As I walked in and getting report, the oncoming CNA did rounds and noticed that the resident was not there. The day shift nurse was still there, and we were in the middle of report. We started searching for the resident. We went in all the rooms on the unit, then the facility. We walked outside and the nurse noted the walker on the hill going toward the apartments. The nurse notified every one of her rollator. Staff member went and knocked on doors and ended speaking with college students. They said we seen her out here and we gave her a ride. She told them where she wanted to go. The college kids took her to the address. When she got there the occupants of the house let the resident in and they left. I went back into the facility to see that the police and the Director of Nursing (DON) was in the facility. When the resident returned, she had bruising on her right hand and right arm. She had an eye that was bruised, and kerlix wrapped on the left arm. I assessed what I seen and the DON walked her to her room. The resident was rowdy about an incident that happened prior to her leaving. She was upset and wanted to leave because of it. It was about a dress, but she was going on about other things. The DON is the person who calmed her down and we assisted her to bed. During an interview on 01/29/2025 at 1:55 PM, the DON revealed, Yes, I am familiar with the incident. I received a phone call saying they were unable to find R1. They checked the unit and facility. Code Dr Hunt (the elopement code) was started, and a nurse found her walker that was on the hill towards the apartment building. The police were already notified. I went to the Magnolia unit then to the apartments. A girl stated that an elderly lady came to her door and said her car broke down. Police officer was there and got the address and went to the address given. Resident had on Sketchers tennis shoes, a long sleeve shirt, a sweater, and a pocketbook, upon her return. She never had signs of elopement and we never had an issue prior to the dispute about a dress. She stated, She did not want to be here anymore, and her daughter told her to leave this place then. R1 was last seen around 6 PM and she returned to the facility at 9:15 PM. We changed the wander guards because of the door will alarm. If they hold the door, it will open, but it will alarm. During an interview on 01/29/2025 at 2:17 PM, CNA1 revealed, I came in and I started picking up trays. I went to her (R1) room, and I seen that it was dark, and her tray was not touched. I asked the nurse where R1 was located. I was told that she was in her room. I checked the rooms on the floor. We did a Dr. Hunt, she was not in the facility, so we went outside and searched. It was cold that day. The last CNA to see her was around 6 pm. We found her walker on the hill going up towards the college apartments. I spoke with the college kids, and they told me that she asked them for help to go to (a friend's house). They gave her a ride to her friend's home. We got the address to where she was. It took the sheriff a while to bring her back. She was determined not to return, and she stated that if she gets another chance she will not come back. There is a problem with the door lock on the Peach Unit. It has been reported, and they told me that it has been checked by maintenance. I told them that it is a problem and that is where she got out at. During an interview on 01/29/2025 at 2:31 PM, R1 revealed, I left the facility because I went to the section to play some games. People steal here and I asked a good friend to watch my purse. They keep stealing my food, my clothes and my money. I told the three nurses at the nurse's station. A man punched the door code, and I went out. The only reason they knew to find me was because of my daughter. It was dark and my way was lit by the moon. I went up the hill to not be seen by the people at this facility. I tried to push the rollator up the hill but could not, so I tried to pick it up and I hit my eye. I left because they do nothing for you. I did not see anyone and then I seen a man. I asked him to take me to my girlfriend's house. He got another boy and girl, and they told me they go to Limestone College. They drove me to my girlfriend's house. I will not answer the question if I will try to leave again. The facility's plan of removal included the following: The immediate action taken for this deficient practice include the following: -A body audit was done on Resident #1 upon return to the facility. -Resident was placed on 15 minute checks. -Emotional support was provided to resident by the Director of Nursing. -Inservice was completed 1/25/25-1/26/25 to all staff by the Staff Development Coordinator and Director of Nursing on CMS guidelines regarding elopement. -Maintenance staff checked and recorded that all doors on units with residents who are at risk for elopement were found to be in working order. Facility recognizes that all residents have the potential to be affected by this deficient practice. Measures put into place to ensure that this deficient practice does not reoccur include the following: -A professional contractor was brought into the building to inspect all alarms and provide any work required if issues were found. -The facility requested a quote from the contractor to upgrade all door monitoring alarms in the facility. Monitors to be put in place to ensure the deficient practice does not reoccur include: -Door alarms inspections were increased from weekly to daily by the maintenance staff. -Inservice will be provided to staff regarding any issues with the doors/alarms must be reported directly to the Director of Nursing or Administrator. -The facility has set the TELS system, used to document the completion of the monitoring, to alert the administrator via e-mail and mobile application that the task was completed. Administrator will take findings of this monitoring tool to the QAPI committee monthly for three months and quarterly thereafter until the issue is deemed to require no further review. The facility alleges compliance on 1/26/2025.

Based on observation, interview, review of facility policy, and review of the Centers of Disease Control (CDC) recommendation for Food Safety, the facility failed to ensure that food items were properly stored and maintained below 41 Degrees Fahrenheit (F) to reduce the potential of foodborne illnesses. The facility further failed to ensure that monitoring of kitchen equipment (refrigerators and freezer) was completed accurately for 1 of 1 kitchen. On [DATE] at 1:30 PM, the Administrator was notified that the failure to ensure food items were properly stored and maintained below 41 Degrees Fahrenheit (F) and the failure to ensure the monitoring of kitchen equipment was completed accurately constituted Immediate Jeopardy (IJ) at F812. On [DATE] at 1:30 PM, the survey team provided the Administrator and Director of Nursing (DON) with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to S483.60 - Food and Nutrition Services. On [DATE], the facility provided an acceptable IJ Removal Plan. On [DATE] at 11:50 AM, the survey team validated the facility's corrective actions and removed the IJ as of [DATE]. The facility remained out of compliance at a scope and severity level of F. Findings include: Review of the facility policy titled, Food Storage revealed, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and by methods designed to prevent contamination. Procedures include, Temperature for refrigerators should be 41 degrees F and below. They must be recorded daily. Every refrigerator must be equipped with an internal thermometer. Cooked foods must be stored above raw foods to prevent contamination. Freezer temperatures: Temperatures for freezer be 0 degrees or below and must be recorded daily. Holding temperature for frozen foods is 0 degrees or below. Frozen meats must be defrosted in a refrigerator on tray on a lower shelf. Every freezer must be equipped with an internal thermometer, even if equipped with an external thermometer. Chemicals must be clearly labeled, kept in original containers when possible, and kept in a locked area away from food. Review of the facility policy titled Hair Restraints revealed, Hair restraints shall be worn by all Dining Services staff when in food production, dishwashing areas or when serving food from the steam table. Procedures include, Staff shall wear restraints in all food production, dishwashing and serving areas. Hair restraints, hats, and or bear guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged, any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. Review of the facility policy titled Refrigerator and Freezer Temperatures revealed, A food item is selected, and the temperature is taken. If this is the first check of the day, and the food item(s) are below 41 F and cannot be validated to have been below 41 F for less than four hours, the food is discarded. If this is a visual check during normal operating hours, and the food is below 41 F the staff member will validate if it has been in the danger zone for four or less the product is moved to another refrigerator/freezer and monitored to cool to proper temperature within four hours. If the food is below 41F the unit will be emptied and the food stuff transferred to another refrigerator/freezer and the unit locked out/tagged out per facility policy. Food stuff will be transferred back into the refrigerator/freezer until it is repaired and returned to service or until the temperature reaches and maintains the appropriate temperature. Review of the Centers of Disease Control (CDC) recommendation for Food Safety revealed, CDC Steps to Food Safety . Prevention Steps and Strategies dated [DATE] revealed, Chill: refrigerate promptly. Bacteria can multiply rapidly if left at room temperature or in the Danger Zone between 40 F and 140 F. Never leave perishable food out for more than 2 hours (or 1 hour if exposed to temperatures above 90 F). Keep your refrigerator at 40 F or below and your freezer at 0 F or below and know when to throw food out before it spoils. If your refrigerator doesn't have a built-in thermometer, keep an appliance thermometer inside it to check the temperature. Package warm or hot food into several clean, shallow containers and then refrigerate. It is okay to put small portions of hot food in the refrigerator since they will chill faster. Refrigerate perishable food (meat, seafood, dairy, cut fruit, some vegetables, and cooked leftovers) within 2 hours. If the food is exposed to temperatures above 90 F, like a hot car or picnic, refrigerate it within 1 hour. Thaw frozen food safely in the refrigerator, in cold water, or in the microwave. Never thaw food on the counter because bacteria multiply quickly in the parts of the food that reach room temperature. During an initial tour of the kitchen on [DATE] at 10:43 AM, the dry food storage revealed the following: ,d+[DATE] oz (once) dented can of corn beef hash. ,d+[DATE] oz dented can of sliced carrots. ,d+[DATE] oz box of instant mashed potatoes on the floor. 14 boxes of [NAME] oatmeal with a best by date of [DATE]. ,d+[DATE] lb (pound) box of premium parboiled rice opened, with no open date and not sealed. ,d+[DATE] lb boxes of lasagna noodles open, not sealed or labeled with an open date. ,d+[DATE] lb bags of penne pasta open and not labeled. ,d+[DATE] oz box of raisins opened and not sealed. ,d+[DATE] oz boxes of raisins with a best by date of [DATE]. ,d+[DATE] lb packages of spaghetti noodles opened, not sealed, and not labeled. 1 package of 5 burrito wraps opened with no open date and not sealed. Sugar bin not labeled and no scoop. During an observation and interview with the Dietary Manager (DM) on [DATE] at 10:50 AM, the walk-in refrigerator revealed the internal thermometer temperature reading at 60 F. Further observation revealed the refrigerator ceiling fans motor cover has ice accumulated on its surface and was actively defrosting, with a black substance coating the pipes connected to the fan. The DM revealed that the veggie walk-in refrigerator had been down but came back up today. The DM states that they receive deliveries three times a week and staff check for outdated items in the refrigerator once a week. During an observation on [DATE] at 10:55 AM, of the walk-in refrigerator revealed the following food items that were expired/not properly labeled and or stored: ,d+[DATE] lb containers of cottage cheese with a best by date of [DATE]. ,d+[DATE] lb container of cottage cheese with best by date of [DATE]. ,d+[DATE] lb boxes of macaroni salad with a use by date of [DATE]. 7 prepared bowls of salad not dated. During an observation on [DATE] at 11:37 AM, of the meat freezer, revealed a puddle of water on the floor and approximately 40 boxes of food items actively defrosting, with some boxes having water damage and dripping with water. Further observation revealed the following food items were not properly stored 3 bags of garlic bread opened with no open date. ,d+[DATE] lb bags of sweet peas not properly stored. ,d+[DATE] lb bags of white diced chicken meat not properly stored. Further observation of the meat freezer revealed the internal thermometer was unreadable, the outside digital thermometer displayed an error code (APn6). The temperature log for the meat freezer for [DATE] documented, -3 F. During an interview with the DM and Maintenance Manager on [DATE] at 11:55 AM, revealed the first shift cook checked the meat freezer temperature when she arrived this morning. There were no issues with the temperature. The DM further explained that there is more food in the meat freezer due to the veggie freezer being down and that there is never usually any water on the floor. During the interview the Maintenance Manager stated, I think they had the door open for a long period of time. During an observation and interview on [DATE], during the lunch meal prep, revealed Kitchen Staff (KS)1 prepping food without a beard restraint. KS1 stated that male staff are expected to wear beard restraints when prepping food. KS1 put on a beard guard after the interview. During a follow up interview with the DM on [DATE], revealed that staff members are expected to cover all hair, including facial hair. During an observation on [DATE] at 1:00 PM, the stand-up freezer revealed an internal thermometer temperature of 52 F and the external thermometer gauge reading at 43 F. During an observation on [DATE] at 1:01 PM, the ice cream freezer revealed an internal thermometer temperature of 52 F and the external thermometer gauge reading at 43 F. During an observation on [DATE] at 1:10 PM, the walk-in cooler revealed the internal thermometer reading at 50 F and the external thermometer gauge reading at 43 F. Review of the temperature log for the meat walk-in freezer for [DATE], revealed the following: [DATE] the morning/AM temperature was documented at -3 F. [DATE] - [DATE] the afternoon/PM logs were incomplete. Review of the temperature log of the stand-up freezer for [DATE], revealed missing initials for morning/AM temperature checks on [DATE] - [DATE]. Review of the temperature log for the ice cream freezer for [DATE], revealed the following: [DATE] - [DATE] missing morning/AM documentation. Review of the temperature log for the veggie freezer for [DATE], revealed the following: [DATE] no morning documentation; afternoon/PM (DOWN). [DATE] no documentation. [DATE] no morning documentation; afternoon/PM (DOWN) [DATE] no afternoon/PM documentation. [DATE] no morning/AM documentation. [DATE] no documentation. [DATE] no morning documentation; afternoon (DOWN). During an interview on [DATE] at 1:51 PM, the DM revealed there were no issues with neither the refrigerator nor freezers this morning. The DM continued to explain that when there is an issue, kitchen staff notifies them immediately and they call maintenance. During an interview on [DATE] at 1:55 PM, the 2nd Shift [NAME] revealed today's dinner will be a cold plate with deli sandwiches, macaroni salad and cucumber salad with an alternative of patty melts, scallop potatoes, and carrots. The 2nd Shift [NAME] stated they only had to prepare the sandwiches, patty melts and scallop potatoes. The 2nd Shift [NAME] further stated the macaroni salad and cucumber salad were prepared yesterday, we usually prepare those items a day in advance. The 2nd Shift [NAME] concluded temperatures for the refrigerators and freezers were already completed when they arrived to work today and they check them and document them daily at night before the they leave. During an interview on [DATE] at 1:59 PM, the Maintenance Director revealed they were unaware of any issues with the refrigerator/freezer, and there were no issues earlier this morning. During an observation on [DATE] at 2:11 PM, revealed the walk-in cooler internal thermometer reading at 55 F. During this observation, a green sanitizing bucket was observed next to a container of sliced cucumbers and boiled eggs. Additionally, there was a moist towel above the container storing boiled eggs. During an observation on [DATE] at 2:22 PM, revealed the stand-up freezer internal thermometer temperature at 30 F. The vegetable freezer revealed an internal thermometer temperature of 30 F. During a phone interview on [DATE] at 2:32 PM, the 1st Shift [NAME] stated, I check freezer and refrigerator temperatures when I use them. The 1st Shift [NAME] further stated the freezer on the porch wasn ' t' freezing well and staff noticed the issue on Friday [[DATE]], they had to throw away a few wet boxes because they were defrosting in the freezer. The 1st shift [NAME] recalled throwing away food yesterday [[DATE]], due to the defrosting food items. The 1st Shift [NAME] concluded they notified the DM about the freezers and was told that it was reported to Maintenance Staff. During a phone interview with the Registered Dietician (RD) on [DATE] at 2:56 PM, revealed the RD was made aware of the kitchen equipment (cooler/freezer) not reaching an adequate temperature of 41 F or below. The RD stated that she recommended the facility use the emergency food supply for the dinner meal to ensure foods will be stored/served at the appropriate temperature. During an observation and interview with the DM on [DATE] at 3:22 PM, revealed the kitchen staff plan to serve cold items as planned since cold items were prepared prior to the refrigerator/freezers malfunction. Additionally, the DM revealed the cold food items have been placed into the veggie cooler to cool down. The DM stated that the menu for the dinner meal is deli sandwiches, macaroni salad, cucumber salad, scallop potatoes, carrots, and bean salad. The DM stated the macaroni salad and cucumber salad were prepared in advance, and the carrots and bean salad were from the canned goods/emergency supply. The concluded tomorrow's meal ([DATE]) would be changed due to the lack of working equipment and that the food items would come from the facilities emergency supply. During an observation of the walk-in cooler, where the macaroni salad and cucumber salad were stored, revealed the internal thermometer temperature of 55 F. During an interview on [DATE] at 4:08 PM, the Administrator revealed they were made aware of the issues in the kitchen related to the refrigerators and freezer today. The Administrator stated that the cold items that were prepared yesterday such as the macaroni salad and cucumber salad would be served tonight since they were prepared before the appliances malfunctioned and that the facility would serve food from their emergency supply tomorrow, until the temporary portable freezers were delivered to the facility by their food vendor. During an observation on [DATE] at 4:32 PM, of the 2nd Shift [NAME] conducting holding temperature checks of the dinner meal, revealed the following: Pasta Salad Puree - 46 F. Deli Meat Puree - 45 F. Macaroni Salad - 68 F. Deli Sandwiches - 58 F. Cucumber Salad - 62 F. All items were discarded after observation. During an interview with the 2nd Shift [NAME] on [DATE] at 4:35 PM, the 2nd Shift [NAME] revealed the cold items were prepared the day before and had been sitting in the walk-in cooler all day and was moved into the stand-up refrigerator about an hour ago. During an observation on [DATE] at 4:39 PM, revealed the stand-up refrigerator had an internal thermometer temperature of 50 F. During an observation on [DATE] at 4:50 PM, revealed the meat freezer had an internal thermometer temperature of 30 F. During an observation on [DATE] at 4:51 PM, revealed the stand-up refrigerator had an internal thermometer temperature of 50 F, and the external thermometer gauge reading was 45 F. During an observation on [DATE] at 4:53 PM, revealed the walk-in refrigerator had an internal temperature of 52 F. And the veggie freezer revealed an internal thermometer temperature of 20 F. During an observation and interview on [DATE] at 5:00 PM, the Administrator was informing them (kitchen staff) the food that was planned for the dinner meal no longer meet the requirements of being served safely according to the CDC standards and federal regulation. The Administrator stated the kitchen staff will not serve that meal and will prepare a different meal using their emergency food supply. During an interview on [DATE] at an unspecified time, Resident (R)220 stated, The food is awful, for example the toast is rubbery and scrambled eggs are nasty. I was recently (within the last week but unsure of which day) given spoiled milk and it wasn't expired but the taste and smell was disgusting. R220 further stated that they spoke with someone from the kitchen related to the food and substitutions, and for a few days the food improved. Now, they are serving foods that don't match his preferences. Review of R220's Face Sheet revealed R220 was admitted to the facility on [DATE], with diagnoses including but not limited to: muscle weakness, pain, and lack of coordination. Review of R220's Admission Minimum Data Set (MDS) with an Assessment Reference Date of [DATE], revealed R220 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicates R220 is cognitively intact. During an interview on [DATE] at an unspecified time, R37 revealed their lunch and dinner meal is always served cold. R37 further stated at times they are not able to identify what they are being served and calls it mystery meat. Review of R37's Face Sheet revealed R37 was admitted to the facility on [DATE], with diagnoses including but not limited to: dementia without behaviors, muscle weakness, and type 2 diabetes. Review of R37's Quarterly MDS with an ARD of [DATE], revealed R37 has a BIMS score of 14 out of 15, which indicates she is cognitively intact. During an observation and record review on [DATE] at 9:30 AM, revealed the meat freezer external thermometer was malfunctioning, displaying an error code APn6, the internal thermometer reading was 10 F. Review of the [DATE] Meat Freezer Temperature Log for [DATE], revealed a documented temperature of -3 F with no initials for who documented the log. During an observation and record review on [DATE] at 9:53 AM, revealed the walk-in refrigerator's internal thermometer temperature reading at 50 F and the external thermometer gauge reading at -40 F. Review of the Walk-In Refrigerator [DATE] Temperature Log, revealed no documentation for the morning log on [DATE]. During an observation and record review on [DATE] at 9:54 AM, revealed the stand-up refrigerator had no food items at this time, the internal thermometer temperature read at 70 F. Review of the [DATE] Stand-Up Refrigerator Temperature Log revealed the log for [DATE] was 42 F. During an interview on [DATE] at 9:55 AM, the DM revealed the temperature for the stand-up refrigerator was reading 50 F this morning. The DM states she was notified by the first shift cook, who came in at 5:00 AM, of the temperature of the refrigerator when she (DM) came in at 7:00 AM. The DM revealed the food that was in the stand-up refrigerator was moved to a refrigerator on one of the halls and what couldn't fit was discarded. The DM explained the residents were served bacon, sausage and eggs which were pulled from the stand-up refrigerator, along with oatmeal and grits that came from the dry storage for breakfast. During an interview on [DATE] at 10:00 AM, the 1st Shift [NAME] revealed for breakfast the residents were served bacon, sausage, eggs, grits, and oatmeal. The 1st Shift [NAME] stated the bacon, and sausage were pulled from the stand-up refrigerator and the eggs came from the walk-in refrigerator. The 1st Shift [NAME] stated the temperatures for the freezers should be -3 F and the refrigerators should be 40 F, I think. The 1st Shift [NAME] further explained, I write down the temperatures that are shown on the outside of the freezers and refrigerators. The 1st Shift [NAME] confirmed that they documented the temperature for the meat freezer this morning was -3 F and the temperature for the stand- up refrigerator was 42 F. When asked if the stand-up refrigerator's temperature was reading 42 F, was that temperature too high to use the food from that refrigerator, the 1st Shift [NAME] responded, No, I don't think it was too high. During an interview with the DM on [DATE] at 10:07 AM, revealed the temperatures for the freezers should be below zero and the refrigerator temperatures should be below 40 F or 41 F. The DM further stated that the food from the stand- up refrigerator was moved as fast as possible to a refrigerator on the unit and the rest was thrown away if it couldn't fit. The DM stated for lunch today they will be using the emergency supply and they used liquid eggs and that the food needed for today's breakfast was pulled from the walk-in refrigerator the night before to make it more convenient for the cook to start their prep when they come in. When asked if the food from the stand-up refrigerator, which had a temperature of 42 F, should have been used to serve the residents, the DM replied, probably not. During an observation on [DATE] at 11:27 AM, the 1st Shift [NAME] and DM, during the lunch meal temperature observation, revealed the following items not at the appropriate temperature and were discarded: Milk - 44 F. Cranberry Juice - 47 F. Mighty Shake (nourishment drink) - 46 F. Further observation and interview with the DM revealed that those drinks were pulled from the walk-in cooler. During observation of the walk-in cooler, the internal thermometer temperature had a reading of 55 F. The DM confirmed that the temperature in the refrigerator was higher than recommended. During an observation and interview on [DATE] at 12:00 PM, of the refrigerator in the Therapy Room on the Peach Unit revealed the food that was moved earlier from the stand-up refrigerator in the kitchen. Further observation revealed a pan of scrambled eggs, 1 pan of sausage, 1 pan labeled pureed bacon, 1 pan labeled pureed meat, and a bag of salad mix. The DM revealed that deliveries are received on Monday, Wednesday, and Friday. An order was placed on Monday and a delivery will come on Wednesday, they will place an order on Wednesday to replenish the emergency supply. The internal temperature of the Therapy Room Refrigerator was at 41 F, there was no documentation related to daily logs of the temperature for this refrigerator. During an interview on [DATE] at 1:25 PM, the 1st Shift [NAME] revealed they documented the temperatures for the refrigerators and freezers by reading the external thermometer. During the interview the survey team asked how they were able document the temperature of the meat freezer due to the error code and they stated that they were unsure. During an observation on [DATE] at 11:20 AM, of the lunch meal temperature check revealed the temperature of the toss salad was 71 F, and was discarded after observation. During an observation and interview on [DATE] at 5:50 PM, revealed the walk-in cooler had an internal thermometer temperature of 47.5 F. The DM confirmed the current temperature of the walk-in cooler was out of compliance. The DM further stated the food in the walk-in cooler was delivered earlier in the morning and the food would have to be discarded. During an observation on [DATE] at 6:00 PM, the Administrator was informing the kitchen staff that the Immediate Jeopardy is still on-going due to the non-compliance in the kitchen because of improper temperatures in the walk-in cooler. The Administrator further informed the kitchen staff the shipment that arrived earlier would have to be discard. During an observation and interview on [DATE] at 11:46 AM, the Walk-In Cooler, Meat Freezer, and Stand- Up Refrigerator (all malfunctioning) were empty. The Veggie Freezer read 0 F. Observation of the Temporary Refrigerator revealed an internal temperature of 40 F (observation during lunch time and staff using this fridge to prep). The DM revealed that all food being prepped is coming from the Temporary Refrigerator and Veggie Freezer. 49818 On [DATE], the facility provided an acceptable IJ Removal Plan which included the following: Inservice was completed on [DATE], to 100% of the dietary staff by the Staff Development Coordinator on CMS guidelines. Refrigerator temperatures are to be maintained at 41F. Freezer temperatures are to be maintained at 0F. Temperatures are to be recorded: first shift, midday, and end of second shift. If any temperatures do not fall within guidelines, the supervisor is to be notified and use emergency food supply. Do not use food from equipment that does not meet regulatory temperature. A new refrigerator and freezer temperature log were created, specific instructions were placed on the logs regarding required temperature and actions to take if temperature does not meet regulation. 100% present of staff were in-serviced under the new temperature log on [DATE]. New logs were implemented on [DATE]. Facility recognizes that all residents have the potential to be affected by this deficient practice. Measures put into place to ensure that this deficient practice does not occur again include the following: education to dietary staff on proper storage and maintenance of food will be provided upon hire and annually. Dietary staff will be required to complete an annual competency on these requirements. Education was provided to staff on taking food temperatures prior to servicing and recording with every meal. Unannounced observations of temperature logs will be conducted by the Administrator, Dietary Manager, and Registered Dietician. Dietary Manager was re-educated on [DATE] on the maintenance system which identifies maintenance needs in all departments. Monitors to be put in place to ensure the deficient practice does not reoccur include new temperature logs were created and implemented. Re-education on the maintenance system and unannounced observations. The Dietary Manager will be informed of any adverse findings, re-education will be provided. Results of these audits will be brought to the Quality Assurance and Performance Improvement (QAPI) committee monthly for the next months and quarterly thereafter until the issue is deemed to require no further review. Other actions taken include: A contracted refrigeration repair service was called to the facility and repairs were provided on [DATE] and [DATE]. All refrigeration equipment in the facility was checked by contracted refrigeration technician. All food in the effected freezer and refrigerator was discarded. Emergency food supplies were utilized until the new refrigerator was installed and brought to proper temperature. Temporary refrigerator was purchased and installed on [DATE]. The facility obtained new perishable food and placed them in the new refrigerator until food supplies are delivered from distributor on [DATE].

Based on record review and interviews, the facility failed to provide a policy related to the handling of or monitoring of outside food bought into the facility, for 1 of 1 main kitchen. Findings include: During an interview on 08/14/24 at 11:27 AM, the Dietary Manager (DM) revealed the facility does not have a policy related to personal food. During an interview on 08/14/24 at 2:35 PM, the Administrator revealed there is no policy related to monitoring outside food coming into the facility.

Based on interview and record review, the facility failed to have appropriate Registered Nurse (RN) staffing for 8 hours a day, for 3 of 6 days reviewed Findings include: Review of facility daily schedule for 01/17/24, revealed the facility did not have a registered nurse in the facility for 8 consecutive hours. Review of facility Patient Per Day Posting for 01/17/24, revealed the facility did not have a registered nurse in the facility for 8 consecutive hours. Review of facility daily schedule for 02/10/24, revealed the facility did not have a registered nurse in the facility for 8 consecutive hours. Review of facility Patient Per Day Posting for 02/10/24, revealed the facility did not have a registered nurse in the facility for 8 consecutive hours. Review of facility daily schedule for 02/24/24, the facility did not have a registered nurse in the facility for 8 consecutive hours. Review of facility Patient Per Day Posting for 02/24/24, the facility did not have a registered nurse in the facility for 8 consecutive hours. During an interview on 08/15/24 at 3:59 PM, the Director of Nursing (DON) revealed that the facility does not have a policy related to staffing and that they follow the federal regulation. During an interview on 8/15/24 at 4:21 PM, the DON and Staffing Coordinator revealed it is expected to have 8 hours of RN coverage every day. The DON and Staffing Coordinator revealed that the facility did not have an RN for 8 consecutive hours for the following days: 01/27/24, 02/10/24 and 02/24/24.

Based on review of the facility policy, record review, and interview, the facility failed to prohibit misappropriation of property for 2 of 2 residents ((R)3 and R4) related to missing medications. Findings include: Review of the facility policy titled, Medication Administration: General Guidelines (Revised 04/10/2019) stated, Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Review of R3's medical record revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to; anxiety, pain, chronic obstructive pulmonary disease and gastro-esophageal reflux disease. Review of R3's Physician Orders revealed an order for, Hydrocodone-acetaminophen 7.5-325 mg (milligrams); take 1 tablet twice a day for severe pain. During an interview on 03/11/24 at 2:16 PM, R3 stated, I did not get my medicine on 11/27/23. I am unsure of the type of medication, but I was in a lot of pain from my sciatic nerve. She stated this was the only time she recalls not getting her medication. During record review for 03/11/24 at 2:30 PM, review of the Controlled Drug Record for R3 showed HYDROco/APAP Tab 7.5-325 mg 1 tab by mouth twice daily as needed. The medications were signed for on the following dates: 11/22/23 at 0900, 1700 (5 PM)- 1 tablet removed with unrecognized signatures 11/24/23 at 0800- 1 tablet removed, unrecognized signature 11/25/23 at 1900 (7 PM)- 1 tablet removed, unrecognized signature 11/26/23 at 1300 (1 PM)- 1 tablet removed Agency Nurse signature Review of the Medication Administration Record (MAR) revealed there was no administration of the medication. Review of R4's medical record revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to; left femur fracture, muscle weakness, and left hip pain. Review of R4's Physician Orders revealed an order for, Hydrocodone-acetaminophen-Schedule II tablet; 7.5-325 mg; amount 1 tablet oral every 8 hours. During an interview on 3/11/24 at 2:20 PM, R4 stated I was in pain and did not receive medicine on 11/27/23. She said this was the only time she recalls not getting her meds. Review of the CDR for R4 revealed, HYDROco/APAP Tab 7.5-325mg 1 tab by mouth every 8 hours for 30 days. The medications were signed for on the following dates: 11/25/23 at 0800- 1 tablet removed, unrecognized signature 11/25/23 at 4 PM- 1 tablet removed, unrecognized signature 11/26/23 at 1200- 1 tablet removed, unrecognized signature 11/26/23 at 0800-1 tablet removed, Agency Nurse signature 11/26/23 at 1600 (4 PM)-1 tablet removed, Agency Nurse signature Review of the Medication Administration Record (MAR) revealed there was no administration of the medication. During an interview on 3/11/24 at 3:11 PM, the Director of Nursing (DON) stated, The cart count was correct per the third shift nurse. The third shift nurse saw that medications were signed out crazy. The medications were signed out with dates off and the signatures didn't match. During a phone interview on 3/11/24 at 3:46 PM, an attempt was made to contact the alleged Nurse through the staffing agency. Per the Regional [NAME] President of the staffing agency, she stated We are unable to give out that information. I can pass it up to get permission. She stated to send additional information via email.

Based on observation, interview, and review of facility policy, the facility failed to: 1. ensure foods stored in the freezer and dry storage were labeled, dated, and resealed closed when opened; 2. ensure cleanliness of dishes was maintained and all pans and dishes were air dried before stacking the items; 3. ensure equipment was in working order; and 4. ensure the correct size spoons and ladles were used for portion sizes. These failures had the potential to affect 71 out of 73 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's policy, Sanitizing Flatware, not dated, revealed The following procedure will be used to sanitize flatware .After washing, allow to air dry. Review of the facility's policy, Pot and Pan Washing, not dated, revealed Pots and pans must be air dried .Dish towels must never be used. The following observations in the kitchen were made with and verified by Cook 2 and/or the Dietary Manager (DM). 1. On 07/06/22 at 9:30 AM, the dry storage room contained one large plastic bin of salt that was not sealed closed. The following items were not labeled and dated: one bag of gravy mix, one chocolate cake mix, and a plastic sugar bin. A bin that contained food thickener was dated 05/21/21. The freezer contained one bag of waffles, one bag of biscuits, one bag of pork patties, and one bag of chicken that was not labeled, dated, or sealed closed. The opened bags of food all contained ice from being left open. The refrigerator had a container of pureed strawberries with a date of 06/02/22 and a deli salad container with no label and/or date. 2. On 07/06/22 at 9:30 AM, there were five wet loaf pans, and seven wet bowls observed stacked together. The lids used to cover the plate warmers were dirty with food debris. Observation and interview on 07/08/22 at 12:16 PM revealed Dietary Aide (DA) 2 collecting clean bowls and using her fingers to hold multiple bowls at one time. DA2's fingers were touching the inside of the bowls, and she did not have on gloves. Continued observation revealed DA2 drinking a cold drink that was located on a shelf under the tray line. When asked if she was supposed to have a drink in the kitchen while working on the tray line, she stated she was hot. Observation was made of DA2 using a cloth to dry a serving spoon. The DM instructed DA2 to wash the spoon again. 3. On 07/06/22 at 9:30 AM, the last compartment on the steam table was not working, so staff added boiling water to the compartment to keep the food hot. The plate warmer was not turned on. Observation and interview on 07/08/22 at 11:55 AM, revealed Cook 1 taking the temperature of the Brussel sprouts while on the stove with an open flame. When asked if this is how she usually temps the food, Cook 1 stated No. 4. Continued observation on 07/08/22 at 11:55 AM revealed five ladles and spoons that had been gathered for use in the food line were the incorrect size for proper portion sizes. When Cook 1 was asked what the serving size should be used, she did not know so the DM obtained the correct serving spoon or ladle to use. During an interview on 07/08/22 at 12:26 PM, the DM had no comment about the observations. Interview with the Administrator on 07/08/22 at 4:23 PM revealed that she stated, My expectations are that the regulations are to be followed. There is no excuse.

Based on observations, staff interviews and policy review, the facility failed to maintained infection control practices by not demonstrating proper hand hygiene, failed to ensure frequent daily cleaning of high touch surfaces and failed to ensure access to hand sanitizer was readily available. This had the potential to affect all residents and staff in the facility. This deficient practice occurred during the COVID-19 pandemic. The findings included: 1. During a tour of the Magnolia and Dogwood Units on 06/13/2020 starting at 5:42 PM, it was noted that hand sanitizer dispensers were located inside of residents' rooms but none on the hallways. There was a breezeway between the two units. Anyone entering the unit had to enter numbers on a keypad and turn doorknob twice to exit the building and enter the next building. On 06/13/2020 at 5:50 PM, while exiting the Magnolia Unit, it was noted there was no hand sanitizer to perform hand hygiene after touching the keypads and doorknobs. The first visible hand sanitizer dispenser, that was not in a resident's room, was located behind the Dogwood Unit's nurses' station, approximately 75 feet from exiting the Magnolia Unit. Near the nurses' station, approximately another 25 feet, was an exit door with a standing hand sanitizer dispenser in the vestibule. A code was needed to unlock the door to access the dispenser. A restroom was across from the nurses' station, but it required a key to unlock it to access soap and water to wash hands. The surveyor did not have access to a hand sanitizer dispenser. The surveyor passed through the breezeway twice touching the keypads and doorknobs four times, then two more doorknobs to return to the conference room. No staff were observed wiping down the doorknobs or keypads during the tour. During an interview with the Administrator on 06/13/2020 at 7:10 PM, s/he stated the facility provided hand sanitizer dispensers at the entrance of Dogwood and Magnolia buildings, in the dining rooms on Peach and Magnolia units, at the nurse's stations and in residents' rooms. Staff generally sanitize their hands while providing care in residents' rooms. The facility did not furnish personal hand sanitizer bottles for staff to use. Review of the facility policy entitled Handwashing/Hand Hygiene, dated 08/2015, revealed, Hand hygiene products and supplies shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 2. During an observation on 06/13/2020 at 5:55 PM, Licensed Practical Nurse (LPN) #1 walked up the hall and then approached an LPN sitting at the station on Dogwood unit. LPN #1 requested facial masks and was handed a plastic bag containing approximately a dozen masks. LPN #1 was not observed performing hand hygiene before she reached in the bag and removed 2 or 3 masks and brushed the other contents. LPN #1 placed the bag back on the counter. During an interview on 06/13/2020 at 6:05 PM, LPN #1 was interviewed about hand hygiene practices and stated that s/he had washed her/his hands on the hall before she reached inside of the bag. During an interview on 06/13/2020 at 7:10 PM with the Administrator, she stated LPN #1 should have washed her/his hands before s/he reached into the bag. During an observation on 06/14/2020 between 10:47 AM until 11:00 AM, Certified Nurse Aides (CNA) #1 and CNA #2 were observed entering data on the care tracker computer hung on the wall on the Magnolia Unit and in the Dining Room on the same unit. After the aides were finished, they left the care tracker and walked off the hall. CNA #1 had a small bottle of hand sanitizer hung around her/his neck. Neither CNA #1 or CNA #2 were observed cleaning their hands after touching the care tracker machines. An interview on 06/14/2020 at 11:07 AM with LPN #3 indicated the care tracker machine was supposed to be cleaned with a disinfectant wipe after use. During an interview on 06/14/2020 at 11:10 AM with CNA #1, s/he acknowledged that s/he did not clean her/his hands after using the care tracker machine. CNA #1 mentioned that staff were supposed to use a disinfectant wipe to clean common use equipment. The wipes were kept at the nurses' station and s/he was not observed going to the station to retrieve any wipes. During an interview on 06/14/2020 at 12:32 PM with the Administrator, s/he indicated the instructions from the manufacturer did not suggest using a chemical agent to clean the care tracker screen because it could be damaged. The Administrator said the staff had been trained to clean their hands before and after using the care tracker machines. Review of the facility policy entitled Handwashing/Hand Hygiene, dated 08/2015, revealed, Hand hygiene products and supplies shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and/or posted throughout the facility. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water after handling contaminated equipment.

Based on interviews in Resident Council Meeting facility did not take into consideration resident choices of food. ( 6 of 6 Residents interviewed in Resident Council) The findings included: Six residents interviewed during the Resident Council Meeting voiced concerns that dietary staff did not always follow their likes and dislikes on the the menu foods served. Most of the time the residents were served foods on their do not like list. Interview with the Assistant Dietary Manager on 8/21/19 at 10:30 AM revealed no one discussed the residents likes and dislikes with them except when they were admitted to the facility. If a staff member came and told them the resident did not like a specific food the dietary department would change that on the ticket. However, the residents in Council said the foods were never removed and they were still receiving foods they did not like or want.

Based on observation and interview the facility failed to prepare, store, and serve foods in a sanitary manner. (Main kitchen and Dogwood unit pantry.) The findings included: During the initial tour on 8/19/19 at 9:52 AM with dietary staff, the following items were noted: the outside of the stove had grease and splatters on all sides. The stand alone ovens had dark brown splatters on all inside walls and bottom, grease and splatters on all areas of outside walls, deep fryer had large amount of crumbs built up on top of oil. Outsides of walk-in freezer, refrigerator and reach-in refrigerator had grease and food splatters, steam table had a grease build up on all surfaces, the floor had a build up of grease and dirt ( floor sticky and shoes slid) tea container, juice container, paper towel holder, ice maker, microwave and outside of deep fryer all had grease build up. The microwave in the Dogwood unit pantry had dark brown splatters on top and inside walls of microwave. This observation was confirmed by Nurse #1 The Assistant Dietary Manager was asked to present a cleaning schedule which took him/her 2 days to find. The Assistant Dietary Manager's initial statement was We clean as things need cleaning. The floor was last deep cleaned by Maintenance on 7/21/19. The dietary staff mop and clean daily. On 8/21/19 a cleaning schedule was finally presented with initials marked on areas. There was no documentation noting the Supervisor had checked areas. These areas were reviewed with the Corporate Dietary Consultant and the Assistant Dietary Manager on 8/22/19 and areas confirmed. The Dietary Consultant stated new areas of equipment cleaning had already been added to their cleaning schedule.

Based on record review and interviews, the facility failed to follow their Abuse and Neglect Policy and Procedure related to reporting and investigating an observed resident to resident altercation for Resident #12 and Resident #11 and a timely 5-Day report for Resident #90. 3 of 3 residents reviewed for not reporting timely. The findings included: The facility admitted Resident #12 on (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. The facility admitted Resident # 11 on (MONTH) 29, (YEAR) with [DIAGNOSES REDACTED]. During review of the medical record it was noted that on 05/11/2019 at 2:59 PM-Resident # 11 was in the dining room eating and Resident #12 was sitting beside Resident #11 cursing and carrying on about various subjects. Resident #11 asked Resident #12 to please stop twice then became loud with Resident #12. Residents were separated at that time. Resident #12 came back to the dining room table where Resident #11 was sitting and started pulling his/her hair and moving his/her plate around. Resident #11 smacked Resident #12 and s/he grabbed Resident #11's face pinching his/her cheeks causing multiple scratches. Residents were separated and the residents were observed for injury. During an interview with the Director of Nursing (DON) on 08/21/19 at 3:07 PM, it was confirmed that the facility had not reported the resident to resident altercation that occurred on 5/11/19. The DON stated We thought if both residents were confused, we did not have to report it but, we did do an incident report. Review of the facility's Abuse and Neglect Policy and Procedure revealed All alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to: the Director of Nursing, the administrator or the designated representative, Regional Director of Operations and Regional Clinical Nurse, the resident's attending physician- obtain order for treatment if needed,the resident's family/responsible party. Follow State guidelines for reporting. The facility admitted Resident #90 on 01/08/2013 with [DIAGNOSES REDACTED]. joint, initial encounter,Recurrent dislocation, right shoulder, Factitial [MEDICAL CONDITION] Unspecified dementia with behavioral disturbance and [MEDICAL CONDITION]. During review of facility files on 8/22/2019 at 1:00 PM, it was noted that the resident had an Injury of Unknown Origin, a dislocated right shoulder, on 5/29/2019. A 2- Hour Report was sent to the State Agency and the Ombudsman and the 24- Hour Report was sent to the Sate Agency timely. The 5- Day Report was not submitted timely to the State Agency. During an interview on 8/22/19 at 1:31 PM -The Director of Nursing stated that s/he could not get any faxes to go through and kept trying until it finally did. The only fax confirmation provided was the fax where it was accepted, none provided for rejected attempts. Review of the facility Abuse Policy and Procedure revealed under Investigation and 7. Reporting Procedure. The results of all investigations where appropriate will be reported within 5 working days of the incident.

Based on record review and interviews, the facility failed to follow their Abuse and Neglect Policy and Procedure related to reporting an observed resident to resident altercation for Resident #12 and Resident #11 and a timely 5-Day report for Resident #90. 3 of 3 residents reviewed for not reporting timely. The findings included: The facility admitted Resident #12 on (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. The facility admitted Resident # 11 on (MONTH) 29, (YEAR) with [DIAGNOSES REDACTED]. During review of the medical record it was noted that on 5/11/2019 at 2:59 PM-Resident #11 was in dining room eating and Resident #12 was sitting beside Resident #11 cursing and carrying on about various subjects. Resident #11 asked Resident #12 to please stop twice then became loud with Resident #12. Residents were separated at that time. Resident #12 came back to the dining room table where Resident #11 was sitting and started pulling his/her hair and moving his/her plate around. Resident #11 smacked Resident #12 and Resident #12 grabbed Resident #11's face pinching his/her cheeks causing multiple scratches. Residents were separated and the residents were observed for injury. During an interview with the Director of Nursing on 8/21/19 3:07 PM , it was confirmed that the facility had not reported the resident to resident altercation that occurred on 5/11/19. The Director of Nursing stated We thought if both residents were confused, we did not have to report it but we did do an incident report. The facility admitted Resident #90 on 01/08/2013 with [DIAGNOSES REDACTED]. joint, initial encounter,Recurrent dislocation, right shoulder, Factitial [MEDICAL CONDITION] Unspecified dementia with behavioral disturbance and [MEDICAL CONDITION]. During review of facility files on 8/22/2019 at 1:00 PM, it was noted that the resident had an Injury of Unknown Origin, a dislocated right shoulder, on 5/29/2019. A 2- Hour Report was sent to the State Agency and the Ombudsman and the 24- Hour Report was sent to the Sate Agency timely. The 5- Day Report was not submitted timely to the State Agency. During an interview on 8/22/19 at 1:31 PM the Director of Nursing stated that s/he could not get any faxes to go through and kept trying until it finally did. The only fax confirmation provided was the fax where it was accepted, none provided for rejected attempts. During an interview on 8/22/19 at 12:31 PM the Administrator was asked why the resident to resident altercation that occurred on 5/11/2019 was not reported as required. The administrator replied that is a Memory Unit and they did not know what they were doing, I have a Psychiatrist that comes and I was off. The staff did a wonderful job separating and protecting the residents but, when the incident report was completed, they did not call the DON and when (s/he) saw it , (s/he) was going by there was no serious body injury. If I had been here and seen the incident report, a red flag would have went off.

Based on record review and interviews, the facility failed to follow their Abuse and Neglect Policy and Procedure related to investigating an observed resident to resident altercation for Resident #12 and Resident #11. 2 of 2 residents reviewed for abuse. The findings included: The facility admitted Resident #12 on (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. The facility admitted Resident # 11 on (MONTH) 29, (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #11's medical record revealed a Quarterly Review dated 5/28/19 that indicated resident had a Brief Interview for Mental Status score of 7 indicating severely cognitively impaired. Resident is alert and oriented x 2 to person and place with confusion and forgetfulness. Resident is verbal and can make his/her needs known to staff. During review of Resident #11's medical record it was noted that on 05/11/2019 at 02:59 PM-Resident # 11 was in dining room eating and resident #12 was sitting beside resident #11 cursing and carrying on about various subjects. Resident #11 asked Resident #12 to please stop twice then became loud with Resident #12. Residents were separated at that time. Resident #12 came back to the dining room table where resident #11 was sitting and started pulling his/her hair and moving his/her plate around. Resident#11 smacked resident #12 grabbed resident #11's face pinching her cheeks causing multiple scratches. Residents were separated and the residents were observed for injury. No treatments needed at this time. Body audit on 5/17/19 revealed scratches to the resident's face. Review of Resident #12's medical record revealed on 5/11/2019 at 1:53 PM- Resident was arguing and fussing with others in dining room around 12:30 PM. Resident removed 2 times from dining room. Resident went back into dining room around 12:40 PM and was arguing with another resident. CNA went into dining room and saw both residents have each other by the hair and hitting each other. This resident was also trying to scratch other resident in the eyes. CNA stated that resident did scratch other resident on the face. This nurse went to check on other resident and scratch was noted to right cheek. This nurse give resident [MEDICATION NAME] at 12:45 PM and medication was effective. This nurse also tried to contact responsible party but unable to contact. During an interview with the Director of Nursing on 8/21/19 3:07 PM, it was confirmed that the facility had not reported the resident to resident altercation that occurred on 5/11/19. We thought if both residents were confused, we did not have to report it but, we did do an incident report. Review of the facility Abuse Policy and Procedure revealed under 6. Investigation and Reporting Procedure. The facility will thoroughly investigate and document each alleged violation and will prevent further potential abuse while the incident is under investigation. The 5/11/19 resident to resident altercation was not reported to the police or State Agency at all. The Incident Report only had staff statements and was not investigated thoroughly. The facility did not follow their Policy/ Procedure for Reporting.

Based on observation, interview and limited record reviews, the facility failed to provide the care as identified on the physician orders [REDACTED]. The findings included: Review of the medical record on 1/23/18 revealed that resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. On 1/23/18 at 12:00 PM, review of Resident #1's care plan with problem start date 9/26/17 revealed impaired skin integrity identified as a problem area. Interventions and approaches included treatments to left and right lower shins initiated on 10/21/17. The care plan was updated on 10/30/17 to include changes in treatment regimens. On 1/23/18 at 12:10 PM, review of the Daily Skilled Nurse's Note for Resident #1 dated 10/30/17 at 11:29 AM revealed the following: During wound rounds Res noted to have dressings dated 10-27-17 with the initials for LPN (Licensed Practical Nurse) #3 on them. Upon removing the old dressings the wounds to bilateral shins were noted to have deteriorated significantly. The wounds went from 100% granular to 100% slough with moderate purulent drainage noted. MD was notified and the treatment was changed to clean with NS, apply santyl to the wound beds, and cover with a border gauze and as needed until healed. RP also notified of new orders and change in wound status. Review of the Physicians Orders on 1/23/18 at 12:15 PM revealed an order with start date of 10/23/17 which read cleanse left lower shin with NS (normal saline)/WC (wound cleanser)-apply [MEDICATION NAME] and cover with border gauze change daily. Further review of the Physician order [REDACTED]. Review of the Treatment Administration Record on 1/23/18 at 12:20 PM revealed that the treatment initiated on 10/23/17 to the left lower shin was electronically signed by LPN#1 as being administered on 10/28/17 and 10/29/17 during 7:00 am-3:00 pm shift. On 1/23/18 at 12:45 PM, review of the facility's Five-Day Follow-Up Report dated 11/3/17 indicated that on 10/30/17 during wound rounds, dressings to Resident #1's bilateral shins were noted to have nurse initials (LPN#3) and date from 10/27/17 despite being a once daily treatment to both shins. Review of written statement provided by RN (Registered Nurse) #1 on 10/30/17 revealed that upon completing wound rounds on 10/30/17, it was identified that Resident #1 was noted to have bandages with the initials of LPN#3 and the date of 10/27/17. It was further noted that the wounds were to have deteriorated to bilateral shins. Review of written statement provided by LPN #2 revealed that while s/he was assisting with wound rounds, it was noted that Resident #1 had wounds on bilateral shins with the date of 10/27/17 and the initial for LPN#3. LPN#2 further stated that the old dressings were removed and the wounds had deteriorated. Interviews were conducted with RN #1 and LPN #2, when asked if they had any information to add to prior statements provided, both RN #1 and LPN #2 replied no. During an interview with the DON (Director of Nursing) and administrator on 1/23/18 at approximately 2:00 PM, both verified that LPN #1 failed to follow physician orders [REDACTED].

On the day of the Complaint and Extended Survey based on record reviews, interviews and observations, the facility failed to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, notification of the physician and reporting of alleged neglect. Despite the initiation of plan(s) by the facility to address resident assessment, care and services and reporting of abuse/neglect concerns were identified during the survey for two of seven residents sampled during the survey. The findings included: F-520 previously cited as part of the Recertification Survey conducted [DATE] and corrected on the follow up survey conducted [DATE]. On [DATE] F-520 was cited at Immediate Jeopardy "L" related to an allegation of neglect. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each resident's provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-281 as it relates to the failure of the facility to provide accurate, current and appropriate assessments, interventions and re-assessments to residents with acute changes in condition. Resident #1 and #4 were identified during the investigation with negative outcomes. Licensed Practical Nurse #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The physician was not notified timely when Resident #4 had an acute change in condition. Cross refers to F-309 as it relates to the failure of the facility to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Resident #1 failed to have the necessary care and services required related to an acute change in condition, the resident was not assessed, vital signs were not obtained and the physician was not notified timely of an acute change in condition. Resident #4 had a delay in physician notification of an acute change in condition. Cross refers to F-490 as it relates to the failure of the facility to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 acted negligently. The facility also failed to identify, report and follow up on another potential allegation of neglect related to Resident #4. During an interview with the surveyor on [DATE] the Director of Nurses (DON) and Administrator confirmed the lack of assessment, intervention and documentation surrounding Residents #1 death on [DATE] at approximately 8:00 AM. Both the DON and Administrator confirmed there was no other documented vital signs since 3:30 AM. They also confirmed the resident Transfer Form contained the vital signs recorded at 3:30 AM, however, both stated that they were not aware at the time the values were the same. The DON and Administrator were also not aware that the resident received a 4 mg dose of [MEDICATION NAME] on [DATE] when the medication was on hold. The Administrator confirmed that she reported the incident as potential neglect to the State Certification Agency, however, had unsubstantiated the findings. She indicated that at the time the facility felt that LPN #1 acted appropriately. The Administrator confirmed again that there was no documentation of assessment, intervention or vital signs recorded since 3:30 AM on [DATE]. She also acknowledged that even though LPN #1 had contacted the physician, the information relayed to the physician was not an accurate assessment of the resident, the physician was not provided current vital signs and the Administrator confirmed that LPN #1 did not re-assess or intervene between the time Transmed transport was notified and arrived at the facility (45 minutes) when the resident was noted to no longer have a heart beat and no respirations. The Administrator confirmed the actions of LPN #1 were negligent. During an interview with the surveyor on [DATE], the Director of Nurses confirmed the Resident #4 was sent to the hospital on [DATE] for an acute change in condition, but was not aware of the delay in contacting the physician. The DON and Administrator confirmed the delay in notifying the Physician and confirmed the delay in obtaining the necessary medical treatment. Review of the Quality Assurance Committee Meeting Minutes dated [DATE] that was attended by the Administrator and the Director of Nurses revealed the facility identified concerns related to changes in condition, physician notification and nursing assessments. The "issues are being addressed through the following: Administrator and DON have met with the physician's to explain the education being provided to the nurses regarding proper assessment and identification of abnormal vital signs prior to calling the physician. Education nurses on triaging resident with acute conditions... continued education of the staff in understanding abuse and neglect and to report it when it is identified... changes in forms to report changes to physician, changes in the morning meeting forms to enhance monitoring for the nurses for improved resident outcomes..." There were no time lines indicated for implementation or completion. A formal action plan had not been developed at the time of survey. The above information was confirmed with the Administrator on [DATE]. The Administrator also confirmed that actions put in place were not effective related to the identification of Resident #4's delay in physician notification and delay in obtaining medical treatment. On [DATE] at 4:40 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy was identified at F-520 at a scope and severity of "L". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on [DATE]. The Substandard Quality of Care and Immediate Jeopardy identified at F-520 at a scope and severity of "L" remained ongoing at the time the surveyor exited the facility on [DATE]. FOLLOWUP VISIT During an unannounced onsite visit on [DATE] at 9:45 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice as of [DATE], removing the immediacy of the deficient practice. The actions listed in the Allegation of Compliance included the following: "A chart review was completed by the regional consultant team on #1 and #4 on [DATE] to determine system failures to be immediately addressed for correction. The physicians for both residents #1 and #4 were notified on [DATE] of the Immediate jeopardy that related to residents change of condition. The family of the resident #1 was notified on [DATE]. The family of resident #4 was notified on [DATE]. On [DATE] the Regional Nurse Consultants began a 100% audit of all clinical assessments completed for each facility resident to ensure that proper assessments of current condition and any change in condition were documented, had appropriate interventions initiated and physician notification was provided. The regional nurse consultants provided inservices for all licensed nursing staff on conducting head to toe assessments with return demonstration achieved on [DATE] through [DATE]. All staff that were unavailable for re-education must receive the in-services prior to reporting to work again. The facility nurse managers will inservice any agency staff scheduled to work in the facility prior to reporting to their unit for duty, Regional consultants began providing facility staff oversight in the following areas: Nursing, MDS, Rehabilitation, Dietary, QA and Administration on [DATE]. A RN nursing supervisor was secured on [DATE] for the evening shifts M-F and on weekends to provide additional oversight to the nursing staff of any acute issues and assessment and intervention needs. This position will be ongoing. Regional oversight was initiated 7 days a week beginning [DATE]. Regional oversight will continue until the facility is in compliance and has successfully completed the first SSF (survey special focus) 6 month survey. Depending on survey results, the frequency and duration of Regional oversight may be adjusted. The CEO initiated administrative oversight of all Administrative directives as of [DATE]. The CEO/Regional Licensed Nursing Home Administrator will continue to provide administrative oversight until the facility is in compliance and has successfully completed the first SSF survey. Depending on survey results, the frequency and duration of Regional oversight may be adjusted. The Quality Assessment and Assurance expectations were reviewed and education provided to the Administrator by the CEO on [DATE]. All staff were re-educated on Abuse, Neglect and Misappropriation of Resident Property beginning [DATE] through [DATE], by the Regional Staff. All staff that were unavailable for re-education must receive the inservices prior to reporting to work. The facility will identify other residents having the potential to be affected deficient practice by the following: The Nurses will identify any resident with a change in condition and document such in the nurses notes, 24 hour report, unusual occurrence form and report to the oncoming shift of all residents identified as requiring assessments, interventions, and notification of the resident's physician. This intervention was initiated [DATE] and will be ongoing. The 24 hour report, physician orders, unusual occurrence reports and incident reports will be reviewed during the Morning Management Meeting M-F. The weekend RN supervisor and the evening RN supervisor will complete these reports during the evenings and weekend hours to ensure the necessary standard of care has been provided. This intervention was effective on [DATE] and will be ongoing. The MDS Coordinators will notify the Director of Nurses and Administrator of any significant change in condition assessments that are triggered through the MDS assessment period. This intervention was effective [DATE]. The Unit Managers, M-F, during the day shift, will compile for tracking and QA purposes, a monthly report of all residents requiring assessments for changes in condition, interventions and episodes of physician notification and the treatment outcomes. The RN House Supervisor, M-F, on the ,[DATE] shift, will collect data to give the Unit Managers, M-F for compilation. On Saturday & Sunday, the 12 hours RN House Supervisor, will collect data to provide the M-F, Unit Managers as well. Therefore we will have 7 day a week nursing administrative oversight for the consistent compilation of data to allow us to make the best possible decisions for the best resident outcomes. This report will be submitted to the monthly QA and A committee for tracking, trending and identification of patterns that require further action and education. This intervention was initiated [DATE] and will be ongoing. The Department Managers will make resident interviews a continued part of their morning rounds and observations. These interviews will be discussed during the morning management meetings with discussion completed of any observed change in resident's condition. This will be documented on the room round sheet by each department manager and recorded in the morning meeting minutes by the Administrator. This intervention was initiated [DATE] and will be ongoing. The Administrator will review with a [MEDICATION NAME] OPCP, LLC operations manager all grievances and potential [MEDICATION NAME] to ensure that complete investigations are achieved. This intervention was initiated [DATE] and will be ongoing." The citation at F-520 remained at a lowered scope and severity of "E". The facility will be in compliance at F-520 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the day of the Complaint and Extended Survey, the facility staff failed to provide accurate, current and appropriate assessments, interventions and re-assessments to residents with acute changes in condition. Resident #1 and #4 were identified during the investigation with negative outcomes. Licensed Practical Nurse #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The physician was not notified timely, when Resident #4 had an acute change in condition, delaying necessary medical care. The findings included: F-281 previously cited as part of the Recertification Survey conducted [DATE] and not corrected on the follow up survey conducted [DATE]. On [DATE] F-281 was cited at a "G" and elevated to an Immediate Jeopardy at a "L" on [DATE] related to the failure of the facility to follow acceptable standards of practice. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each resident's provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-309 as it relates to the failure of the facility to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Resident #1 failed to have the necessary care and services required related to an acute change in condition, the resident was not assessed, vital signs were not obtained and the physician was not notified timely of an acute change in condition. Resident #4 had a delay in physician notification of an acute change in condition. Cross refers to F-490 as it relates to the failure of the facility to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 acted negligently. The facility also failed to identify, report and follow up on another potential allegation of neglect related to Resident #4. Cross refers to F-520 as it relates to the failure of the facility to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, notification of the physician and reporting of alleged neglect. Despite the initiation of plan(s) by the facility to address resident assessment, care and services and reporting of abuse/neglect concerns were identified during the survey for two of seven sampled resident's during the survey. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed the resident's blood pressure on [DATE] at 3:20 AM was ,[DATE]. On [DATE] at 10 PM the blood pressure was ,[DATE]. Further review revealed the resident's blood pressure varied between ,[DATE]'s systolic and ,[DATE]'s diastolic during her stay at the facility. The resident was also noted to have been prescribed Cardiazem ER (extended release) 240 mg (milligram) daily, [MEDICATION NAME]/HCTZ ,[DATE].5 mg daily, [MEDICATION NAME] 500 mg three times daily, [MEDICATION NAME] 25 mg daily and [MEDICATION NAME] 1 mg three times daily. There were no changes in the resident's cardiotonic medications during her stay at the facility. On [DATE] at 8 AM the resident was noted to not void during third shift and "skin tenting" was documented. The physician was notified and the staff was encouraged to push fluids. At 2:30 PM, the resident still had not voided and "consumed very little fluids." On [DATE] the resident reported an upset stomach and refused medications. On [DATE] at 10 PM, "when changing resident's brief this shift, CNA (certified nurse assistant) noticed what seemed to be blood and notified this nurse, when I went to assess her, there was no obvious point of bleeding. Will continue to monitor. No signs and symptoms of distress or pain. (Due to a discrepancy in the Nurse's Notes dated [DATE] at 10 PM and [DATE] at 7 AM the surveyor was unable to determine when the bleeding was noted in Resident #1's brief.) [DATE] at 7 AM, "has been no more blood in brief or any c/o (complained of) pain or distress..." 11:30 AM, "INR 3.84, called to (Physician) telephone order d/c (discontinue) [MEDICATION NAME] 4 mg give [MEDICATION NAME] 3 mg PO (by mouth) QD (daily). Re-check INR in one week." 12:20 PM, "Res (resident) consumes a few bites of foods, spoonfed to her by staff. Makes needs self understood c slurred speech..." At 2:50 PM, "Res has been OOB (out of bed) s (without) distress. No reported bleeding vaginal or rectal." 3:30 AM, "Urine obtained for U/A via in/out cath. Blood noted in urine..." 4:30 PM, "Pt's U/A results called to (Physician) new order received [MEDICATION NAME] mg twice daily x 7 days... Pts [MEDICATION NAME] D/C'd on [DATE]. Pt will have PT/INR drawn in AM..." [DATE] at 4:15 AM, the resident was noted to have a large loose stool. at 10:30 AM, "Res continues to have loose stools..." 1:30 PM, "Loose stool has worsened...Send stool for C.Diff..." 5 PM, "Res laying in bed, says she doesn't want any meds or food. Res did have another loose stool." [DATE] at 1 PM, "C.Diff neg (negative), INR 2.44-called (Physician) ordered to keep [MEDICATION NAME] stopped and recheck INR Mon(day)." [DATE] at 3:30 AM, "VS (vital signs) ,[DATE], 97.6, 50, 17, 93%. [MEDICATION NAME] supp 25 mg given @ 2:45 AM for nausea. [MEDICATION NAME] UTI. Stool (checked) for C.Diff [DATE] c neg results r/t loose stools. Blood noted in brief [DATE] and UA was done [MEDICATION NAME] for UTI (urinary tract infection). No blood noted tonight. [MEDICATION NAME] remains on hold. PT/INR on Mon [DATE]. Res alert and able to make needs known." 7 AM, "Res noted vomiting dark brown liquid at 6:30 AM, hemocult was (+) for blood. CNA called nurse back to room at 6:40 AM and res had dark brown liquid from left nostril and mouth. Called (Physician) and ordered to send to (Hospital) to see GI ([MEDICATION NAME]) MD." 7:10 AM, Called Transmed to transport." 8:15 AM, "Transmed here to transport, followed staff (Transmed) to room and noted res had no pulse or resp. Res noted to have dark brown liquid from mouth and nose. Liquid was almost black in color and smelled of blood." CPR (cardiopulmonary resuscitation) started (after) checking chart for DNR (do not resuscitate), called CODE BLUE. (Physician) called and made aware. Transmed attendants started CPR. 911 called." CPR started (after) checking chart for DNR, called CODE BLUE. (Physician) called and made aware. Transmed attendants started CPR. 911 called." CPR was stopped per ER physician's orders [REDACTED]. There was no evidence that an assessment was completed by the night shift nurse on ,[DATE] - [DATE] (LPN #1), there was no evidence vital signs were taken or any intervention performed when the resident was noted to have occult blood. Review of the Transfer form completed by LPN #1 revealed the "Vital signs at time of transfer" were the same recorded vital signs at 3:30 AM. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (The [MEDICATION NAME] dosage had been changed on [DATE] and then discontinued on ,[DATE].) Further review revealed on [DATE] at 2:45 AM, that the resident received 25 mg of [MEDICATION NAME] via rectal suppository for N/V (Nausea and Vomiting). LPN #1 documented "not eff(ective)." There was no time recorded of the "not effective" assessment and no evidence that any other intervention or physician notification was attempted related to the nausea and vomiting until after 7 AM. During a telephone interview with the surveyor on [DATE] at 12 PM, the Physician stated that he specifically remembered the phone call the morning of [DATE] because he was eating breakfast with his family. The Physician stated that he was informed that Resident #1 was vomiting blood, he stated that the nurse did not have any vital signs or any other assessment data at the time of the phone call. The Physician stated that he requested the nurse place him on hold and obtain a current set of vital signs. He stated that the vital signs reported to him were not "emergent" in nature and did not alarm him. He stated that he ordered the resident sent to the hospital for evaluation but did not need to be sent via 911. He stated that he was later called and informed that the resident's blood pressure was 60 over palp and no respirations and that EMS was coding her. He was informed that the resident expired in the facility. The Physician stated that he could not remember what the actual vital signs reported were. He also stated that he did not know the resident well enough to know what her vital signs were typically. The Physician also confirmed that he was aware that the resident had blood in her urinary tract and the [MEDICATION NAME] was on hold. He was not aware that the resident received a 4 mg dose of [MEDICATION NAME] on [DATE] when the medication was on hold. During a telephone interview with the surveyor on [DATE] at 12:20 PM, Licensed Practical Nurse (LPN) #1 stated that she was assigned to Resident #1 on the night shift of ,[DATE]-[DATE]. She stated that at 12 AM, the resident was "fine." At 3:30 AM, the resident complained of nausea and she stated that she gave a [MEDICATION NAME] suppository; the resident did not have any more complaints. At 6:30 AM, the CNA reported that the resident had thrown up brown emesis and she checked the emesis for occult blood, which was heme positive. She stated that she went back to her med cart and was finishing up her med pass, when approximately 10 minutes later, the CNA reported the resident had thrown up again and was coming from her nose. LPN #1 stated that that the resident was on her side with her head down then she left the room and called the physician. She stated that the resident's blood pressure had been running low previously but she was alert and talking to her. LPN #1 also stated that she "had a lot going on" that shift and had other residents that she needed to call the doctor for; the change of shift had arrived and she asked LPN #2 to go to the room with her to check on the resident. LPN #1 stated that approximately ,[DATE] minutes later Transmed was in the room coding her. The nurse stated that while on the phone with the Physician, he did not request any further information or request she obtain vital signs. She stated that she "could not remember" when the vital signs were obtained. LPN #1 stated that she did not perform an assessment on the resident or perform any interventions for the resident. She confirmed that she did not return to the resident's room until Transmed arrived. LPN #1 also confirmed her documentation on the back of the MAR indicated [REDACTED]. She confirmed that she did not provide any other interventions to the resident for the nausea. During a telephone interview with the surveyor on [DATE] at 2:35 PM, LPN #2 stated that she was the oncoming nurse on [DATE] for the 7AM-3 PM shift. LPN #2 stated that she was at the nurse's desk and LPN #1 was down the hall at her med cart. At 7:15 AM, LPN #1 informed LPN #2 that she had sick patients and that she needed to call the doctor for four. LPN #2 stated that LPN #1 was called back down the hall to Resident #1's room. She stated that LPN #1 then came back up the hall and requested that she (LPN#2) go to the resident's room with her because the resident had blood coming out of her nose and mouth. LPN #2 stated that when she got to the room, the CNA was cleaning her up and she did not see any blood. LPN #2 stated that the resident did not look good and was "very pale." She stated that both nurses left the room and returned to the desk. LPN #1 proceeded to call the doctor and she, LPN #2 was making copies and preparing the chart for the resident to be transferred out. During an interview with the surveyor on [DATE] the Director of Nurses and Administrator confirmed that there was no documentation of assessment, intervention or vital signs recorded since 3:30 AM on [DATE]. She also acknowledged that even though LPN #1 had contacted the physician, the information relayed to the physician was not an accurate assessment of the resident and was not provided current vital signs. The Administrator confirmed that LPN #1 did not re-assess or intervene between the time Transmed was notified and then arrived at the facility (45 minutes) when the resident was noted to no longer have a heart beat and no respirations. The Administrator confirmed the actions of LPN #1 were negligent. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Resident #4 was noted to have recurrent hospitalization s [MEDICAL CONDITION] and was re-admitted to the facility on [DATE]. Resident #4 was in the hospital at the time of survey. Review of the Nurse's Notes revealed on [DATE] at 10 :30 AM, "Spoke c (Physician) regarding resident condition. Informed MD of res (resident) in and out of responsiveness. Res holding food and snuff in her mouth. Res stares at you, but does not respond to verbal commands. MD states to send res out to ER." At 11:30 AM, the resident was transferred to the ER via Transmed. Further review of the "Physician's Notification of Change in Condition Form" revealed "During breakfast, res noted to be laying c head in table. Res easily aroused by this nurse, but was in and out of responsiveness. ST attempted to awake res for meal. Res holding food in her mouth along c snuff. Meds held due to unresponsiveness (ALOC-altered level of consciousness)." There was no evidence that the nurse assessed the resident or provided an intervention to the resident. In addition, there was a delay in notifying the physician of the acute change in condition, thereby delaying her transfer to the hospital and necessary medical treatment. The nurse, after she was informed of the acute change, carried out her other duties, held the resident's medications and did not contact the physician until 10:30 AM. During an interview on [DATE], the Director of Nurses confirmed the resident was sent to the hospital on [DATE] for an acute change in condition, but was not aware of the delay in contacting the physician. The DON and Administrator confirmed the delay in notifying the Physician and confirmed that the delay in obtaining the necessary medical treatment. On [DATE] at 4:40 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy was identified at F-281 at a scope and severity of "L". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on [DATE]. The Substandard Quality of Care and Immediate Jeopardy identified at F-281 at a scope and severity of "L" remained ongoing at the time the surveyor exited the facility on [DATE].

On the day of the Complaint and Extended Survey, the facility staff failed to provide accurate, current and appropriate assessments, interventions and re-assessments to residents with acute changes in condition. Resident #1 and #4 were identified during the investigation with negative outcomes. Licensed Practical Nurse #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The physician was not notified timely, when Resident #4 had an acute change in condition, delaying necessary medical care. The findings included: F-281 previously cited as part of the Recertification Survey conducted [DATE] and not corrected on the follow up survey conducted [DATE]. On [DATE] F-281 was cited at a "G" and elevated to an Immediate Jeopardy at a "L" on [DATE] related to the failure of the facility to follow acceptable standards of practice. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each resident's provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-309 as it relates to the failure of the facility to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Resident #1 failed to have the necessary care and services required related to an acute change in condition, the resident was not assessed, vital signs were not obtained and the physician was not notified timely of an acute change in condition. Resident #4 had a delay in physician notification of an acute change in condition. Cross refers to F-490 as it relates to the failure of the facility to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 acted negligently. The facility also failed to identify, report and follow up on another potential allegation of neglect related to Resident #4. Cross refers to F-520 as it relates to the failure of the facility to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, notification of the physician and reporting of alleged neglect. Despite the initiation of plan(s) by the facility to address resident assessment, care and services and reporting of abuse/neglect concerns were identified during the survey for two of seven sampled resident's during the survey. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed the resident's blood pressure on [DATE] at 3:20 AM was ,[DATE]. On [DATE] at 10 PM the blood pressure was ,[DATE]. Further review revealed the resident's blood pressure varied between ,[DATE]'s systolic and ,[DATE]'s diastolic during her stay at the facility. The resident was also noted to have been prescribed Cardiazem ER (extended release) 240 mg (milligram) daily, [MEDICATION NAME]/HCTZ ,[DATE].5 mg daily, [MEDICATION NAME] 500 mg three times daily, [MEDICATION NAME] 25 mg daily and [MEDICATION NAME] 1 mg three times daily. There were no changes in the resident's cardiotonic medications during her stay at the facility. On [DATE] at 8 AM the resident was noted to not void during third shift and "skin tenting" was documented. The physician was notified and the staff was encouraged to push fluids. At 2:30 PM, the resident still had not voided and "consumed very little fluids." On [DATE] the resident reported an upset stomach and refused medications. On [DATE] at 10 PM, "when changing resident's brief this shift, CNA (certified nurse assistant) noticed what seemed to be blood and notified this nurse, when I went to assess her, there was no obvious point of bleeding. Will continue to monitor. No signs and symptoms of distress or pain. (Due to a discrepancy in the Nurse's Notes dated [DATE] at 10 PM and [DATE] at 7 AM the surveyor was unable to determine when the bleeding was noted in Resident #1's brief.) [DATE] at 7 AM, "has been no more blood in brief or any c/o (complained of) pain or distress..." 11:30 AM, "INR 3.84, called to (Physician) telephone order d/c (discontinue) [MEDICATION NAME] 4 mg give [MEDICATION NAME] 3 mg PO (by mouth) QD (daily). Re-check INR in one week." 12:20 PM, "Res (resident) consumes a few bites of foods, spoonfed to her by staff. Makes needs self understood c slurred speech..." At 2:50 PM, "Res has been OOB (out of bed) s (without) distress. No reported bleeding vaginal or rectal." 3:30 AM, "Urine obtained for U/A via in/out cath. Blood noted in urine..." 4:30 PM, "Pt's U/A results called to (Physician) new order received [MEDICATION NAME] mg twice daily x 7 days... Pts [MEDICATION NAME] D/C'd on [DATE]. Pt will have PT/INR drawn in AM..." [DATE] at 4:15 AM, the resident was noted to have a large loose stool. at 10:30 AM, "Res continues to have loose stools..." 1:30 PM, "Loose stool has worsened...Send stool for C.Diff..." 5 PM, "Res laying in bed, says she doesn't want any meds or food. Res did have another loose stool." [DATE] at 1 PM, "C.Diff neg (negative), INR 2.44-called (Physician) ordered to keep [MEDICATION NAME] stopped and recheck INR Mon(day)." [DATE] at 3:30 AM, "VS (vital signs) ,[DATE], 97.6, 50, 17, 93%. [MEDICATION NAME] supp 25 mg given @ 2:45 AM for nausea. [MEDICATION NAME] UTI. Stool (checked) for C.Diff [DATE] c neg results r/t loose stools. Blood noted in brief [DATE] and UA was done [MEDICATION NAME] for UTI (urinary tract infection). No blood noted tonight. [MEDICATION NAME] remains on hold. PT/INR on Mon [DATE]. Res alert and able to make needs known." 7 AM, "Res noted vomiting dark brown liquid at 6:30 AM, hemocult was (+) for blood. CNA called nurse back to room at 6:40 AM and res had dark brown liquid from left nostril and mouth. Called (Physician) and ordered to send to (Hospital) to see GI ([MEDICATION NAME]) MD." 7:10 AM, Called Transmed to transport." 8:15 AM, "Transmed here to transport, followed staff (Transmed) to room and noted res had no pulse or resp. Res noted to have dark brown liquid from mouth and nose. Liquid was almost black in color and smelled of blood." CPR (cardiopulmonary resuscitation) started (after) checking chart for DNR (do not resuscitate), called CODE BLUE. (Physician) called and made aware. Transmed attendants started CPR. 911 called." CPR started (after) checking chart for DNR, called CODE BLUE. (Physician) called and made aware. Transmed attendants started CPR. 911 called." CPR was stopped per ER physician's orders [REDACTED]. There was no evidence that an assessment was completed by the night shift nurse on ,[DATE] - [DATE] (LPN #1), there was no evidence vital signs were taken or any intervention performed when the resident was noted to have occult blood. Review of the Transfer form completed by LPN #1 revealed the "Vital signs at time of transfer" were the same recorded vital signs at 3:30 AM. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (The [MEDICATION NAME] dosage had been changed on [DATE] and then discontinued on ,[DATE].) Further review revealed on [DATE] at 2:45 AM, that the resident received 25 mg of [MEDICATION NAME] via rectal suppository for N/V (Nausea and Vomiting). LPN #1 documented "not eff(ective)." There was no time recorded of the "not effective" assessment and no evidence that any other intervention or physician notification was attempted related to the nausea and vomiting until after 7 AM. During a telephone interview with the surveyor on [DATE] at 12 PM, the Physician stated that he specifically remembered the phone call the morning of [DATE] because he was eating breakfast with his family. The Physician stated that he was informed that Resident #1 was vomiting blood, he stated that the nurse did not have any vital signs or any other assessment data at the time of the phone call. The Physician stated that he requested the nurse place him on hold and obtain a current set of vital signs. He stated that the vital signs reported to him were not "emergent" in nature and did not alarm him. He stated that he ordered the resident sent to the hospital for evaluation but did not need to be sent via 911. He stated that he was later called and informed that the resident's blood pressure was 60 over palp and no respirations and that EMS was coding her. He was informed that the resident expired in the facility. The Physician stated that he could not remember what the actual vital signs reported were. He also stated that he did not know the resident well enough to know what her vital signs were typically. The Physician also confirmed that he was aware that the resident had blood in her urinary tract and the [MEDICATION NAME] was on hold. He was not aware that the resident received a 4 mg dose of [MEDICATION NAME] on [DATE] when the medication was on hold. During a telephone interview with the surveyor on [DATE] at 12:20 PM, Licensed Practical Nurse (LPN) #1 stated that she was assigned to Resident #1 on the night shift of ,[DATE]-[DATE]. She stated that at 12 AM, the resident was "fine." At 3:30 AM, the resident complained of nausea and she stated that she gave a [MEDICATION NAME] suppository; the resident did not have any more complaints. At 6:30 AM, the CNA reported that the resident had thrown up brown emesis and she checked the emesis for occult blood, which was heme positive. She stated that she went back to her med cart and was finishing up her med pass, when approximately 10 minutes later, the CNA reported the resident had thrown up again and was coming from her nose. LPN #1 stated that that the resident was on her side with her head down then she left the room and called the physician. She stated that the resident's blood pressure had been running low previously but she was alert and talking to her. LPN #1 also stated that she "had a lot going on" that shift and had other residents that she needed to call the doctor for; the change of shift had arrived and she asked LPN #2 to go to the room with her to check on the resident. LPN #1 stated that approximately ,[DATE] minutes later Transmed was in the room coding her. The nurse stated that while on the phone with the Physician, he did not request any further information or request she obtain vital signs. She stated that she "could not remember" when the vital signs were obtained. LPN #1 stated that she did not perform an assessment on the resident or perform any interventions for the resident. She confirmed that she did not return to the resident's room until Transmed arrived. LPN #1 also confirmed her documentation on the back of the MAR indicated [REDACTED]. She confirmed that she did not provide any other interventions to the resident for the nausea. During a telephone interview with the surveyor on [DATE] at 2:35 PM, LPN #2 stated that she was the oncoming nurse on [DATE] for the 7AM-3 PM shift. LPN #2 stated that she was at the nurse's desk and LPN #1 was down the hall at her med cart. At 7:15 AM, LPN #1 informed LPN #2 that she had sick patients and that she needed to call the doctor for four. LPN #2 stated that LPN #1 was called back down the hall to Resident #1's room. She stated that LPN #1 then came back up the hall and requested that she (LPN#2) go to the resident's room with her because the resident had blood coming out of her nose and mouth. LPN #2 stated that when she got to the room, the CNA was cleaning her up and she did not see any blood. LPN #2 stated that the resident did not look good and was "very pale." She stated that both nurses left the room and returned to the desk. LPN #1 proceeded to call the doctor and she, LPN #2 was making copies and preparing the chart for the resident to be transferred out. During an interview with the surveyor on [DATE] the Director of Nurses and Administrator confirmed that there was no documentation of assessment, intervention or vital signs recorded since 3:30 AM on [DATE]. She also acknowledged that even though LPN #1 had contacted the physician, the information relayed to the physician was not an accurate assessment of the resident and was not provided current vital signs. The Administrator confirmed that LPN #1 did not re-assess or intervene between the time Transmed was notified and then arrived at the facility (45 minutes) when the resident was noted to no longer have a heart beat and no respirations. The Administrator confirmed the actions of LPN #1 were negligent. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Resident #4 was noted to have recurrent hospitalization s [MEDICAL CONDITION] and was re-admitted to the facility on [DATE]. Resident #4 was in the hospital at the time of survey. Review of the Nurse's Notes revealed on [DATE] at 10 :30 AM, "Spoke c (Physician) regarding resident condition. Informed MD of res (resident) in and out of responsiveness. Res holding food and snuff in her mouth. Res stares at you, but does not respond to verbal commands. MD states to send res out to ER." At 11:30 AM, the resident was transferred to the ER via Transmed. Further review of the "Physician's Notification of Change in Condition Form" revealed "During breakfast, res noted to be laying c head in table. Res easily aroused by this nurse, but was in and out of responsiveness. ST attempted to awake res for meal. Res holding food in her mouth along c snuff. Meds held due to unresponsiveness (ALOC-altered level of consciousness)." There was no evidence that the nurse assessed the resident or provided an intervention to the resident. In addition, there was a delay in notifying the physician of the acute change in condition, thereby delaying her transfer to the hospital and necessary medical treatment. The nurse, after she was informed of the acute change, carried out her other duties, held the resident's medications and did not contact the physician until 10:30 AM. During an interview on [DATE], the Director of Nurses confirmed the resident was sent to the hospital on [DATE] for an acute change in condition, but was not aware of the delay in contacting the physician. The DON and Administrator confirmed the delay in notifying the Physician and confirmed that the delay in obtaining the necessary medical treatment. On [DATE] at 4:40 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy was identified at F-281 at a scope and severity of "L". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on [DATE]. The Substandard Quality of Care and Immediate Jeopardy identified at F-281 at a scope and severity of "L" remained ongoing at the time the surveyor exited the facility on [DATE]. FOLLOWUP VISIT During an unannounced onsite visit on [DATE] at 9:45 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice as of [DATE], removing the immediacy of the deficient practice. The actions listed in the Allegation of Compliance included the following: "A chart review was completed by the regional consultant team on #1 and #4 on [DATE] to determine system failures to be immediately addressed for correction. The physicians for both residents #1 and #4 were notified on [DATE] of the Immediate jeopardy that related to residents change of condition. The family of the resident #1 was notified on [DATE]. The family of resident #4 was notified on [DATE]. On [DATE] the Regional Nurse Consultants began a 100% audit of all clinical assessments completed for each facility resident to ensure that proper assessments of current condition and any change in condition were documented, had appropriate interventions initiated and physician notification was provided. The regional nurse consultants provided inservices for all licensed nursing staff on conducting head to toe assessments with return demonstration achieved on [DATE] through [DATE]. All staff that were unavailable for re-education must receive the in-services prior to reporting to work again. The facility nurse managers will inservice any agency staff scheduled to work in the facility prior to reporting to their unit for duty, Regional consultants began providing facility staff oversight in the following areas: Nursing, MDS, Rehabilitation, Dietary, QA and Administration on [DATE]. A RN nursing supervisor was secured on [DATE] for the evening shifts M-F and on weekends to provide additional oversight to the nursing staff of any acute issues and assessment and intervention needs. This position will be ongoing. Regional oversight was initiated 7 days a week beginning [DATE]. Regional oversight will continue until the facility is in compliance and has successfully completed the first SSF (survey special focus) 6 month survey. Depending on survey results, the frequency and duration of Regional oversight may be adjusted. The CEO initiated administrative oversight of all Administrative directives as of [DATE]. The CEO/Regional Licensed Nursing Home Administrator will continue to provide administrative oversight until the facility is in compliance and has successfully completed the first SSF survey. Depending on survey results, the frequency and duration of Regional oversight may be adjusted. The Quality Assessment and Assurance expectations were reviewed and education provided to the Administrator by the CEO on [DATE]. All staff were re-educated on Abuse, Neglect and Misappropriation of Resident Property beginning [DATE] through [DATE], by the Regional Staff. All staff that were unavailable for re-education must receive the inservices prior to reporting to work. The facility will identify other residents having the potential to be affected deficient practice by the following: The Nurses will identify any resident with a change in condition and document such in the nurses notes, 24 hour report, unusual occurrence form and report to the oncoming shift of all residents identified as requiring assessments, interventions, and notification of the resident's physician. This intervention was initiated [DATE] and will be ongoing. The 24 hour report, physician orders, unusual occurrence reports and incident reports will be reviewed during the Morning Management Meeting M-F. The weekend RN supervisor and the evening RN supervisor will complete these reports during the evenings and weekend hours to ensure the necessary standard of care has been provided. This intervention was effective on [DATE] and will be ongoing. The MDS Coordinators will notify the Director of Nurses and Administrator of any significant change in condition assessments that are triggered through the MDS assessment period. This intervention was effective [DATE]. The Unit Managers, M-F, during the day shift, will compile for tracking and QA purposes, a monthly report of all residents requiring assessments for changes in condition, interventions and episodes of physician notification and the treatment outcomes. The RN House Supervisor, M-F, on the ,[DATE] shift, will collect data to give the Unit Managers, M-F for compilation. On Saturday & Sunday, the 12 hours RN House Supervisor, will collect data to provide the M-F, Unit Managers as well. Therefore we will have 7 day a week nursing administrative oversight for the consistent compilation of data to allow us to make the best possible decisions for the best resident outcomes. This report will be submitted to the monthly QA and A committee for tracking, trending and identification of patterns that require further action and education. This intervention was initiated [DATE] and will be ongoing. The Department Managers will make resident interviews a continued part of their morning rounds and observations. These interviews will be discussed during the morning management meetings with discussion completed of any observed change in resident's condition. This will be documented on the room round sheet by each department manager and recorded in the morning meeting minutes by the Administrator. This intervention was initiated [DATE] and will be ongoing. The Administrator will review with a [MEDICATION NAME] OPCP, LLC operations manager all grievances and potential [MEDICATION NAME] to ensure that complete investigations are achieved. This intervention was initiated [DATE] and will be ongoing." The citation at F-281 remained at a lowered scope and severity of "E". The facility will be in compliance at F-281 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the day of the Complaint and Extended Survey, based on record review and interview the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Resident #1 failed to have the necessary care and services required related to an acute change in condition, the resident was not assessed, vital signs were not obtained and the physician was not notified timely of an acute change in condition. Resident #4 had a delay in physician notification of an acute change in condition. The findings included: F-309 previously cited on [DATE] at a "G" was cited again on [DATE] at Substandard Quality of Care and Immediate Jeopardy at a "L" related to the failure of the facility to provide the necessary care and services for 2 of 3 residents. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each residents provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-281 as it relates to the failure of the facility to provide accurate, current and appropriate assessments, interventions and re-assessments to residents with acute changes in condition. Resident #1 and #4 were identified during the investigation with negative outcomes. Licensed Practical Nurse #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The physician was not notified timely when Resident #4 had an acute change in condition. Cross refers to F-490 as it relates to the failure of the facility to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 acted negligently. The facility also failed to identify, report and follow up on another potential allegation of neglect related to Resident #4. Cross refers to F-520 as it relates to the failure of the facility to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, notification of the physician and reporting of alleged neglect. Despite the initiation of plan(s) by the facility to address resident assessment, care and services and reporting of abuse/neglect concerns were identified during the survey for two of seven sampled resident's during the survey. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] revealed the resident scored a "2" on the Brief Interview for Mental Status indicating severe cognitive impairment. The resident was also coded as requiring two person total dependence for transfers and required extensive assistance with all other activities of daily living. No behaviors were coded during the assessment period. Review of the physician's orders [REDACTED]. On [DATE] the resident's INR (International Normalizing Ratio) was 3.84 (Critically High) and the [MEDICATION NAME] was decreased to 3 mg. Also, on [DATE] (after the 3 mg was given) the resident's [MEDICATION NAME] was discontinued due to blood noted in the resident's brief. On [DATE] the INR was 2.44 (within therapeutic limits) however, the [MEDICATION NAME] remained on hold per physicians order. On [DATE] Resident #1 was started on an antibiotic for a urinary tract infection. Review of the Nurse's Notes revealed the resident's blood pressure on [DATE] at 3:20 AM was ,[DATE]. On [DATE] at 10 PM the blood pressure was ,[DATE]. Further review revealed the resident's blood pressure varied between ,[DATE]'s systolic and ,[DATE]'s diastolic during her stay at the facility. The resident was also noted to have been prescribed Cardiazem ER 240 mg daily, [MEDICATION NAME]/HCTZ ,[DATE].5 mg daily, [MEDICATION NAME] 500 mg three times daily, [MEDICATION NAME] 25 mg daily and [MEDICATION NAME] 1 mg three times daily. There were no changes in the resident's cardiotonic medications during her stay at the facility. On [DATE] at 8 AM the resident was noted to not void during third shift and "skin tenting" was documented. The physician was notified and the staff was encouraged to push fluids. At 2:30 PM, the resident still had not voided and "consumed very little fluids." On [DATE] the resident reported an upset stomach and refused medications. On [DATE] at 10 PM, "when changing resident's brief this shift, CNA (certified nurse assistant) noticed what seemed to be blood and notified this nurse, when I went to assess her, there was no obvious point of bleeding. Will continue to monitor. No signs and symptoms of distress or pain. [DATE] at 7 AM, "has been no more blood in brief or any c/o pain or distress..." (Due to a discrepancy in the Nurse's Notes dated [DATE] at 10 PM and [DATE] at 7 AM the surveyor was unable to determine when the bleeding was noted in Resident #1's brief.) 11:30 AM, "INR 3.84, called to (Physician) telephone order d/c [MEDICATION NAME] 4 mg give [MEDICATION NAME] 3 mg PO (by mouth) QD (daily). Re-check INR in one week." 12:20 PM, "Res consumes a few bites of foods, spoonfed to her by staff. Makes needs self understood c slurred speech..." 2:50 PM, "Res has been OOB (out of bed) s (without) distress. No reported bleeding vaginal or rectal." 3:30 AM, "Urine obtained for U/A via in/out cath. Blood noted in urine..." 4:30 PM, "Pt's U/A results called to (Physician) new order received [MEDICATION NAME] mg twice daily x 7 days... Pts [MEDICATION NAME] D/C'd (discontinued) on [DATE]. Pt will have PT/INR drawn in AM..." [DATE] at 4:15 AM, the resident was noted to have a large loose stool. at 10:30 AM, "Res continues to have loose stools..." 1:30 PM, "Loose stool has worsened... Send stool for C.Diff..." 5 PM, "Res laying in bed, says she doesn't want any meds or food. Res did have another loose stool." [DATE] at 1 PM, "C.Diff neg (negative), INR 2.44-called (Physician) ordered to keep [MEDICATION NAME] stopped and recheck INR Mon(day)." [DATE] at 3:30 AM, "VS ,[DATE], 97.6, 50, 17, 93%. [MEDICATION NAME] supp 25 mg given @ 2:45 AM for nausea. [MEDICATION NAME] UTI (urinary tract infection). Stool (checked) for C.Diff [DATE] c neg results r/t loose stools. Blood noted in brief [DATE] and UA was done [MEDICATION NAME] for UTI. No blood noted tonight. [MEDICATION NAME] remains on hold. PT/INR on Mon [DATE]. Res alert and able to make needs known." 7 AM, "Res noted vomiting dark brown liquid at 6:30 AM, hemocult was (+) for blood. CNA called nurse back to room at 6:40 AM and res had dark brown liquid from left nostril and mouth. Called (Physician) and ordered to send to (Hospital) to see GI ([MEDICATION NAME]) MD." 7:10 AM, "Called Transmed to transport." 8:15 AM, "Transmed here to transport, followed staff (Transmed) to room and noted res had no pulse or resp. Res noted to have dark brown liquid from mouth and nose. Liquid was almost black in color and smelled of blood." CPR (cardiopulmonary resuscitation) started (after) checking chart for DNR (do not resuscitate), called CODE BLUE. (Physician) called and made aware. Transmed attendants started CPR. 911 called." CPR was stopped per ER physician's orders [REDACTED]. There was no evidence that an assessment was completed by the night shift nurse on ,[DATE] - [DATE] (LPN #1), there was no evidence vital signs were taken or any intervention performed when the resident was noted to have occult blood. Review of the Transfer form completed by LPN #1 revealed the "Vital signs at time of transfer" were the same recorded vital signs at 3:30 AM. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (The [MEDICATION NAME] dosage had been changed on [DATE] and then discontinued on ,[DATE], after the dose was given). Further review revealed on [DATE] at 2:45 AM, the resident received 25 mg of [MEDICATION NAME] via rectal suppository for N/V (Nausea and Vomiting). LPN #1 documented "not eff(ective)." However, there was no time recorded of the "not effective" assessment and no evidence that any other intervention or physician notification was attempted related to the nausea and vomiting until after 7 AM. Record Review revealed a History and Physical was done on [DATE], however, no physician progress notes [REDACTED]. During a telephone interview with the surveyor on [DATE] at 12 PM, the Physician stated that he specifically remembered the phone call the morning of [DATE] because he was eating breakfast with his family. The Physician stated that he was informed that Resident #1 was vomiting blood, he stated that the nurse did not have any vital signs or any other assessment data at the time of the phone call. The Physician stated that he requested the nurse place him on hold and obtain a current set of vital signs. He stated that the vital signs reported to him were not "emergent" in nature and did not alarm him. He stated that he ordered the resident be sent to the hospital for evaluation but did not need to be sent via 911. He stated that he was called again and was informed that the resident's blood pressure was 60 over palp and no respirations and that EMS was coding her. He was then informed that the resident had expired in the facility. The Physician stated that he could not remember what the actual vital signs reported were. He also stated that he did not know the resident well enough to know what her vital signs were typically. The Physician also confirmed that he was aware that the resident had blood in her urinary tract and the [MEDICATION NAME] was on hold. He was not aware that the resident received a 4 mg dose of [MEDICATION NAME] on [DATE] when the medication was ordered to be on hold. During a telephone interview with the surveyor on [DATE] at 12:20 PM, Licensed Practical Nurse (LPN) #1 stated that she was assigned to Resident #1 on the night shift of ,[DATE]-[DATE]. She stated that at 12 AM, the resident was "fine." At 3:30 AM, the resident complained of nausea and she stated that she gave a [MEDICATION NAME] suppository; the resident did not have any more complaints. At 6:30 AM, the CNA reported that the resident had thrown up brown emesis and she checked the emesis for occult blood, which was heme positive. She stated that she went back to her med cart and was finishing up her med pass, when approximately 10 minutes later, the CNA reported the resident had thrown up again and was coming from her nose. LPN #1 stated that that the resident was on her side with her head down then she left the room and called the physician. She stated that the resident's blood pressure had been running low previously but she was alert and talking to her. LPN #1 also stated that she "had a lot going on" that shift and had other residents that she needed to call the doctor for; the change of shift had arrived and she asked LPN #2 to go to the room with her to check on the resident. LPN #1 stated that approximately ,[DATE] minutes later Transmed was in the room coding her. The nurse stated that while on the phone with the Physician, he did not request any further information or request she obtain vital signs. She stated that she "could not remember" when the vital signs were obtained. LPN #1 stated that she did not perform an assessment on the resident or perform any interventions for the resident. She confirmed that she did not return to the resident's room until Transmed arrived. LPN #1 also confirmed her documentation on the back of the MAR indicated [REDACTED]. She confirmed that she did not provide any other interventions to the resident for the nausea. During a telephone interview with the surveyor on [DATE] at 2:35 PM, LPN #2 stated that she was the oncoming nurse on [DATE] for the 7AM-3 PM shift. LPN #2 stated that she was at the nurse's desk and LPN #1 was down the hall at her med cart. At 7:15 AM, LPN #1 informed LPN #2 that she had sick patients and had 4 she needed to call the doctor for. LPN #2 stated that LPN #1 was called back down the hall to Resident #1's room. She stated that LPN #1 then came back up the hall and requested that she (LPN#2) go to the resident's room with her because the resident had blood coming out of her nose and mouth. LPN #2 stated that when she got to the room, the CNA was cleaning her up and she did not see any blood. LPN #2 stated that the resident did not look good and was "very pale." She stated that both nurses left the room and returned to the desk. LPN #1 proceeded to call the doctor and she, LPN #2 was making copies and preparing the chart for the resident to be transferred out. During an interview with the surveyor on [DATE] the Director of Nurses and Administrator confirmed the lack of assessment, intervention and documentation surrounding the events on ,[DATE] - [DATE]. Both the DON and Administrator confirmed there were no other documented vital signs since 3:30 AM. They also confirmed the resident Transfer Form contained the vital signs recorded at 3:30 AM, however, both stated that they were not aware at the time, the values were the same. The DON and Administrator were also not aware that the resident received a 4 mg dose of [MEDICATION NAME] on [DATE] when the medication was on hold. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Resident #4 was noted to have recurrent hospitalization s [MEDICAL CONDITION] and was most recently re-admitted to the facility on [DATE]. Resident #4 was in the hospital at the time of survey. Review of the Nurse's Notes revealed on [DATE] at 10 :30 AM, "Spoke c (Physician) regarding resident condition. Informed MD of res (resident) in and out of responsiveness. Res holding food and snuff in her mouth. Res stares at you, but does not respond to verbal commands. MD states to send res out to ER." At 11:30 AM, the resident was transferred to the ER via Transmed. Further review of the "Physician's Notification of Change in Condition Form" revealed "During breakfast, res noted to be laying c head in table. Res easily aroused by this nurse, but was in and out of responsiveness. ST attempted to awake res for meal. Res holding food in her mouth along c snuff. Meds held due to unresponsiveness (ALOC-altered level of consciousness)." There was no evidence that the nurse assessed the resident or provided an intervention to the resident. In addition, there was a delay in notifying the physician of the acute change in condition. The nurse, after she was informed of the acute change, carried out her other duties, held the resident's medications and did not contact the physician until 10:30 AM. During an interview with the surveyor on [DATE], the Director of Nurses confirmed that Resident #4 was sent to the hospital on [DATE] for an acute change in condition, but was not aware of the delay in contacting the physician. On [DATE] at 4:40 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy was identified at F-309 at a scope and severity of "L". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on [DATE]. The Substandard Quality of Care and Immediate Jeopardy identified at F-309 at a scope and severity of "L" remained ongoing at the time the surveyor exited the facility on [DATE].

On the day of the Complaint and Extended Survey, based on record review and interview the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Resident #1 failed to have the necessary care and services required related to an acute change in condition, the resident was not assessed, vital signs were not obtained and the physician was not notified timely of an acute change in condition. Resident #4 had a delay in physician notification of an acute change in condition. The findings included: F-309 previously cited on [DATE] at a "G" was cited again on [DATE] at Substandard Quality of Care and Immediate Jeopardy at a "L" related to the failure of the facility to provide the necessary care and services for 2 of 3 residents. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each residents provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-281 as it relates to the failure of the facility to provide accurate, current and appropriate assessments, interventions and re-assessments to residents with acute changes in condition. Resident #1 and #4 were identified during the investigation with negative outcomes. Licensed Practical Nurse #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The physician was not notified timely when Resident #4 had an acute change in condition. Cross refers to F-490 as it relates to the failure of the facility to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 acted negligently. The facility also failed to identify, report and follow up on another potential allegation of neglect related to Resident #4. Cross refers to F-520 as it relates to the failure of the facility to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, notification of the physician and reporting of alleged neglect. Despite the initiation of plan(s) by the facility to address resident assessment, care and services and reporting of abuse/neglect concerns were identified during the survey for two of seven sampled resident's during the survey. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] revealed the resident scored a "2" on the Brief Interview for Mental Status indicating severe cognitive impairment. The resident was also coded as requiring two person total dependence for transfers and required extensive assistance with all other activities of daily living. No behaviors were coded during the assessment period. Review of the physician's orders [REDACTED]. On [DATE] the resident's INR (International Normalizing Ratio) was 3.84 (Critically High) and the [MEDICATION NAME] was decreased to 3 mg. Also, on [DATE] (after the 3 mg was given) the resident's [MEDICATION NAME] was discontinued due to blood noted in the resident's brief. On [DATE] the INR was 2.44 (within therapeutic limits) however, the [MEDICATION NAME] remained on hold per physicians order. On [DATE] Resident #1 was started on an antibiotic for a urinary tract infection. Review of the Nurse's Notes revealed the resident's blood pressure on [DATE] at 3:20 AM was ,[DATE]. On [DATE] at 10 PM the blood pressure was ,[DATE]. Further review revealed the resident's blood pressure varied between ,[DATE]'s systolic and ,[DATE]'s diastolic during her stay at the facility. The resident was also noted to have been prescribed Cardiazem ER 240 mg daily, [MEDICATION NAME]/HCTZ ,[DATE].5 mg daily, [MEDICATION NAME] 500 mg three times daily, [MEDICATION NAME] 25 mg daily and [MEDICATION NAME] 1 mg three times daily. There were no changes in the resident's cardiotonic medications during her stay at the facility. On [DATE] at 8 AM the resident was noted to not void during third shift and "skin tenting" was documented. The physician was notified and the staff was encouraged to push fluids. At 2:30 PM, the resident still had not voided and "consumed very little fluids." On [DATE] the resident reported an upset stomach and refused medications. On [DATE] at 10 PM, "when changing resident's brief this shift, CNA (certified nurse assistant) noticed what seemed to be blood and notified this nurse, when I went to assess her, there was no obvious point of bleeding. Will continue to monitor. No signs and symptoms of distress or pain. [DATE] at 7 AM, "has been no more blood in brief or any c/o pain or distress..." (Due to a discrepancy in the Nurse's Notes dated [DATE] at 10 PM and [DATE] at 7 AM the surveyor was unable to determine when the bleeding was noted in Resident #1's brief.) 11:30 AM, "INR 3.84, called to (Physician) telephone order d/c [MEDICATION NAME] 4 mg give [MEDICATION NAME] 3 mg PO (by mouth) QD (daily). Re-check INR in one week." 12:20 PM, "Res consumes a few bites of foods, spoonfed to her by staff. Makes needs self understood c slurred speech..." 2:50 PM, "Res has been OOB (out of bed) s (without) distress. No reported bleeding vaginal or rectal." 3:30 AM, "Urine obtained for U/A via in/out cath. Blood noted in urine..." 4:30 PM, "Pt's U/A results called to (Physician) new order received [MEDICATION NAME] mg twice daily x 7 days... Pts [MEDICATION NAME] D/C'd (discontinued) on [DATE]. Pt will have PT/INR drawn in AM..." [DATE] at 4:15 AM, the resident was noted to have a large loose stool. at 10:30 AM, "Res continues to have loose stools..." 1:30 PM, "Loose stool has worsened... Send stool for C.Diff..." 5 PM, "Res laying in bed, says she doesn't want any meds or food. Res did have another loose stool." [DATE] at 1 PM, "C.Diff neg (negative), INR 2.44-called (Physician) ordered to keep [MEDICATION NAME] stopped and recheck INR Mon(day)." [DATE] at 3:30 AM, "VS ,[DATE], 97.6, 50, 17, 93%. [MEDICATION NAME] supp 25 mg given @ 2:45 AM for nausea. [MEDICATION NAME] UTI (urinary tract infection). Stool (checked) for C.Diff [DATE] c neg results r/t loose stools. Blood noted in brief [DATE] and UA was done [MEDICATION NAME] for UTI. No blood noted tonight. [MEDICATION NAME] remains on hold. PT/INR on Mon [DATE]. Res alert and able to make needs known." 7 AM, "Res noted vomiting dark brown liquid at 6:30 AM, hemocult was (+) for blood. CNA called nurse back to room at 6:40 AM and res had dark brown liquid from left nostril and mouth. Called (Physician) and ordered to send to (Hospital) to see GI ([MEDICATION NAME]) MD." 7:10 AM, "Called Transmed to transport." 8:15 AM, "Transmed here to transport, followed staff (Transmed) to room and noted res had no pulse or resp. Res noted to have dark brown liquid from mouth and nose. Liquid was almost black in color and smelled of blood." CPR (cardiopulmonary resuscitation) started (after) checking chart for DNR (do not resuscitate), called CODE BLUE. (Physician) called and made aware. Transmed attendants started CPR. 911 called." CPR was stopped per ER physician's orders [REDACTED]. There was no evidence that an assessment was completed by the night shift nurse on ,[DATE] - [DATE] (LPN #1), there was no evidence vital signs were taken or any intervention performed when the resident was noted to have occult blood. Review of the Transfer form completed by LPN #1 revealed the "Vital signs at time of transfer" were the same recorded vital signs at 3:30 AM. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (The [MEDICATION NAME] dosage had been changed on [DATE] and then discontinued on ,[DATE], after the dose was given). Further review revealed on [DATE] at 2:45 AM, the resident received 25 mg of [MEDICATION NAME] via rectal suppository for N/V (Nausea and Vomiting). LPN #1 documented "not eff(ective)." However, there was no time recorded of the "not effective" assessment and no evidence that any other intervention or physician notification was attempted related to the nausea and vomiting until after 7 AM. Record Review revealed a History and Physical was done on [DATE], however, no physician progress notes [REDACTED]. During a telephone interview with the surveyor on [DATE] at 12 PM, the Physician stated that he specifically remembered the phone call the morning of [DATE] because he was eating breakfast with his family. The Physician stated that he was informed that Resident #1 was vomiting blood, he stated that the nurse did not have any vital signs or any other assessment data at the time of the phone call. The Physician stated that he requested the nurse place him on hold and obtain a current set of vital signs. He stated that the vital signs reported to him were not "emergent" in nature and did not alarm him. He stated that he ordered the resident be sent to the hospital for evaluation but did not need to be sent via 911. He stated that he was called again and was informed that the resident's blood pressure was 60 over palp and no respirations and that EMS was coding her. He was then informed that the resident had expired in the facility. The Physician stated that he could not remember what the actual vital signs reported were. He also stated that he did not know the resident well enough to know what her vital signs were typically. The Physician also confirmed that he was aware that the resident had blood in her urinary tract and the [MEDICATION NAME] was on hold. He was not aware that the resident received a 4 mg dose of [MEDICATION NAME] on [DATE] when the medication was ordered to be on hold. During a telephone interview with the surveyor on [DATE] at 12:20 PM, Licensed Practical Nurse (LPN) #1 stated that she was assigned to Resident #1 on the night shift of ,[DATE]-[DATE]. She stated that at 12 AM, the resident was "fine." At 3:30 AM, the resident complained of nausea and she stated that she gave a [MEDICATION NAME] suppository; the resident did not have any more complaints. At 6:30 AM, the CNA reported that the resident had thrown up brown emesis and she checked the emesis for occult blood, which was heme positive. She stated that she went back to her med cart and was finishing up her med pass, when approximately 10 minutes later, the CNA reported the resident had thrown up again and was coming from her nose. LPN #1 stated that that the resident was on her side with her head down then she left the room and called the physician. She stated that the resident's blood pressure had been running low previously but she was alert and talking to her. LPN #1 also stated that she "had a lot going on" that shift and had other residents that she needed to call the doctor for; the change of shift had arrived and she asked LPN #2 to go to the room with her to check on the resident. LPN #1 stated that approximately ,[DATE] minutes later Transmed was in the room coding her. The nurse stated that while on the phone with the Physician, he did not request any further information or request she obtain vital signs. She stated that she "could not remember" when the vital signs were obtained. LPN #1 stated that she did not perform an assessment on the resident or perform any interventions for the resident. She confirmed that she did not return to the resident's room until Transmed arrived. LPN #1 also confirmed her documentation on the back of the MAR indicated [REDACTED]. She confirmed that she did not provide any other interventions to the resident for the nausea. During a telephone interview with the surveyor on [DATE] at 2:35 PM, LPN #2 stated that she was the oncoming nurse on [DATE] for the 7AM-3 PM shift. LPN #2 stated that she was at the nurse's desk and LPN #1 was down the hall at her med cart. At 7:15 AM, LPN #1 informed LPN #2 that she had sick patients and had 4 she needed to call the doctor for. LPN #2 stated that LPN #1 was called back down the hall to Resident #1's room. She stated that LPN #1 then came back up the hall and requested that she (LPN#2) go to the resident's room with her because the resident had blood coming out of her nose and mouth. LPN #2 stated that when she got to the room, the CNA was cleaning her up and she did not see any blood. LPN #2 stated that the resident did not look good and was "very pale." She stated that both nurses left the room and returned to the desk. LPN #1 proceeded to call the doctor and she, LPN #2 was making copies and preparing the chart for the resident to be transferred out. During an interview with the surveyor on [DATE] the Director of Nurses and Administrator confirmed the lack of assessment, intervention and documentation surrounding the events on ,[DATE] - [DATE]. Both the DON and Administrator confirmed there were no other documented vital signs since 3:30 AM. They also confirmed the resident Transfer Form contained the vital signs recorded at 3:30 AM, however, both stated that they were not aware at the time, the values were the same. The DON and Administrator were also not aware that the resident received a 4 mg dose of [MEDICATION NAME] on [DATE] when the medication was on hold. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Resident #4 was noted to have recurrent hospitalization s [MEDICAL CONDITION] and was most recently re-admitted to the facility on [DATE]. Resident #4 was in the hospital at the time of survey. Review of the Nurse's Notes revealed on [DATE] at 10 :30 AM, "Spoke c (Physician) regarding resident condition. Informed MD of res (resident) in and out of responsiveness. Res holding food and snuff in her mouth. Res stares at you, but does not respond to verbal commands. MD states to send res out to ER." At 11:30 AM, the resident was transferred to the ER via Transmed. Further review of the "Physician's Notification of Change in Condition Form" revealed "During breakfast, res noted to be laying c head in table. Res easily aroused by this nurse, but was in and out of responsiveness. ST attempted to awake res for meal. Res holding food in her mouth along c snuff. Meds held due to unresponsiveness (ALOC-altered level of consciousness)." There was no evidence that the nurse assessed the resident or provided an intervention to the resident. In addition, there was a delay in notifying the physician of the acute change in condition. The nurse, after she was informed of the acute change, carried out her other duties, held the resident's medications and did not contact the physician until 10:30 AM. During an interview with the surveyor on [DATE], the Director of Nurses confirmed that Resident #4 was sent to the hospital on [DATE] for an acute change in condition, but was not aware of the delay in contacting the physician. On [DATE] at 4:40 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy was identified at F-309 at a scope and severity of "L". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on [DATE]. The Substandard Quality of Care and Immediate Jeopardy identified at F-309 at a scope and severity of "L" remained ongoing at the time the surveyor exited the facility on [DATE]. FOLLOWUP VISIT During an unannounced onsite visit on [DATE] at 9:45 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice as of [DATE], removing the immediacy of the deficient practice. The actions listed in the Allegation of Compliance included the following: "A chart review was completed by the regional consultant team on #1 and #4 on [DATE] to determine system failures to be immediately addressed for correction. The physicians for both residents #1 and #4 were notified on [DATE] of the Immediate jeopardy that related to residents change of condition. The family of the resident #1 was notified on [DATE]. The family of resident #4 was notified on [DATE]. On [DATE] the Regional Nurse Consultants began a 100% audit of all clinical assessments completed for each facility resident to ensure that proper assessments of current condition and any change in condition were documented, had appropriate interventions initiated and physician notification was provided. The regional nurse consultants provided inservices for all licensed nursing staff on conducting head to toe assessments with return demonstration achieved on [DATE] through [DATE]. All staff that were unavailable for re-education must receive the in-services prior to reporting to work again. The facility nurse managers will inservice any agency staff scheduled to work in the facility prior to reporting to their unit for duty, Regional consultants began providing facility staff oversight in the following areas: Nursing, MDS, Rehabilitation, Dietary, QA and Administration on [DATE]. A RN nursing supervisor was secured on [DATE] for the evening shifts M-F and on weekends to provide additional oversight to the nursing staff of any acute issues and assessment and intervention needs. This position will be ongoing. Regional oversight was initiated 7 days a week beginning [DATE]. Regional oversight will continue until the facility is in compliance and has successfully completed the first SSF (survey special focus) 6 month survey. Depending on survey results, the frequency and duration of Regional oversight may be adjusted. The CEO initiated administrative oversight of all Administrative directives as of [DATE]. The CEO/Regional Licensed Nursing Home Administrator will continue to provide administrative oversight until the facility is in compliance and has successfully completed the first SSF survey. Depending on survey results, the frequency and duration of Regional oversight may be adjusted. The Quality Assessment and Assurance expectations were reviewed and education provided to the Administrator by the CEO on [DATE]. All staff were re-educated on Abuse, Neglect and Misappropriation of Resident Property beginning [DATE] through [DATE], by the Regional Staff. All staff that were unavailable for re-education must receive the inservices prior to reporting to work. The facility will identify other residents having the potential to be affected deficient practice by the following: The Nurses will identify any resident with a change in condition and document such in the nurses notes, 24 hour report, unusual occurrence form and report to the oncoming shift of all residents identified as requiring assessments, interventions, and notification of the resident's physician. This intervention was initiated [DATE] and will be ongoing. The 24 hour report, physician orders, unusual occurrence reports and incident reports will be reviewed during the Morning Management Meeting M-F. The weekend RN supervisor and the evening RN supervisor will complete these reports during the evenings and weekend hours to ensure the necessary standard of care has been provided. This intervention was effective on [DATE] and will be ongoing. The MDS Coordinators will notify the Director of Nurses and Administrator of any significant change in condition assessments that are triggered through the MDS assessment period. This intervention was effective [DATE]. The Unit Managers, M-F, during the day shift, will compile for tracking and QA purposes, a monthly report of all residents requiring assessments for changes in condition, interventions and episodes of physician notification and the treatment outcomes. The RN House Supervisor, M-F, on the ,[DATE] shift, will collect data to give the Unit Managers, M-F for compilation. On Saturday & Sunday, the 12 hours RN House Supervisor, will collect data to provide the M-F, Unit Managers as well. Therefore we will have 7 day a week nursing administrative oversight for the consistent compilation of data to allow us to make the best possible decisions for the best resident outcomes. This report will be submitted to the monthly QA and A committee for tracking, trending and identification of patterns that require further action and education. This intervention was initiated [DATE] and will be ongoing. The Department Managers will make resident interviews a continued part of their morning rounds and observations. These interviews will be discussed during the morning management meetings with discussion completed of any observed change in resident's condition. This will be documented on the room round sheet by each department manager and recorded in the morning meeting minutes by the Administrator. This intervention was initiated [DATE] and will be ongoing. The Administrator will review with a [MEDICATION NAME] OPCP, LLC operations manager all grievances and potential [MEDICATION NAME] to ensure that complete investigations are achieved. This intervention was initiated [DATE] and will be ongoing." The citation at F-309 remained at a lowered scope and severity of "E". The facility will be in compliance at F-309 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the day of the Complaint and Extended Survey the facility Administration failed to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 acted negligently. The facility also failed to identify, report and follow up on another potential allegation of neglect related to Resident #4. The findings included: F-490 previously cited as part of the Recertification Survey conducted [DATE] and not corrected on the follow up survey conducted [DATE]. On [DATE] F-490 was cited at Immediate Jeopardy "L" related to an allegation of neglect. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each residents provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-281 as it relates to the failure of the facility to provide accurate, current and appropriate assessments, interventions and re-assessments to residents with acute changes in condition. Resident #1 and #4 were identified during the investigation with negative outcomes. Licensed Practical Nurse #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The physician was not notified timely when Resident #4 had an acute change in condition. Cross refers to F-309 as it relates to the failure of the facility to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Resident #1 failed to have the necessary care and services required related to an acute change in condition, the resident was not assessed, vital signs were not obtained and the physician was not notified timely of an acute change in condition. Resident #4 had a delay in physician notification of an acute change in condition. Cross refers to F-520 as it relates to the failure of the facility to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, notification of the physician and reporting of alleged neglect. Despite the initiation of plan(s) by the facility to address resident assessment, care and services and reporting of abuse/neglect concerns were identified during the survey for two of seven sampled resident's during the survey. Review of the Facility 24-Hour Report dated [DATE] (two days after the incident occurred) revealed, "Nurse notified MD of change in condition, obtained orders but failed to assess resident." Review of the Facility 5-Day report dated [DATE] (10 days after the incident occurred) revealed "It was determined at the conclusion of the investigation that (LPN #1) provided appropriate goods and services to this resident (Resident #1), however (LPN #1) did need to be more accurate in her reporting and recording of events when making entries in the medical record." Review of the Summary of Events revealed: "(LPN #1) stated to this writer (ADON) that she had monitored (Resident #1) throughout the night. The first time she saw (Res #1) after the aide reported a small amount of dried brown vomitus, it was late in the shift. (LPN #1) questioned the resident regarding her stomach upset and the resident stated she was nauseous. (LPN #1) provided a [MEDICATION NAME] suppository at that time and looked at the med sheet to see that (Res #1) was [MEDICATION NAME] that can be irritating to the stomach lining. (LPN #1) checked on the resident again when she doing (sic) her AM medication pass, the resident again had a small amount of dark brown fluid dried to her chin so this time (LPN #1) checked to see if it might be blood. The vomitus did test positive for blood. (LPN #1) said that the resident was alert, talking with her and in not distress but had an upset stomach. When the oncoming staff arrived, (LPN #1) stated to the nurse that she had to confer with the doctor regarding several acute issues including (Res #1). At about the same time, the night shift aide, who was still on duty, called (LPN #1) to the resident's room. (LPN #1) went to the room to see that (Res #1) had vomited a moderate amount of brown vomit. (LPN #1) said that the resident still did not appear to be in any distress, she asked the aide to get VS. (LPN #1) then went and got (LPN #2) to come to see the resident as this time, there had been some vomit from the nares as well... (LPN #1) stated that the last time she saw the resident before EMS arrived, (Res #1's) color was good, her Vital Signs were stable, she was able to carry on a conversation and it was (LPN #1's) judgement that (Res #1) was not in critical condition..." CPR was stopped per ER physician's orders [REDACTED]. There was no evidence that an assessment had been completed by the night shift nurse on ,[DATE] - [DATE] (LPN #1), there was no evidence vital signs were taken or any intervention performed when the resident was noted to have occult blood. Review of the Transfer form completed by LPN #1 revealed the "Vital signs at time of transfer" were the same recorded vital signs at 3:30 AM. During an interview with the surveyor on [DATE] the Administrator confirmed that she reported the incident as potential neglect to the State Certification Agency. She indicated that at the time the facility felt that Licensed Practical Nurse (LPN) #1 acted appropriately and neglect was not substantiated. The Administrator confirmed again that there was no documentation of assessment, intervention or vital signs recorded since 3:30 AM on [DATE]. The Administrator confirmed the actions of LPN #1 were negligent. Resident #4 had a delay in obtaining medically necessary treatment related to an acute change in condition. During an interview on [DATE], the Director of Nurses confirmed the resident was sent to the hospital on [DATE] for an acute change in condition, but was not aware of the delay in contacting the physician. The DON and Administrator confirmed the delay in notifying the Physician and confirmed that the delay in obtaining the necessary medical treatment. On [DATE] at 4:40 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy was identified at F-490 at a scope and severity of "L". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on [DATE]. The Substandard Quality of Care and Immediate Jeopardy identified at F-490 at a scope and severity of "L" remained ongoing at the time the surveyor exited the facility on [DATE].

On the day of the Complaint and Extended Survey the facility Administration failed to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 acted negligently. The facility also failed to identify, report and follow up on another potential allegation of neglect related to Resident #4. The findings included: F-490 previously cited as part of the Recertification Survey conducted [DATE] and not corrected on the follow up survey conducted [DATE]. On [DATE] F-490 was cited at Immediate Jeopardy "L" related to an allegation of neglect. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each residents provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-281 as it relates to the failure of the facility to provide accurate, current and appropriate assessments, interventions and re-assessments to residents with acute changes in condition. Resident #1 and #4 were identified during the investigation with negative outcomes. Licensed Practical Nurse #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The physician was not notified timely when Resident #4 had an acute change in condition. Cross refers to F-309 as it relates to the failure of the facility to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Resident #1 failed to have the necessary care and services required related to an acute change in condition, the resident was not assessed, vital signs were not obtained and the physician was not notified timely of an acute change in condition. Resident #4 had a delay in physician notification of an acute change in condition. Cross refers to F-520 as it relates to the failure of the facility to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, notification of the physician and reporting of alleged neglect. Despite the initiation of plan(s) by the facility to address resident assessment, care and services and reporting of abuse/neglect concerns were identified during the survey for two of seven sampled resident's during the survey. Review of the Facility 24-Hour Report dated [DATE] (two days after the incident occurred) revealed, "Nurse notified MD of change in condition, obtained orders but failed to assess resident." Review of the Facility 5-Day report dated [DATE] (10 days after the incident occurred) revealed "It was determined at the conclusion of the investigation that (LPN #1) provided appropriate goods and services to this resident (Resident #1), however (LPN #1) did need to be more accurate in her reporting and recording of events when making entries in the medical record." Review of the Summary of Events revealed: "(LPN #1) stated to this writer (ADON) that she had monitored (Resident #1) throughout the night. The first time she saw (Res #1) after the aide reported a small amount of dried brown vomitus, it was late in the shift. (LPN #1) questioned the resident regarding her stomach upset and the resident stated she was nauseous. (LPN #1) provided a [MEDICATION NAME] suppository at that time and looked at the med sheet to see that (Res #1) was [MEDICATION NAME] that can be irritating to the stomach lining. (LPN #1) checked on the resident again when she doing (sic) her AM medication pass, the resident again had a small amount of dark brown fluid dried to her chin so this time (LPN #1) checked to see if it might be blood. The vomitus did test positive for blood. (LPN #1) said that the resident was alert, talking with her and in not distress but had an upset stomach. When the oncoming staff arrived, (LPN #1) stated to the nurse that she had to confer with the doctor regarding several acute issues including (Res #1). At about the same time, the night shift aide, who was still on duty, called (LPN #1) to the resident's room. (LPN #1) went to the room to see that (Res #1) had vomited a moderate amount of brown vomit. (LPN #1) said that the resident still did not appear to be in any distress, she asked the aide to get VS. (LPN #1) then went and got (LPN #2) to come to see the resident as this time, there had been some vomit from the nares as well... (LPN #1) stated that the last time she saw the resident before EMS arrived, (Res #1's) color was good, her Vital Signs were stable, she was able to carry on a conversation and it was (LPN #1's) judgement that (Res #1) was not in critical condition..." CPR was stopped per ER physician's orders [REDACTED]. There was no evidence that an assessment had been completed by the night shift nurse on ,[DATE] - [DATE] (LPN #1), there was no evidence vital signs were taken or any intervention performed when the resident was noted to have occult blood. Review of the Transfer form completed by LPN #1 revealed the "Vital signs at time of transfer" were the same recorded vital signs at 3:30 AM. During an interview with the surveyor on [DATE] the Administrator confirmed that she reported the incident as potential neglect to the State Certification Agency. She indicated that at the time the facility felt that Licensed Practical Nurse (LPN) #1 acted appropriately and neglect was not substantiated. The Administrator confirmed again that there was no documentation of assessment, intervention or vital signs recorded since 3:30 AM on [DATE]. The Administrator confirmed the actions of LPN #1 were negligent. Resident #4 had a delay in obtaining medically necessary treatment related to an acute change in condition. During an interview on [DATE], the Director of Nurses confirmed the resident was sent to the hospital on [DATE] for an acute change in condition, but was not aware of the delay in contacting the physician. The DON and Administrator confirmed the delay in notifying the Physician and confirmed that the delay in obtaining the necessary medical treatment. On [DATE] at 4:40 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy was identified at F-490 at a scope and severity of "L". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on [DATE]. The Substandard Quality of Care and Immediate Jeopardy identified at F-490 at a scope and severity of "L" remained ongoing at the time the surveyor exited the facility on [DATE]. FOLLOWUP VISIT During an unannounced onsite visit on [DATE] at 9:45 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice as of [DATE], removing the immediacy of the deficient practice. The actions listed in the Allegation of Compliance included the following: "A chart review was completed by the regional consultant team on #1 and #4 on [DATE] to determine system failures to be immediately addressed for correction. The physicians for both residents #1 and #4 were notified on [DATE] of the Immediate jeopardy that related to residents change of condition. The family of the resident #1 was notified on [DATE]. The family of resident #4 was notified on [DATE]. On [DATE] the Regional Nurse Consultants began a 100% audit of all clinical assessments completed for each facility resident to ensure that proper assessments of current condition and any change in condition were documented, had appropriate interventions initiated and physician notification was provided. The regional nurse consultants provided inservices for all licensed nursing staff on conducting head to toe assessments with return demonstration achieved on [DATE] through [DATE]. All staff that were unavailable for re-education must receive the in-services prior to reporting to work again. The facility nurse managers will inservice any agency staff scheduled to work in the facility prior to reporting to their unit for duty, Regional consultants began providing facility staff oversight in the following areas: Nursing, MDS, Rehabilitation, Dietary, QA and Administration on [DATE]. A RN nursing supervisor was secured on [DATE] for the evening shifts M-F and on weekends to provide additional oversight to the nursing staff of any acute issues and assessment and intervention needs. This position will be ongoing. Regional oversight was initiated 7 days a week beginning [DATE]. Regional oversight will continue until the facility is in compliance and has successfully completed the first SSF (survey special focus) 6 month survey. Depending on survey results, the frequency and duration of Regional oversight may be adjusted. The CEO initiated administrative oversight of all Administrative directives as of [DATE]. The CEO/Regional Licensed Nursing Home Administrator will continue to provide administrative oversight until the facility is in compliance and has successfully completed the first SSF survey. Depending on survey results, the frequency and duration of Regional oversight may be adjusted. The Quality Assessment and Assurance expectations were reviewed and education provided to the Administrator by the CEO on [DATE]. All staff were re-educated on Abuse, Neglect and Misappropriation of Resident Property beginning [DATE] through [DATE], by the Regional Staff. All staff that were unavailable for re-education must receive the inservices prior to reporting to work. The facility will identify other residents having the potential to be affected deficient practice by the following: The Nurses will identify any resident with a change in condition and document such in the nurses notes, 24 hour report, unusual occurrence form and report to the oncoming shift of all residents identified as requiring assessments, interventions, and notification of the resident's physician. This intervention was initiated [DATE] and will be ongoing. The 24 hour report, physician orders, unusual occurrence reports and incident reports will be reviewed during the Morning Management Meeting M-F. The weekend RN supervisor and the evening RN supervisor will complete these reports during the evenings and weekend hours to ensure the necessary standard of care has been provided. This intervention was effective on [DATE] and will be ongoing. The MDS Coordinators will notify the Director of Nurses and Administrator of any significant change in condition assessments that are triggered through the MDS assessment period. This intervention was effective [DATE]. The Unit Managers, M-F, during the day shift, will compile for tracking and QA purposes, a monthly report of all residents requiring assessments for changes in condition, interventions and episodes of physician notification and the treatment outcomes. The RN House Supervisor, M-F, on the ,[DATE] shift, will collect data to give the Unit Managers, M-F for compilation. On Saturday & Sunday, the 12 hours RN House Supervisor, will collect data to provide the M-F, Unit Managers as well. Therefore we will have 7 day a week nursing administrative oversight for the consistent compilation of data to allow us to make the best possible decisions for the best resident outcomes. This report will be submitted to the monthly QA and A committee for tracking, trending and identification of patterns that require further action and education. This intervention was initiated [DATE] and will be ongoing. The Department Managers will make resident interviews a continued part of their morning rounds and observations. These interviews will be discussed during the morning management meetings with discussion completed of any observed change in resident's condition. This will be documented on the room round sheet by each department manager and recorded in the morning meeting minutes by the Administrator. This intervention was initiated [DATE] and will be ongoing. The Administrator will review with a [MEDICATION NAME] OPCP, LLC operations manager all grievances and potential [MEDICATION NAME] to ensure that complete investigations are achieved. This intervention was initiated [DATE] and will be ongoing." The citation at F-490 remained at a lowered scope and severity of "E". The facility will be in compliance at F-490 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the day of the Complaint and Extended Survey based on record reviews, interviews and observations, the facility failed to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, notification of the physician and reporting of alleged neglect. Despite the initiation of plan(s) by the facility to address resident assessment, care and services and reporting of abuse/neglect concerns were identified during the survey for two of seven residents sampled during the survey. The findings included: F-520 previously cited as part of the Recertification Survey conducted [DATE] and corrected on the follow up survey conducted [DATE]. On [DATE] F-520 was cited at Immediate Jeopardy "L" related to an allegation of neglect. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each resident's provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-281 as it relates to the failure of the facility to provide accurate, current and appropriate assessments, interventions and re-assessments to residents with acute changes in condition. Resident #1 and #4 were identified during the investigation with negative outcomes. Licensed Practical Nurse #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The physician was not notified timely when Resident #4 had an acute change in condition. Cross refers to F-309 as it relates to the failure of the facility to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Resident #1 failed to have the necessary care and services required related to an acute change in condition, the resident was not assessed, vital signs were not obtained and the physician was not notified timely of an acute change in condition. Resident #4 had a delay in physician notification of an acute change in condition. Cross refers to F-490 as it relates to the failure of the facility to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 acted negligently. The facility also failed to identify, report and follow up on another potential allegation of neglect related to Resident #4. During an interview with the surveyor on [DATE] the Director of Nurses (DON) and Administrator confirmed the lack of assessment, intervention and documentation surrounding Residents #1 death on [DATE] at approximately 8:00 AM. Both the DON and Administrator confirmed there was no other documented vital signs since 3:30 AM. They also confirmed the resident Transfer Form contained the vital signs recorded at 3:30 AM, however, both stated that they were not aware at the time the values were the same. The DON and Administrator were also not aware that the resident received a 4 mg dose of [MEDICATION NAME] on [DATE] when the medication was on hold. The Administrator confirmed that she reported the incident as potential neglect to the State Certification Agency, however, had unsubstantiated the findings. She indicated that at the time the facility felt that LPN #1 acted appropriately. The Administrator confirmed again that there was no documentation of assessment, intervention or vital signs recorded since 3:30 AM on [DATE]. She also acknowledged that even though LPN #1 had contacted the physician, the information relayed to the physician was not an accurate assessment of the resident, the physician was not provided current vital signs and the Administrator confirmed that LPN #1 did not re-assess or intervene between the time Transmed transport was notified and arrived at the facility (45 minutes) when the resident was noted to no longer have a heart beat and no respirations. The Administrator confirmed the actions of LPN #1 were negligent. During an interview with the surveyor on [DATE], the Director of Nurses confirmed the Resident #4 was sent to the hospital on [DATE] for an acute change in condition, but was not aware of the delay in contacting the physician. The DON and Administrator confirmed the delay in notifying the Physician and confirmed the delay in obtaining the necessary medical treatment. Review of the Quality Assurance Committee Meeting Minutes dated [DATE] that was attended by the Administrator and the Director of Nurses revealed the facility identified concerns related to changes in condition, physician notification and nursing assessments. The "issues are being addressed through the following: Administrator and DON have met with the physician's to explain the education being provided to the nurses regarding proper assessment and identification of abnormal vital signs prior to calling the physician. Education nurses on triaging resident with acute conditions... continued education of the staff in understanding abuse and neglect and to report it when it is identified... changes in forms to report changes to physician, changes in the morning meeting forms to enhance monitoring for the nurses for improved resident outcomes..." There were no time lines indicated for implementation or completion. A formal action plan had not been developed at the time of survey. The above information was confirmed with the Administrator on [DATE]. The Administrator also confirmed that actions put in place were not effective related to the identification of Resident #4's delay in physician notification and delay in obtaining medical treatment. On [DATE] at 4:40 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy was identified at F-520 at a scope and severity of "L". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on [DATE]. The Substandard Quality of Care and Immediate Jeopardy identified at F-520 at a scope and severity of "L" remained ongoing at the time the surveyor exited the facility on [DATE].

On the day of the Complaint and Extended Survey based on record review, information provided by the facility and review of the Policy on Abuse and Neglect Prohibition the facility failed to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The findings included: F-226 previously cited as part of the Recertification Survey conducted 2/29/12 and not corrected on the follow up survey conducted 4/26/12. On 5/24/12 F-226 was cited at a "D" and elevated to Substandard Quality of Care and Immediate Jeopardy at "L" on 6/14/12 related to the failure of the facility to follow their abuse policy. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each resident's provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-309 as it relates to the failure of the facility to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Resident #1 failed to have the necessary care and services required related to an acute change in condition, the resident was not assessed, vital signs were not obtained and the physician was not notified timely of an acute change in condition. Resident #4 had a delay in physician notification of an acute change in condition. Cross refers to F-490 as it relates to the failure of the facility to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 acted negligently. The facility also failed to identify, report and follow up on another potential incident of neglect related to Resident #4. Cross refers to F-520 as it relates to the failure of the facility to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, notification of the physician and reporting of alleged neglect. Despite the initiation of plan(s) by the facility to address resident assessment, care and services and reporting of abuse/neglect concerns were identified during the survey for two of seven residents sampled during the survey. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the 24 Hour Report dated 6/4/12 (two days after the incident occurred) revealed, "Nurse notified MD of change in condition, obtained orders but failed to assess resident." Review of the 5 Day report dated 6/12/12 (10 days after the incident occurred) revealed "It was determined at the conclusion of the investigation that (LPN #1) provided appropriate goods and services to this resident (Resident #1), however (LPN #1) did need to be more accurate in her reporting and recording of events when making entries in the medical record." The facility failed to immediately, thoroughly investigate the incident related to Resident #1 and initiate corrective actions to prevent neglect. Resident #4 with an acute change in condition was sent out to the hospital on [DATE] and was not reviewed to determine if the care provided was adequate. Review of the facility Policy on Abuse and Neglect Prohibition revealed the following: "Prevention ... 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring... Investigation 1. The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance with state law. 2. The facility will report such allegations to the state, as per state regulations. 3. The facility will report all investigation findings to the state as per state regulations. 4. The facility will investigate all patterns, trends or incidents that suggest the possible presence of abuse, neglect or misappropriation of resident property, identified through analysis conducted by the QA&A committee, with intervention, reporting or policy/procedure modification as appropriate..." On 6/14/12 at 4:40 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy was identified at F-226 at a scope and severity of "L". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on 6/2/12. Substandard Quality of Care and Immediate Jeopardy identified at F-226 at a scope and severity of "L" remained ongoing at the time the surveyor exited the facility on 6/14/12. FOLLOWUP VISIT During an unannounced onsite visit on 06/28/2012 at 9:45 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on 06/26/2012 had been implemented by the facility and was in practice as of 06/27/2012, removing the immediacy of the deficient practice. The Allegation of Compliance with a completion date of 6/27/2012 was submitted by the facility on 6/26/2012. The actions listed in the Allegation of Compliance included the following: "A chart review was completed by the regional consultant team on #1 and #4 on 6-14-2012 to determine system failures to be immediately addressed for correction. The physicians for both residents #1 and #4 were notified on 6-14-12 of the Immediate jeopardy that related to residents change of condition. The family of the resident #1 was notified on 6-2-12. The family of resident #4 was notified on 6-12-12. On 6/15/12 the Regional Nurse Consultants began a 100% audit of all clinical assessments completed for each facility resident to ensure that proper assessments of current condition and any change in condition were documented, had appropriate interventions initiated and physician notification was provided. The regional nurse consultants provided inservices for all licensed nursing staff on conducting head to toe assessments with return demonstration achieved on 6-15-12 through 6-27-12. All staff that were unavailable for re-education must receive the in-services prior to reporting to work again. The facility nurse managers will inservice any agency staff scheduled to work in the facility prior to reporting to their unit for duty, Regional consultants began providing facility staff oversight in the following areas: Nursing, MDS, Rehabilitation, Dietary, QA and Administration on 6-15-2012. A RN nursing supervisor was secured on 6-5-12 for the evening shifts M-F and on weekends to provide additional oversight to the nursing staff of any acute issues and assessment and intervention needs. This position will be ongoing. Regional oversight was initiated 7 days a week beginning 6-15-2012. Regional oversight will continue until the facility is in compliance and has successfully completed the first SSF (survey special focus) 6 month survey. Depending on survey results, the frequency and duration of Regional oversight may be adjusted. The CEO initiated administrative oversight of all Administrative directives as of 6-15-2012. The CEO/Regional Licensed Nursing Home Administrator will continue to provide administrative oversight until the facility is in compliance and has successfully completed the first SSF survey. Depending on survey results, the frequency and duration of Regional oversight may be adjusted. The Quality Assessment and Assurance expectations were reviewed and education provided to the Administrator by the CEO on 6-15-2012. All staff were re-educated on Abuse, Neglect and Misappropriation of Resident Property beginning 6-15-2012 through 6-27-12, by the Regional Staff. All staff that were unavailable for re-education must receive the inservices prior to reporting to work. The facility will identify other residents having the potential to be affected deficient practice by the following: The Nurses will identify any resident with a change in condition and document such in the nurses notes, 24 hour report, unusual occurrence form and report to the oncoming shift of all residents identified as requiring assessments, interventions, and notification of the resident's physician. This intervention was initiated 6-14-12 and will be ongoing. The 24 hour report, physician orders, unusual occurrence reports and incident reports will be reviewed during the Morning Management Meeting M-F. The weekend RN supervisor and the evening RN supervisor will complete these reports during the evenings and weekend hours to ensure the necessary standard of care has been provided. This intervention was effective on 6-15-12 and will be ongoing. The MDS Coordinators will notify the Director of Nurses and Administrator of any significant change in condition assessments that are triggered through the MDS assessment period. This intervention was effective 6-15-12. The Unit Managers, M-F, during the day shift, will compile for tracking and QA purposes, a monthly report of all residents requiring assessments for changes in condition, interventions and episodes of physician notification and the treatment outcomes. The RN House Supervisor, M-F, on the 3-11 shift, will collect data to give the Unit Managers, M-F for compilation. On Saturday & Sunday, the 12 hours RN House Supervisor, will collect data to provide the M-F, Unit Managers as well. Therefore we will have 7 day a week nursing administrative oversight for the consistent compilation of data to allow us to make the best possible decisions for the best resident outcomes. This report will be submitted to the monthly QA and A committee for tracking, trending and identification of patterns that require further action and education. This intervention was initiated 6-14-12 and will be ongoing. The Department Managers will make resident interviews a continued part of their morning rounds and observations. These interviews will be discussed during the morning management meetings with discussion completed of any observed change in resident's condition. This will be documented on the room round sheet by each department manager and recorded in the morning meeting minutes by the Administrator. This intervention was initiated 6-15-12 and will be ongoing. The Administrator will review with a [MEDICATION NAME] OPCP, LLC operations manager all grievances and potential [MEDICATION NAME] to ensure that complete investigations are achieved. This intervention was initiated 6-15-12 and will be ongoing." The citation at F-226 remained at a lowered scope and severity of "E". The facility will be in compliance at F-226 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the day of the Complaint and Extended Survey, the facility failed to ensure that each resident provided the necessary good and services to avoid physical harm. Residents #1 and #4 were identified during the investigation as having negative outcomes. Licensed Practical Nurse (LPN) #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition, delaying the necessary medical care. The findings included: F-224 previously cited as part of the Recertification Survey conducted [DATE] and corrected on the follow up survey conducted [DATE]. On [DATE] F-224 was cited at a "D" and elevated to Substandard Quality of Care and Immediate Jeopardy at "L" on [DATE] related to an allegation of neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-281 as it relates to the failure of the facility to provide accurate, current and appropriate assessments, interventions and re-assessments to residents with acute changes in condition. Resident #1 and #4 were identified during the investigation with negative outcomes. Licensed Practical Nurse #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The physician was not notified timely when Resident #4 had an acute change in condition. Cross refers to F-309 as it relates to the failure of the facility to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Resident #1 failed to have the necessary care and services required related to an acute change in condition, the resident was not assessed, vital signs were not obtained and the physician was not notified timely of an acute change in condition. Resident #4 had a delay in physician notification of an acute change in condition. Cross refers to F-490 as it relates to the failure of the facility to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 acted negligently. The facility also failed to identify, report and follow up on potential neglect related to Resident #4. Cross refers to F-520 as it relates to the failure of the facility to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, notification of the physician and reporting of alleged neglect. Despite the initiation of plan(s) by the facility to address resident assessment, care and services and reporting of abuse/neglect concerns were identified during the survey for two of seven sampled resident's. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the 24 Hour Report dated [DATE] (two days after the incident occurred) revealed, "Nurse notified MD of change in condition, obtained orders but failed to assess resident." Review of the 5 Day report dated [DATE] (10 days after the incident occurred) revealed "It was determined at the conclusion of the investigation that (LPN #1) provided appropriate goods and services to this resident (Resident #1), however (LPN #1) did need to be more accurate in her reporting and recording of events when making entries in the medical record." Review of the physician's orders [REDACTED].#1 was prescribed [MEDICATION NAME] 4 milligrams (mg) daily. On [DATE] the resident's INR (International Normalizing Ratio) was 3.84 (Critically High) and the [MEDICATION NAME] was decreased to 3 mg. Also, on [DATE] (after the 3 mg dose had been given) the resident's [MEDICATION NAME] was discontinued due to blood noted in the resident's brief. On [DATE] the INR was 2.44 (within therapeutic limits) however, the [MEDICATION NAME] remained on hold for the remainder of the resident's stay at the facility. Resident #1 was also noted to have a Urinary Tract Infection and was started on an antibiotic on [DATE]. Review of the Nurse's Notes revealed the resident's blood pressure on [DATE] at 3:20 AM was ,[DATE]. On [DATE] at 10 PM the blood pressure was ,[DATE]. Further review revealed the resident's blood pressure varied between ,[DATE]'s systolic and ,[DATE]'s diastolic during her stay at the facility. The resident was also noted to have been prescribed Cardiazem ER (extended release) 240 mg daily, [MEDICATION NAME]/HCTZ ,[DATE].5 mg (milligrams) daily, [MEDICATION NAME] 500 mg three times daily, [MEDICATION NAME] 25 mg daily and [MEDICATION NAME] 1 mg three times daily. There were no changes in the resident's cardiotonic medications during her stay at the facility. On [DATE] at 8 AM the resident was noted to not void during third shift and "skin tenting" was documented. The physician was notified and the staff was encouraged to push fluids. At 2:30 PM, the resident still had not voided and "consumed very little fluids." On [DATE] the resident reported an upset stomach and refused medications. On [DATE] at 10 PM, "when changing resident's brief this shift, CNA (certified nurse assistant) noticed what seemed to be blood and notified this nurse, when I went to assess her, there was no obvious point of bleeding. Will continue to monitor. No signs and symptoms of distress or pain. (Due to a discrepancy in the Nurse's Notes dated [DATE] at 10 PM and [DATE] at 7 AM the surveyor was unable to determine when the bleeding was noted in Resident #1's brief.) [DATE] at 7 AM, "has been no more blood in brief or any c/o (complaint of) pain or distress..." 11:30 AM, "INR 3.84, called to (Physician) telephone order d/c (discontinue) [MEDICATION NAME] 4 mg give [MEDICATION NAME] 3 mg PO QD. Re-check INR in one week." 12:20 PM, "Res consumes a few bites of foods, spoonfed to her by staff. Makes needs self understood c slurred speech..." At 2:50 PM, "Res has been OOB (out of bed) s (without) distress. No reported bleeding vaginal or rectal." 3:30 AM, "Urine obtained for U/A via in/out cath. Blood noted in urine..." 4:30 PM, "Pt's U/A results called to (Physician) new order received [MEDICATION NAME] mg twice daily x 7 days... Pts [MEDICATION NAME] D/C'd on [DATE]. Pt will have PT/INR drawn in AM..." [DATE] at 4:15 AM, the resident was noted to have a large loose stool. at 10:30 AM, "Res continues to have loose stools..." 1:30 PM, "Loose stool has worsened...Send stool for C.Diff..." 5 PM, "Res laying in bed, says she doesn't want any meds or food. Res did have another loose stool." [DATE] 1 PM, "C.Diff neg (negative), INR 2.44-called (Physician) ordered to keep [MEDICATION NAME] stopped and recheck INR Mon(day)." [DATE] 3:30 AM, "VS ,[DATE], 97.6, 50, 17, 93%. [MEDICATION NAME] supp (suppository) 25 mg given @ 2:45 AM for nausea. [MEDICATION NAME] UTI (urinary tract infection). Stool (checked) for C.Diff [DATE] c neg results r/t loose stools. Blood noted in brief [DATE] and UA was done [MEDICATION NAME] for UTI. No blood noted tonight. [MEDICATION NAME] remains on hold. PT/INR on Mon [DATE]. Res alert and able to make needs known." 7 AM, "Res noted vomiting dark brown liquid at 6:30 AM, hemocult was (+) for blood. CNA (certified nurses assistant) called nurse back to room at 6:40 AM and res had dark brown liquid from left nostril and mouth. Called (Physician) and ordered to send to (Hospital) to see GI ([MEDICATION NAME]) MD." 7:10 AM, Called Transmed to transport." 8:15 AM, "Transmed here to transport, followed staff (Transmed) to room and noted res had no pulse or resp. Res noted to have dark brown liquid from mouth and nose. Liquid was almost black in color and smelled of blood." CPR (cardiopulmonary resuscitation) started (after) checking chart for DNR (do not resuscitate), called CODE BLUE. (Physician) called and made aware. Transmed attendants started CPR. 911 called." CPR was stopped per ER physician's orders [REDACTED]. There was no evidence that an assessment was completed by the night shift nurse on ,[DATE] - [DATE] (LPN #1), there was no evidence vital signs were taken or intervention performed when the resident was noted to have occult blood. Review of the Transfer form completed by LPN #1 revealed the "Vital signs at time of transfer" were the same recorded vital signs at 3:30 AM. Review of the Medication Administration Record [REDACTED]. (The [MEDICATION NAME] dosage had been changed on [DATE] and then discontinued on ,[DATE].) Further review revealed on [DATE] at 2:45 AM, the resident received 25 mg of [MEDICATION NAME] via rectal suppository for N/V (Nausea and Vomiting). LPN #1 documented "not eff(ective)." However, there was no time recorded of the "not effective" assessment and no evidence that any other intervention or physician notification was attempted related to the nausea and vomiting until after 7 AM. During an interview with the surveyor on [DATE] at 12 PM, the Physician stated that he specifically remembered the phone call the morning of [DATE] because he was eating breakfast with his family. The Physician stated that he was informed that Resident #1 was vomiting blood, he stated that the nurse did not have any vital signs or any other assessment data at the time of the phone call. The Physician stated that he requested the nurse place him on hold and obtain a current set of vital signs. He stated that the vital signs reported to him were not "emergent" in nature and did not alarm him. He stated that he ordered the resident sent to the hospital for evaluation but did not need to be sent via 911. He stated that he was called later and informed that the resident's blood pressure was 60 over palp and no respirations and that EMS was coding her. He was then informed that the resident had expired in the facility. The Physician stated that he could not remember what the actual vital signs reported were. He also stated that he did not know the resident well enough to know what her vital signs were typically. The Physician also confirmed that he was aware that the resident had blood in her urinary tract and the [MEDICATION NAME] was on hold. He was not aware that the resident received a 4 mg dose of [MEDICATION NAME] on [DATE] when the medication was on hold. Review of the Summary of Events revealed: "(LPN #1) stated to this writer (ADON) that she had monitored (Resident #1) throughout the night. The first time she saw (Res #1) after the aide reported a small amount of dried brown vomitus, it was late in the shift. (LPN #1) questioned the resident regarding her stomach upset and the resident stated she was nauseous. (LPN #1) provided a [MEDICATION NAME] suppository at that time and looked at the med sheet to see that (Res #1) was [MEDICATION NAME] that can be irritating to the stomach lining. (LPN #1) checked on the resident again when she doing (sic) her AM medication pass, the resident again had a small amount of dark brown fluid dried to her chin so this time (LPN #1) checked to see if it might be blood. The vomitus did test positive for blood. (LPN #1) said that the resident was alert, talking with her and in no distress but had an upset stomach. When the oncoming staff arrived, (LPN #1) stated to the nurse that she had to confer with the doctor regarding several acute issues including (Res #1). At about the same time, the night shift aide, who was still on duty, called (LPN #1) to the resident's room. (LPN #1) went to the room to see that (Res #1) had vomited a moderate amount of brown vomit. (LPN #1) said that the resident still did not appear to be in any distress, she asked the aide to get VS. (LPN #1) then went and got (LPN #2) to come to see the resident as this time, there had been some vomit from the nares as well... (LPN #1) stated that the last time she saw the resident before EMS (emergency medical service) arrived, (Res #1's) color was good, her Vital Signs were stable, she was able to carry on a conversation and it was (LPN #1's) judgment that (Res #1) was not in critical condition..." During a telephone interview with the surveyor on [DATE] at 12:20 PM, LPN #1 stated that she was assigned to Resident #1 on the night shift of ,[DATE]-[DATE]. She stated that at 12 AM, the resident was "fine." At 3:30 AM, the resident complained of nausea and she stated that she gave a [MEDICATION NAME] suppository; the resident did not have any more complaints. At 6:30 AM, the CNA reported that the resident had thrown up brown emesis and she checked the emesis for occult blood, which was heme positive. She stated that she went back to her med cart and was finishing up her med pass, when approximately 10 minutes later, the CNA reported the resident had thrown up again and was coming from her nose. LPN #1 stated that the resident was on her side with her head down then she left the room and called the physician. She stated that the resident's blood pressure had been running low previously but she was alert and talking to her. LPN #1 also stated that she "had a lot going on" that shift and had other residents that she needed to call the doctor for; the change of shift had arrived and she asked LPN #2 to go to the room with her to check on the resident. LPN #1 stated that approximately ,[DATE] minutes later Transmed was in the room coding her. The nurse stated that while on the phone with the Physician, he did not request any further information or request she obtain vital signs. She stated that she "could not remember" when the vital signs were obtained. LPN #1 stated that she did not perform an assessment on the resident or perform any interventions for the resident. She confirmed that she did not return to the resident's room until Transmed arrived. LPN #1 also confirmed her documentation on the back of the MAR indicated [REDACTED]. She confirmed that she did not provide any other interventions to the resident for the nausea. Review of the facility obtained statement from LPN #2 revealed "At about 7:15 AM, (LPN #1) came to desk stating I have got 4 people to call the dr on, (Res #1) threw up earlier and I tested it, it was positive for blood. (LPN #1) got called down the hall to room by CNA. (LPN #1) went and then came back to desk stating you need to come see this, we went back to room. (LPN #1) was stating as we was walking down hall, blood is now coming out of her nose. Upon entering room, CNA was cleaning res up. No blood noted. (LPN #1) stated she has already cleaned her up. I stated that she don't look good. We then came to desk. (LPN #1) paged MD about 7:30 AM, I started making the paperwork." During a telephone interview with the surveyor on [DATE] at 2:35 PM, LPN #2 stated that she was the oncoming nurse on [DATE] for the 7AM-3 PM shift. LPN #2 stated that she was at the nurse's desk and LPN #1 was down the hall at her med cart. At 7:15 AM, LPN #1 informed LPN #2 that she had sick patients and she needed to call the doctor for four. LPN #2 stated that LPN #1 was called back down the hall to Resident #1's room. She stated that LPN #1 then came back up the hall and requested that she (LPN#2) go to the resident's room with her because the resident had blood coming out of her nose and mouth. LPN #2 stated that when she got to the room, the CNA was cleaning her up and she did not see any blood. LPN #2 stated that the resident did not look good and was "very pale." She stated that both nurses left the room and returned to the desk. LPN #1 proceeded to call the doctor and she, LPN #2 was making copies and preparing the chart for the resident to be transferred out. During an interview with the surveyor on [DATE] the Director of Nurses and Administrator confirmed the lack of assessment, intervention and documentation surrounding the events on ,[DATE] - [DATE]. Both the DON and Administrator confirmed there were no other documented vital signs since 3:30 AM. They also confirmed the resident Transfer Form contained the vital signs recorded at 3:30 AM, however, both stated that they were not aware at the time the values were the same. The DON and Administrator were also not aware that the resident received a 4 mg dose of [MEDICATION NAME] on [DATE] when the medication was on hold. The Administrator confirmed that she reported the incident as potential neglect to the State Certification Agency. She indicated that at the time the facility felt that LPN #1 acted appropriately and failed to substantiate neglect. The Administrator confirmed again that there was no documentation of assessment, intervention or vital signs recorded since 3:30 AM on [DATE]. She also acknowledged that even though LPN #1 contacted the physician, the information relayed to the physician was not an accurate assessment of the resident, and the physician was not provided current vital signs. The Administrator confirmed that LPN #1 did not re-assess or intervene between the time Transmed was notified and arrived at the facility (45 minutes) when the resident was noted to no longer have a heart beat and no respirations. The Administrator confirmed the actions of LPN #1 were negligent. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Resident #4 was noted to have recurrent hospitalization s [MEDICAL CONDITION] and was recently re-admitted to the facility on [DATE]. Resident #4 was in the hospital at the time of survey. Review of the Nurse's Notes revealed on [DATE] at 10 :30 AM, "Spoke c (Physician) regarding resident condition. Informed MD of res (resident) in and out of responsiveness. Res holding food and snuff in her mouth. Res stares at you, but does not respond to verbal commands. MD states to send res out to ER." At 11:30 AM, the resident was transferred to the ER via Transmed. Further review of the "Physician's Notification of Change in Condition Form" revealed "During breakfast, res noted to be laying c head in table. Res easily aroused by this nurse, but was in and out of responsiveness. ST (speech therapy) attempted to awake res for meal. Res holding food in her mouth along c snuff. Meds held due to unresponsiveness (ALOC-altered level of consciousness)." There was no evidence that the nurse assessed the resident or provided an intervention to the resident. In addition, there was a delay in notifying the physician of the acute change in condition, thereby delaying her transfer to the hospital and necessary medical treatment. The nurse, after she was informed of the acute change, carried out her other duties, held the resident's medications and did not contact the physician until 10:30 AM. During an interview on [DATE], the Director of Nurses confirmed the resident was sent to the hospital on [DATE] for an acute change in condition, but was not aware of the delay in contacting the physician. The DON and Administrator confirmed the delay in notifying the Physician and confirmed that the delay in obtaining the necessary medical treatment. On [DATE] at 4:40 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy was identified at F-224 at a scope and severity of "L". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on [DATE]. The Substandard Quality of Care and Immediate Jeopardy identified at F-224 at a scope and severity of "L" remained ongoing at the time the surveyor exited the facility on [DATE]. FOLLOWUP VISIT During an unannounced onsite visit on [DATE] at 9:45 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice as of [DATE], removing the immediacy of the deficient practice. The Allegation of Compliance with a completion date of [DATE] was submitted by the facility on [DATE]. The actions listed in the Allegation of Compliance included the following: "A chart review was completed by the regional consultant team on #1 and #4 on [DATE] to determine system failures to be immediately addressed for correction. The physicians for both residents #1 and #4 were notified on [DATE] of the Immediate jeopardy that related to residents change of condition. The family of the resident #1 was notified on [DATE]. The family of resident #4 was notified on [DATE]. On [DATE] the Regional Nurse Consultants began a 100% audit of all clinical assessments completed for each facility resident to ensure that proper assessments of current condition and any change in condition were documented, had appropriate interventions initiated and physician notification was provided. The regional nurse consultants provided inservices for all licensed nursing staff on conducting head to toe assessments with return demonstration achieved on [DATE] through [DATE]. All staff that were unavailable for re-education must receive the in-services prior to reporting to work again. The facility nurse managers will inservice any agency staff scheduled to work in the facility prior to reporting to their unit for duty, Regional consultants began providing facility staff oversight in the following areas: Nursing, MDS, Rehabilitation, Dietary, QA and Administration on [DATE]. A RN nursing supervisor was secured on [DATE] for the evening shifts M-F and on weekends to provide additional oversight to the nursing staff of any acute issues and assessment and intervention needs. This position will be ongoing. Regional oversight was initiated 7 days a week beginning [DATE]. Regional oversight will continue until the facility is in compliance and has successfully completed the first SSF (survey special focus) 6 month survey. Depending on survey results, the frequency and duration of Regional oversight may be adjusted. The CEO initiated administrative oversight of all Administrative directives as of [DATE]. The CEO/Regional Licensed Nursing Home Administrator will continue to provide administrative oversight until the facility is in compliance and has successfully completed the first SSF survey. Depending on survey results, the frequency and duration of Regional oversight may be adjusted. The Quality Assessment and Assurance expectations were reviewed and education provided to the Administrator by the CEO on [DATE]. All staff were re-educated on Abuse, Neglect and Misappropriation of Resident Property beginning [DATE] through [DATE], by the Regional Staff. All staff that were unavailable for re-education must receive the inservices prior to reporting to work. The facility will identify other residents having the potential to be affected deficient practice by the following: The Nurses will identify any resident with a change in condition and document such in the nurses notes, 24 hour report, unusual occurrence form and report to the oncoming shift of all residents identified as requiring assessments, interventions, and notification of the resident's physician. This intervention was initiated [DATE] and will be ongoing. The 24 hour report, physician orders, unusual occurrence reports and incident reports will be reviewed during the Morning Management Meeting M-F. The weekend RN supervisor and the evening RN supervisor will complete these reports during the evenings and weekend hours to ensure the necessary standard of care has been provided. This intervention was effective on [DATE] and will be ongoing. The MDS Coordinators will notify the Director of Nurses and Administrator of any significant change in condition assessments that are triggered through the MDS assessment period. This intervention was effective [DATE]. The Unit Managers, M-F, during the day shift, will compile for tracking and QA purposes, a monthly report of all residents requiring assessments for changes in condition, interventions and episodes of physician notification and the treatment outcomes. The RN House Supervisor, M-F, on the ,[DATE] shift, will collect data to give the Unit Managers, M-F for compilation. On Saturday & Sunday, the 12 hours RN House Supervisor, will collect data to provide the M-F, Unit Managers as well. Therefore we will have 7 day a week nursing administrative oversight for the consistent compilation of data to allow us to make the best possible decisions for the best resident outcomes. This report will be submitted to the monthly QA and A committee for tracking, trending and identification of patterns that require further action and education. This intervention was initiated [DATE] and will be ongoing. The Department Managers will make resident interviews a continued part of their morning rounds and observations. These interviews will be discussed during the morning management meetings with discussion completed of any observed change in resident's condition. This will be documented on the room round sheet by each department manager and recorded in the morning meeting minutes by the Administrator. This intervention was initiated [DATE] and will be ongoing. The Administrator will review with a [MEDICATION NAME] OPCP, LLC operations manager all grievances and potential [MEDICATION NAME] to ensure that complete investigations are achieved. This intervention was initiated [DATE] and will be ongoing." The citation at F-224 remained at a lowered scope and severity of "E". The facility will be in compliance at F-224 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the day of the Complaint and Extended Survey, the facility failed to ensure that each resident provided the necessary good and services to avoid physical harm. Residents #1 and #4 were identified during the investigation as having negative outcomes. Licensed Practical Nurse (LPN) #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition, delaying the necessary medical care. The findings included: F-224 previously cited as part of the Recertification Survey conducted [DATE] and corrected on the follow up survey conducted [DATE]. On [DATE] F-224 was cited at a "D" and elevated to Substandard Quality of Care and Immediate Jeopardy at "L" on [DATE] related to an allegation of neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-281 as it relates to the failure of the facility to provide accurate, current and appropriate assessments, interventions and re-assessments to residents with acute changes in condition. Resident #1 and #4 were identified during the investigation with negative outcomes. Licensed Practical Nurse #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The physician was not notified timely when Resident #4 had an acute change in condition. Cross refers to F-309 as it relates to the failure of the facility to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Resident #1 failed to have the necessary care and services required related to an acute change in condition, the resident was not assessed, vital signs were not obtained and the physician was not notified timely of an acute change in condition. Resident #4 had a delay in physician notification of an acute change in condition. Cross refers to F-490 as it relates to the failure of the facility to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 acted negligently. The facility also failed to identify, report and follow up on potential neglect related to Resident #4. Cross refers to F-520 as it relates to the failure of the facility to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, notification of the physician and reporting of alleged neglect. Despite the initiation of plan(s) by the facility to address resident assessment, care and services and reporting of abuse/neglect concerns were identified during the survey for two of seven sampled resident's. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the 24 Hour Report dated [DATE] (two days after the incident occurred) revealed, "Nurse notified MD of change in condition, obtained orders but failed to assess resident." Review of the 5 Day report dated [DATE] (10 days after the incident occurred) revealed "It was determined at the conclusion of the investigation that (LPN #1) provided appropriate goods and services to this resident (Resident #1), however (LPN #1) did need to be more accurate in her reporting and recording of events when making entries in the medical record." Review of the physician's orders [REDACTED]. On [DATE] the resident's INR (International Normalizing Ratio) was 3.84 (Critically High) and the [MEDICATION NAME] was decreased to 3 mg. Also, on [DATE] (after the 3 mg dose had been given) the resident's [MEDICATION NAME] was discontinued due to blood noted in the resident's brief. On [DATE] the INR was 2.44 (within therapeutic limits) however, the [MEDICATION NAME] remained on hold for the remainder of the resident's stay at the facility. Resident #1 was also noted to have a Urinary Tract Infection and was started on an antibiotic on [DATE]. Review of the Nurse's Notes revealed the resident's blood pressure on [DATE] at 3:20 AM was ,[DATE]. On [DATE] at 10 PM the blood pressure was ,[DATE]. Further review revealed the resident's blood pressure varied between ,[DATE]'s systolic and ,[DATE]'s diastolic during her stay at the facility. The resident was also noted to have been prescribed Cardiazem ER (extended release) 240 mg daily, [MEDICATION NAME]/HCTZ ,[DATE].5 mg (milligrams) daily, [MEDICATION NAME] 500 mg three times daily, [MEDICATION NAME] 25 mg daily and [MEDICATION NAME] 1 mg three times daily. There were no changes in the resident's cardiotonic medications during her stay at the facility. On [DATE] at 8 AM the resident was noted to not void during third shift and "skin tenting" was documented. The physician was notified and the staff was encouraged to push fluids. At 2:30 PM, the resident still had not voided and "consumed very little fluids." On [DATE] the resident reported an upset stomach and refused medications. On [DATE] at 10 PM, "when changing resident's brief this shift, CNA (certified nurse assistant) noticed what seemed to be blood and notified this nurse, when I went to assess her, there was no obvious point of bleeding. Will continue to monitor. No signs and symptoms of distress or pain. (Due to a discrepancy in the Nurse's Notes dated [DATE] at 10 PM and [DATE] at 7 AM the surveyor was unable to determine when the bleeding was noted in Resident #1's brief.) [DATE] at 7 AM, "has been no more blood in brief or any c/o (complaint of) pain or distress..." 11:30 AM, "INR 3.84, called to (Physician) telephone order d/c (discontinue) [MEDICATION NAME] 4 mg give [MEDICATION NAME] 3 mg PO QD. Re-check INR in one week." 12:20 PM, "Res consumes a few bites of foods, spoonfed to her by staff. Makes needs self understood c slurred speech..." At 2:50 PM, "Res has been OOB (out of bed) s (without) distress. No reported bleeding vaginal or rectal." 3:30 AM, "Urine obtained for U/A via in/out cath. Blood noted in urine..." 4:30 PM, "Pt's U/A results called to (Physician) new order received [MEDICATION NAME] mg twice daily x 7 days... Pts [MEDICATION NAME] D/C'd on [DATE]. Pt will have PT/INR drawn in AM..." [DATE] at 4:15 AM, the resident was noted to have a large loose stool. at 10:30 AM, "Res continues to have loose stools..." 1:30 PM, "Loose stool has worsened...Send stool for C.Diff..." 5 PM, "Res laying in bed, says she doesn't want any meds or food. Res did have another loose stool." [DATE] 1 PM, "C.Diff neg (negative), INR 2.44-called (Physician) ordered to keep [MEDICATION NAME] stopped and recheck INR Mon(day)." [DATE] 3:30 AM, "VS ,[DATE], 97.6, 50, 17, 93%. [MEDICATION NAME] supp (suppository) 25 mg given @ 2:45 AM for nausea. [MEDICATION NAME] UTI (urinary tract infection). Stool (checked) for C.Diff [DATE] c neg results r/t loose stools. Blood noted in brief [DATE] and UA was done [MEDICATION NAME] for UTI. No blood noted tonight. [MEDICATION NAME] remains on hold. PT/INR on Mon [DATE]. Res alert and able to make needs known." 7 AM, "Res noted vomiting dark brown liquid at 6:30 AM, hemocult was (+) for blood. CNA (certified nurses assistant) called nurse back to room at 6:40 AM and res had dark brown liquid from left nostril and mouth. Called (Physician) and ordered to send to (Hospital) to see GI ([MEDICATION NAME]) MD." 7:10 AM, Called Transmed to transport." 8:15 AM, "Transmed here to transport, followed staff (Transmed) to room and noted res had no pulse or resp. Res noted to have dark brown liquid from mouth and nose. Liquid was almost black in color and smelled of blood." CPR (cardiopulmonary resuscitation) started (after) checking chart for DNR (do not resuscitate), called CODE BLUE. (Physician) called and made aware. Transmed attendants started CPR. 911 called." CPR was stopped per ER physician's orders [REDACTED]. There was no evidence that an assessment was completed by the night shift nurse on ,[DATE] - [DATE] (LPN #1), there was no evidence vital signs were taken or intervention performed when the resident was noted to have occult blood. Review of the Transfer form completed by LPN #1 revealed the "Vital signs at time of transfer" were the same recorded vital signs at 3:30 AM. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (The [MEDICATION NAME] dosage had been changed on [DATE] and then discontinued on ,[DATE].) Further review revealed on [DATE] at 2:45 AM, the resident received 25 mg of [MEDICATION NAME] via rectal suppository for N/V (Nausea and Vomiting). LPN #1 documented "not eff(ective)." However, there was no time recorded of the "not effective" assessment and no evidence that any other intervention or physician notification was attempted related to the nausea and vomiting until after 7 AM. During an interview with the surveyor on [DATE] at 12 PM, the Physician stated that he specifically remembered the phone call the morning of [DATE] because he was eating breakfast with his family. The Physician stated that he was informed that Resident #1 was vomiting blood, he stated that the nurse did not have any vital signs or any other assessment data at the time of the phone call. The Physician stated that he requested the nurse place him on hold and obtain a current set of vital signs. He stated that the vital signs reported to him were not "emergent" in nature and did not alarm him. He stated that he ordered the resident sent to the hospital for evaluation but did not need to be sent via 911. He stated that he was called later and informed that the resident's blood pressure was 60 over palp and no respirations and that EMS was coding her. He was then informed that the resident had expired in the facility. The Physician stated that he could not remember what the actual vital signs reported were. He also stated that he did not know the resident well enough to know what her vital signs were typically. The Physician also confirmed that he was aware that the resident had blood in her urinary tract and the [MEDICATION NAME] was on hold. He was not aware that the resident received a 4 mg dose of [MEDICATION NAME] on [DATE] when the medication was on hold. Review of the Summary of Events revealed: "(LPN #1) stated to this writer (ADON) that she had monitored (Resident #1) throughout the night. The first time she saw (Res #1) after the aide reported a small amount of dried brown vomitus, it was late in the shift. (LPN #1) questioned the resident regarding her stomach upset and the resident stated she was nauseous. (LPN #1) provided a [MEDICATION NAME] suppository at that time and looked at the med sheet to see that (Res #1) was [MEDICATION NAME] that can be irritating to the stomach lining. (LPN #1) checked on the resident again when she doing (sic) her AM medication pass, the resident again had a small amount of dark brown fluid dried to her chin so this time (LPN #1) checked to see if it might be blood. The vomitus did test positive for blood. (LPN #1) said that the resident was alert, talking with her and in no distress but had an upset stomach. When the oncoming staff arrived, (LPN #1) stated to the nurse that she had to confer with the doctor regarding several acute issues including (Res #1). At about the same time, the night shift aide, who was still on duty, called (LPN #1) to the resident's room. (LPN #1) went to the room to see that (Res #1) had vomited a moderate amount of brown vomit. (LPN #1) said that the resident still did not appear to be in any distress, she asked the aide to get VS. (LPN #1) then went and got (LPN #2) to come to see the resident as this time, there had been some vomit from the nares as well... (LPN #1) stated that the last time she saw the resident before EMS (emergency medical service) arrived, (Res #1's) color was good, her Vital Signs were stable, she was able to carry on a conversation and it was (LPN #1's) judgment that (Res #1) was not in critical condition..." During a telephone interview with the surveyor on [DATE] at 12:20 PM, LPN #1 stated that she was assigned to Resident #1 on the night shift of ,[DATE]-[DATE]. She stated that at 12 AM, the resident was "fine." At 3:30 AM, the resident complained of nausea and she stated that she gave a [MEDICATION NAME] suppository; the resident did not have any more complaints. At 6:30 AM, the CNA reported that the resident had thrown up brown emesis and she checked the emesis for occult blood, which was heme positive. She stated that she went back to her med cart and was finishing up her med pass, when approximately 10 minutes later, the CNA reported the resident had thrown up again and was coming from her nose. LPN #1 stated that the resident was on her side with her head down then she left the room and called the physician. She stated that the resident's blood pressure had been running low previously but she was alert and talking to her. LPN #1 also stated that she "had a lot going on" that shift and had other residents that she needed to call the doctor for; the change of shift had arrived and she asked LPN #2 to go to the room with her to check on the resident. LPN #1 stated that approximately ,[DATE] minutes later Transmed was in the room coding her. The nurse stated that while on the phone with the Physician, he did not request any further information or request she obtain vital signs. She stated that she "could not remember" when the vital signs were obtained. LPN #1 stated that she did not perform an assessment on the resident or perform any interventions for the resident. She confirmed that she did not return to the resident's room until Transmed arrived. LPN #1 also confirmed her documentation on the back of the MAR indicated [REDACTED]. She confirmed that she did not provide any other interventions to the resident for the nausea. Review of the facility obtained statement from LPN #2 revealed "At about 7:15 AM, (LPN #1) came to desk stating I have got 4 people to call the dr on, (Res #1) threw up earlier and I tested it, it was positive for blood. (LPN #1) got called down the hall to room by CNA. (LPN #1) went and then came back to desk stating you need to come see this, we went back to room. (LPN #1) was stating as we was walking down hall, blood is now coming out of her nose. Upon entering room, CNA was cleaning res up. No blood noted. (LPN #1) stated she has already cleaned her up. I stated that she don't look good. We then came to desk. (LPN #1) paged MD about 7:30 AM, I started making the paperwork." During a telephone interview with the surveyor on [DATE] at 2:35 PM, LPN #2 stated that she was the oncoming nurse on [DATE] for the 7AM-3 PM shift. LPN #2 stated that she was at the nurse's desk and LPN #1 was down the hall at her med cart. At 7:15 AM, LPN #1 informed LPN #2 that she had sick patients and she needed to call the doctor for four. LPN #2 stated that LPN #1 was called back down the hall to Resident #1's room. She stated that LPN #1 then came back up the hall and requested that she (LPN#2) go to the resident's room with her because the resident had blood coming out of her nose and mouth. LPN #2 stated that when she got to the room, the CNA was cleaning her up and she did not see any blood. LPN #2 stated that the resident did not look good and was "very pale." She stated that both nurses left the room and returned to the desk. LPN #1 proceeded to call the doctor and she, LPN #2 was making copies and preparing the chart for the resident to be transferred out. During an interview with the surveyor on [DATE] the Director of Nurses and Administrator confirmed the lack of assessment, intervention and documentation surrounding the events on ,[DATE] - [DATE]. Both the DON and Administrator confirmed there were no other documented vital signs since 3:30 AM. They also confirmed the resident Transfer Form contained the vital signs recorded at 3:30 AM, however, both stated that they were not aware at the time the values were the same. The DON and Administrator were also not aware that the resident received a 4 mg dose of [MEDICATION NAME] on [DATE] when the medication was on hold. The Administrator confirmed that she reported the incident as potential neglect to the State Certification Agency. She indicated that at the time the facility felt that LPN #1 acted appropriately and failed to substantiate neglect. The Administrator confirmed again that there was no documentation of assessment, intervention or vital signs recorded since 3:30 AM on [DATE]. She also acknowledged that even though LPN #1 contacted the physician, the information relayed to the physician was not an accurate assessment of the resident, and the physician was not provided current vital signs. The Administrator confirmed that LPN #1 did not re-assess or intervene between the time Transmed was notified and arrived at the facility (45 minutes) when the resident was noted to no longer have a heart beat and no respirations. The Administrator confirmed the actions of LPN #1 were negligent. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Resident #4 was noted to have recurrent hospitalization s [MEDICAL CONDITION] and was recently re-admitted to the facility on [DATE]. Resident #4 was in the hospital at the time of survey. Review of the Nurse's Notes revealed on [DATE] at 10 :30 AM, "Spoke c (Physician) regarding resident condition. Informed MD of res (resident) in and out of responsiveness. Res holding food and snuff in her mouth. Res stares at you, but does not respond to verbal commands. MD states to send res out to ER." At 11:30 AM, the resident was transferred to the ER via Transmed. Further review of the "Physician's Notification of Change in Condition Form" revealed "During breakfast, res noted to be laying c head in table. Res easily aroused by this nurse, but was in and out of responsiveness. ST (speech therapy) attempted to awake res for meal. Res holding food in her mouth along c snuff. Meds held due to unresponsiveness (ALOC-altered level of consciousness)." There was no evidence that the nurse assessed the resident or provided an intervention to the resident. In addition, there was a delay in notifying the physician of the acute change in condition, thereby delaying her transfer to the hospital and necessary medical treatment. The nurse, after she was informed of the acute change, carried out her other duties, held the resident's medications and did not contact the physician until 10:30 AM. During an interview on [DATE], the Director of Nurses confirmed the resident was sent to the hospital on [DATE] for an acute change in condition, but was not aware of the delay in contacting the physician. The DON and Administrator confirmed the delay in notifying the Physician and confirmed that the delay in obtaining the necessary medical treatment. On [DATE] at 4:40 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy was identified at F-224 at a scope and severity of "L". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on [DATE]. The Substandard Quality of Care and Immediate Jeopardy identified at F-224 at a scope and severity of "L" remained ongoing at the time the surveyor exited the facility on [DATE].

On the day of the Complaint and Extended Survey based on record review, information provided by the facility and review of the Policy on Abuse and Neglect Prohibition the facility failed to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The findings included: F-226 previously cited as part of the Recertification Survey conducted 2/29/12 and not corrected on the follow up survey conducted 4/26/12. On 5/24/12 F-226 was cited at a "D" and elevated to Substandard Quality of Care and Immediate Jeopardy at "L" on 6/14/12 related to the failure of the facility to follow their abuse policy. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each resident's provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-309 as it relates to the failure of the facility to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Resident #1 failed to have the necessary care and services required related to an acute change in condition, the resident was not assessed, vital signs were not obtained and the physician was not notified timely of an acute change in condition. Resident #4 had a delay in physician notification of an acute change in condition. Cross refers to F-490 as it relates to the failure of the facility to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 acted negligently. The facility also failed to identify, report and follow up on another potential incident of neglect related to Resident #4. Cross refers to F-520 as it relates to the failure of the facility to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, notification of the physician and reporting of alleged neglect. Despite the initiation of plan(s) by the facility to address resident assessment, care and services and reporting of abuse/neglect concerns were identified during the survey for two of seven residents sampled during the survey. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the 24 Hour Report dated 6/4/12 (two days after the incident occurred) revealed, "Nurse notified MD of change in condition, obtained orders but failed to assess resident." Review of the 5 Day report dated 6/12/12 (10 days after the incident occurred) revealed "It was determined at the conclusion of the investigation that (LPN #1) provided appropriate goods and services to this resident (Resident #1), however (LPN #1) did need to be more accurate in her reporting and recording of events when making entries in the medical record." The facility failed to immediately, thoroughly investigate the incident related to Resident #1 and initiate corrective actions to prevent neglect. Resident #4 with an acute change in condition was sent out to the hospital on [DATE] and was not reviewed to determine if the care provided was adequate. Review of the facility Policy on Abuse and Neglect Prohibition revealed the following: "Prevention ... 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring... Investigation 1. The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance with state law. 2. The facility will report such allegations to the state, as per state regulations. 3. The facility will report all investigation findings to the state as per state regulations. 4. The facility will investigate all patterns, trends or incidents that suggest the possible presence of abuse, neglect or misappropriation of resident property, identified through analysis conducted by the QA&A committee, with intervention, reporting or policy/procedure modification as appropriate..." On 6/14/12 at 4:40 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy was identified at F-226 at a scope and severity of "L". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on 6/2/12. Substandard Quality of Care and Immediate Jeopardy identified at F-226 at a scope and severity of "L" remained ongoing at the time the surveyor exited the facility on 6/14/12.

On the days of the complaint inspection, based on limited record reviews and interviews, the facility failed to follow acceptable standards of practice by failing to thoroughly assess 1 of 1 resident with a change in condition. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed an Annual MDS dated [DATE]. The resident was coded as having a Brief Interview Mental Status (BIMS) score of 4 indicating memory problems and requiring assistance with daily decision making; limited assistance was required with transfers, toileting, dressing and hygiene. She required extensive assistance with bathing. The resident was continent of bowel and occasionally incontinent of bladder. Resident #1 fell on [DATE] and was sent to the hospital with a head injury. Neuro checks were monitored and the resident's blood pressure fluctuated. On 5/18/12 she was noted by Physical Therapy (PT) to complain of dizziness, was tremulous with a decreased in motor abilities and had a decreased ability to follow simple instruction. Per the Physical Therapy note this information was shared with the nursing staff. There was no evidence the nurse assessed the resident regarding the information from PT. On the evening of 5/19/12, her blood pressure was elevated and she received [MEDICATION NAME] and [MEDICATION NAME]. The resident became more confused and drowsy on 5/19/2012 and complained of stomach pain, she did not eat dinner and complained of not feeling well. The entry for the 5/17/12 fall appeared to be written on 5/18/12. The documentation showed one nurse's note on 5/18/12 at 4:00 AM and then the next note was on 5/19/12 at 4 AM; a 24 hour time period without documentation of the resident's condition following a fall. Review of the Interdisciplinary Progress Notes revealed the following nursing documentation: "5/17/12 2:05 AM No behavior noted. 5/18/12 4A Res cont. neuro assessment R/T (related to) fall. VS 132/87... 4:10 A Entry for 5-17-12 for 10p Res returned from... with new orders R/T fall. 2p ...Pt continues neuro checks R/T Fall on 5/17/12 VS 115/84 97.9 136 24 @12:15 PM... Pt to be confused with periods of lethargy. Pt is able to move all extremities appropriately on command when alert... 5/17/12 4:25 PM Entry for Notified by housekeeping supervisor that resident had falling (sic) on the floor in her bathroom. Resident noted lying on her back on the floor half in bathroom and in the bathroom door entrance. Res (resident) talked confused at this time, but did say she use the commode and wanted someone to flush the commode. Resident noted to have a small laceration on her forehead... Dr. notified and orders written... 911 called... Entry for 10:00 PM Resident returned from... Orders written to cleanse area on forehead with NS (normal saline) and apply triple ABT (Antibiotic) ointment to area daily... Neuro checks were started on resident... 5/19/2012 4A cont. neuro check R/T fall. No change in neuro assessment. VS 165/86... 8:30 am Resident continues neuro... Resident moves all ext (extremities) wnl (within normal limits) VS 138/88... at 5:20 PM Resident sitting in the DR (dining room) for supper. She stated she wanted to lie down because she don't feel like eating. She stated her stomach didn't feel good... Resident v/s (vital signs) T 96, P 113, R 22 B/P 172/112. PRN (as needed) [MEDICATION NAME] give at this time... Resident also given [MEDICATION NAME] 0.5 for anxiety. 5:40 PM Resident took back to room and put to bed as request (sic). Assess resident for pain in the stomach and she stated it felt sore when I press on the lower part of the abdomen. Ck'd to see if resident had bm (bowel movement) today. None recorded. Ck'd resident for hard stool and felt some stool in the rectum but not reachable. Gave resident a fleets enema... let CNA assigned to her that I had given her an enema and to be aware if resident call for help suddenly to go to the bathroom. Resident had previously slipped down in w/c (wheel chair) while eating supper. So a alarm pad was placed under resident when she was put back to bed by CNA... 6:00 PM Resident was taken (sic) to the br (bathroom) by /CNA. She stated she voided x 1. No results from enema. 6:30 PM ...Assessed resident stomach again. Stomach felt slight extended. Stomach softer than before still no results from enema. 7:00 PM ...she said her stomach wasn't hurtin at this time. 8:00 PM Resident lying on left side. Moving around in bed restlessly... Resident hands had felt moist and cool. Took FSBS (Finger stick blood sugar) 151. 9:00 PM Resident still awaking at intervals turning side to side in bed... Explained to resident that she should call for help when she felt like she had to go and resident said ok. Resident did remember how to use the call light because she asked for help previously... 10:15 PM CNA... yelled down the hallway for assistant with resident because she had gotten out of bed and fallen on the floor on her back. Resident noted lying in floor with no shoes on and brief pulled partially off. Resident very confused and disoriented. Resident had begun to have a b.m. Resident assessed and put back to bed. Skin cool and clammy (hands). Resident awake but disoriented. Asked CNA to get vital signs while I call 911 to take her to the hospital... Resident vital signs difficult to obtain. v/s wee b/p 89/55, P 49, Couldn't get O2 sat, Resident became non responsive... 11:50 PM No apical pulse, no respirations no signs of life observed..." Review of the Neurological (neuro) Record, revealed Neuro Checks were done upon return from the hospital every 30 minutes x 4, every 1 hour x 4, every 4 hours x 24, every 8 hours x for remaining 72 hours or as ordered by physician. Review of the blood pressure during the neuro checks revealed the following: 5/17/12 10:30 PM 165/102, 11:00 PM -132/87, 11:30 PM -130/84; 5/18/12 12:00 AM -128/78, 12:30 AM- 126/72, 1:30 AM-155/98, 2:30 AM -163/100, 3:30 AM -168/54, 4:30 AM -158/60, 8:30 AM there was no blood pressure recorded, 12:30 PM - B/P 115/84, 4:30 PM - 130/86, 8:30 PM not legible; 5/19/12 12:30 AM -165/86, 8:30 AM 138/88, 4:30 PM- 160/90. On 5/19/12 at 4:30 PM the resident was documented as drowsy. All other checks recorded her as alert. Review of a PT (Physical Therapy Treatment Note) dated 5/18/12 stated, "11:55-12:20 pm. Pt back from hospital last p.m... Pt. tremulous and c/o dizziness. Pt. unsteady w/static standing and required mod (moderate) A (assistance) to transfer to w/c (wheelchair). 4:52-5:07 pm. Applied pressure pad and gel cushion to w/c for pt use secondary to safety. Discussed w/nurse and CNAs regarding pt unsteady while standing and should not transfer without assist. Pt also exhibiting decreased motor planning and ability to follow simple VCs (voice commands). Pt to use w/c over weekend when out of bed to decrease risk of falls." There was no documentation that the resident was thoroughly assessed following the fall on 5/17/12. On 5/18/12 Physical Therapy noted a change in the resident's mobility and her ability to follow voice commands, this information was shared with the nursing staff. The nursing documentation failed to show an assessment of the change in the resident's condition. On 5/19/12 the resident complained of stomach pain and not feeling well; at 5:20 PM her blood pressure was recorded as 172/112 and [MEDICATION NAME] was given. The physician was not notified of the changes in the resident's condition on 5/18 and 5/19/12. During an interview with the Administrator and the Therapy Program Manager on 5/24/12, they stated they put interventions in place for a wheelchair with an alarm. Resident #1 was to be reviewed on Monday 5/21/12. They confirmed there were changes in the neuro checks and the physician was not notified.

On the days of the complaint inspection, based on limited record reviews and interviews, the facility failed to provide the necessary care and services for 2 of 2 residents. There was no evidence Resident #1 was thoroughly assessed related to a changes in her condition after a fall and the physician was not notified of any of the changes in the resident until after a fall on 5/19/12, when the nurse called to get orders to send her to the hospital. It was discovered on 5/12/12 that Resident #2's dressing ordered for daily dressing change, had not been changed since 5/10/12. There was no evidence that Resident #2's wound was assessed and the physician was not notified when her wound was found to have a foul odor, drainage and the dressing had not been changed for approximately 24 hours. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed an Annual MDS dated [DATE]. The resident was coded as having a Brief Interview Mental Status (BIMS) score of 4, indicating the resident had memory problems and required assistance with daily decision making; limited assistance was required with transfers, toileting, dressing and hygiene. She required extensive assistance with bathing. The resident was continent of bowel and occasionally incontinent of bladder. Resident #1 had a fall on 5/17/12 and was sent to the hospital with a head injury. After returning from the emergency roiagnom on [DATE] neurological (neuro) checks were started and the resident's blood pressure fluctuated. On 5/18/12 she was noted to complain of dizziness and be tremulous. She was noted to have decreased motor abilities and had a decreased ability to follow simple instruction. On the evening of 5/19/12, her blood pressure was elevated and she received [MEDICATION NAME] and [MEDICATION NAME]. She became more confused and drowsy on 5/19/2012. She complained of stomach pain, did not eat dinner, and complained of not feeling well. She was manually checked for impaction and received an enema. Resident #1 fell on the evening of 5/19/12 and became unresponsive. Review of the Interdisciplinary Progress Notes revealed the following nursing documentation: "5/17/12 2:05 AM No behavior noted. 5/18/12 4A Res cont. neuro assessment R/T (related to) fall. VS 132/87... 4:10 A Entry for 5-17-12 for 10p Res returned from... with new orders R/T fall. 2p ...Pt continues neuro checks R/T Fall on 5/17/12 VS 115/84 97.9 136 24 @12:15 PM... Pt to be confused with periods of lethargy. Pt is able to move all extremities appropriately on command when alert... 5/17/12 4:25 PM Entry for Notified by housekeeping supervisor that resident had falling (sic) on the floor in her bathroom. Resident noted lying on her back on the floor half in bathroom and in the bathroom door entrance. Res (resident) talked confused at this time, but did say she use the commode and wanted someone to flush the commode. Resident noted to have a small laceration on her forehead... Dr. notified and orders written... 911 called... Entry for 10:00 PM Resident returned from... Orders written to cleanse area on forehead with NS (normal saline) and apply triple ABT (Antibiotic) ointment to area daily... Neuro checks were started on resident... 5/19/2012 4A cont. neuro check R/T fall. No change in neuro assessment. VS 165/86... 8:30 am Resident continues neuro... Resident moves all ext (extremities) wnl (within normal limits) VS 138/88... at 5:20 PM Resident sitting in the DR (dining room) for supper. She stated she wanted to lie down because she don't feel like eating. She stated her stomach didn't feel good... Resident v/s (vital signs) T 96, P 113, R 22 B/P 172/112. PRN (as needed) [MEDICATION NAME] give at this time... Resident also given [MEDICATION NAME] 0.5 for anxiety. 5:40 PM Resident took back to room and put to bed as request (sic). Assess resident for pain in the stomach and she stated it felt sore when I press on the lower part of the abdomen. Ck'd to see if resident had bm (bowel movement) today. None recorded. Ck'd resident for hard stool and felt some stool in the rectum but not reachable. Gave resident a fleets enema... let CNA assigned to her that I had given her an enema and to be aware if resident call for help suddenly to go to the bathroom. Resident had previously slipped down in w/c (wheel chair) while eating supper. So a alarm pad was placed under resident when she was put back to bed by CNA... 6:00 PM Resident was taken (sic) to the br (bathroom) by /CNA. She stated she voided x 1. No results from enema. 6:30 PM ...Assessed resident stomach again. Stomach felt slight extended. Stomach softer than before still no results from enema. 7:00 PM ...she said her stomach wasn't hurtin at this time. 8:00 PM Resident lying on left side. Moving around in bed restlessly... Resident hands had felt moist and cool. Took FSBS (Finger stick blood sugar) 151. 9:00 PM Resident still awaking at intervals turning side to side in bed... Explained to resident that she should call for help when she felt like she had to go and resident said ok. Resident did remember how to use the call light because she asked for help previously... 10:15 PM CNA... yelled down the hallway for assistant with resident because she had gotten out of bed and fallen on the floor on her back. Resident noted lying in floor with no shoes on and brief pulled partially off. Resident very confused and disoriented. Resident had begun to have a b.m. Resident assessed and put back to bed. Skin cool and clammy (hands). Resident awake but disoriented. Asked CNA to get vital signs while I call 911 to take her to the hospital... Resident vital signs difficult to obtain. v/s wee b/p 89/55, P 49, Couldn't get O2 sat, Resident became non responsive... 11:50 PM No apical pulse, no respirations no signs of life observed..." Review of the Neurological Record, revealed Neuro Checks were done upon return from the hospital every 30 minutes x 4, every 1 hour x 4, every 4 hours x 24, every 8 hours x for remaining 72 hours or as ordered by physician. Review of the blood pressure during the neuro checks revealed the following: 5/17/12 10:30 PM 165/102, 11:00 PM -132/87, 11:30 PM -130/84; 5/18/12 12:00 AM -128/78, 12:30 AM- 126/72, 1:30 AM-155/98, 2:30 AM -163/100, 3:30 AM -168/54, 4:30 AM -158/60, 8:30 AM there was no blood pressure recorded, 12:30 PM - B/P 115/84, 4:30 PM - 130/86, 8:30 PM not legible; 5/19/12 12:30 AM -165/86, 8:30 AM 138/88, 4:30 PM- 160/90. On 5/19/12 at 4:30 PM the resident was documented as drowsy. All other checks recorded her as alert. Review of a PT (Physical Therapy Treatment Note) dated 5/18/12 stated, "11:55-12:20 pm. Pt back from hospital last p.m... Pt. tremulous and c/o dizziness. Pt. unsteady w/static standing and required mod (moderate) A (assistance) to transfer to w/c (wheelchair). 4:52-5:07 pm. Applied pressure pad and gel cushion to w/c for pt use secondary to safety. Discussed w/nurse and CNAs regarding pt unsteady while standing and should not transfer without assist. Pt also exhibiting decreased motor planning and ability to follow simple VCs (voice commands). Pt to use w/c over weekend when out of bed to decrease risk of falls." There was no documentation that the physician was notified regarding the change in the resident's mobility and her ability to follow voice commands. During an interview with the Administrator and the Therapy Program Manager on 5/24/12, they stated they put interventions in place for a wheelchair with an alarm. Resident #1 was to be reviewed on Monday 5/21/12. They confirmed there were changes in the neuro checks and no notification of the physician. The facility admitted resident #2 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] coded the resident as requiring minimal assistance with locomotion and eating; extensive assistance was required with transfers, dressing, hygiene and bathing. The resident was coded as incontinent of bowel and bladder. She was coded as having a Stage II pressure ulcer with the date of origin 3/10/12. On 5/22/12 the State Agency received a facility reported incident from the Administrator that stated that on 5/12/12 Licensed Practical Nurse (LPN) #1 was called to Resident #2's room around 4:00 AM by a Certified Nursing Assistant (CNA) to look at a dressing because of a foul odor. The date on the dressing was 5/10/12. LPN #1 changed the dressing, saved the soiled dressing in a biohazard bag and reported to the Director of Nurses (DON) on 5/12/12 that the dressing had not been changed on 5/11/12. The Administrator stated in her initial 24- hour report that she leaned of the allegation about 12 Midnight on 5/21/12 when LPN #1 told her about the incident. The 24-hour report stated that the Director of Nurses and Wound Care Nurse were suspended pending further investigation. Review of the facility investigation failed to show that the DON assess the condition of the wound or notify the physician of the alleged incident reported to her on 5/12/12.

On the days of the Complaint and Extended Inspection, Substandard Quality of Care and/or Immediate Jeopardy was identified related to the facility's failure to notify the proper authorities of an alleged assault in a timely fashion and the facility's failure to notify the physician timely and to notify the resident's attending physician. Resident #1 was allegedly sexually abused on 7/2/2011 by another resident's spouse. The facility failed to call 911 until three and half hours after the incident. The facility failed to notify the on call physician until six and a half hours after the incident. The facility failed to notify the attending physician of the incident at all. (One of one allegation of sexual abuse reviewed.) The findings included: The facility admitted Resident #1 on 3/30/2011 with [DIAGNOSES REDACTED]. Record review on 7/11/2011 of the Unusual Occurrence Incident Report dated 7/2/2011 at 9:25 AM revealed the following description documented by Registered Nurse #1: "As I was coming out of room [ROOM NUMBER], I saw (Resident #2's family member) have his right hand down resident blouse stating, "your titties feel warm" and using his left hand to try to get resident's hand to touch his penis which was sticking out of his zipper." The incident was reported to RN #2 (weekend supervisor). The on call physician was notified at 3:55 PM. The family was notified at 9:30 AM. Review of the Physician and NP Tracking Form revealed Resident #1 was not placed on the problem list for the Attending Physician to see on 7/5/2011 (the next available day the physician would be in the building). Review of the 24 Hour report revealed no entries were documented related to the incident that occurred on 7/2/2011 involving Resident #1. During an interview on 7/11/2011 at 10 AM the Social Services Assistant (SSA) confirmed 911 was not called until 12:54 PM, three and a half hours after the incident. During an interview on 7/12/2011 at 9:25 AM, the Attending Physician stated that she was not notified of the incident that occurred on 7/2/2011. The Physician stated that Resident #2's family had mentioned the incident to her in passing but stated again that the facility staff had not notified her of the incident. During an interview on 7/12/2011 at 10:30 AM, the On Call Physician confirmed that he was not notified of the incident until approximately 4 PM on 7/2/2011, six and a half hours after the incident occurred. During an interview on 7/12/2011 at 12:20 PM, the Director of Nursing (DON) confirmed Resident #1's physician was not notified of the incident and confirmed that the On Call Physician was not notified until 6 1/2 hours after the incident. The DON confirmed there should not have been a delay in notifying the physicians or 911. Cross Refers to F-223 as it related to the facility failure to put interventions in place to protect Resident #1 and to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Cross Refers to F-226 as it related to the facility failure to implement the policy on sexual abuse related to the protection of residents. Cross Refers to F-250 as it related to the facility failure to ensure that Resident's received the necessary social services following an allegation of sexual abuse. Cross Refers to F-251 as it related to the facility failure to employ a licensed social worker to provide the medically related social services to residents. Cross Refers to F-280 as it related to the facility failure to care plan interventions following an allegation of sexual abuse. Cross Refers to F-319 as it related to the facility failure to provide necessary interventions to address the psychosocial needs of Resident #1 allegedly sexually abused on 7/2/2011 by Resident #2's husband. The psychosocial needs of Resident #2 related to the loss of the daily visits from her husband were not addressed. Cross Refers to F-490 as it related to the failure of the facility Administration to protect residents from further abuse and failed to assure all staff had knowledge of the incident.. On 7/11/2011 at 4:35 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-251, F280, F-319, and F-490 at a scope and severity of "J". The findings related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse. On 7/2/2011 Resident #2's husband allegedly sexually abused Resident #1. The facility failed to put interventions in place to protect Resident #1 after the allegation and failed to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, and staff interviews, the Immediate Jeopardy was removed and citations F-157, F-223, F-226, F-250, F-251 F-280, F-319, and F-490 were lowed to a scope and severity of "D" as of 7/12/2011 at 2:00 PM.

On the days of the Complaint and Extended Inspection, Substandard Quality of Care and/or Immediate Jeopardy was identified related to the facility's failure to put interventions in place to protect Resident #1 and to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. (One of one allegation of sexual abuse reviewed.) The findings included: The facility admitted Resident #1 on 3/30/2011 with [DIAGNOSES REDACTED]. Record review on 7/11/2011 revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] that coded Resident #1 as having short and long term memory and severely impaired abilities for daily decision making. Resident #1 was also coded as requiring one-person extensive assistance for transfers, mobility, locomotion, dressing, hygiene, toilet needs and bathing. Resident #1 was also coded as wandering at least 3-6 times during the assessment period. Review of the Nurse's Notes revealed an entry dated 7/2/2011 at 9:25 AM, "Res (resident) was in hallway at room [ROOM NUMBER]. A family member had his hand down res shirt and his penis out stating, "your titties are warm." I was coming out of room [ROOM NUMBER] when I heard and observed this. I approached family member and stated "No! we do not do this, you need to put it up and go on down the hallway. Put it away and go down the hallway." I proceeded to notify nurse on dogwood unit." At 2 PM, "Body audit performed, no redness, discharge, no outward signs of trauma noted to vagina or breasts. No s/sx (signs and symptoms) of distress noted at this time." At 3:55 PM, "Dr (physician on call) was notified by myself of the situation that occurred this morning. No orders received. Dr informed that body audit was performed, social services contacted and police were notified." Review of the Unusual Occurrence Incident Report dated 7/2/2011 revealed the following description documented by Registered Nurse #1: "As I was coming out of room [ROOM NUMBER], I saw (Resident #2's family member) have his right hand down resident blouse stating, "your titties feel warm" and using his left hand to try to get resident's hand to touch his penis which was sticking out of his zipper." The incident was reported to RN #2 (weekend supervisor). The physician was notified at 3:55 PM. The family was notified at 9:30 AM. Further record review revealed no physician's orders were written related to the incident. No physician progress notes [REDACTED]. Review of the Physician and NP Tracking Form revealed Resident #1 was not placed on the problem list for the Attending Physician to see on 7/5/2011 (7/5/2011 was the next available day the physician would be in the building). Review of the 24 Hour report revealed no entries were documented related to the incident that occurred on 7/2/2011 involving Resident #1. Review of the Care Plan revealed it had been updated on 7/2 to "continue to observe for (increased) depression, social withdrawal, increased agitation, anxiety- related to recent incident, room change." Review of the Police Department Incident Report revealed the police were called and dispatched at 12:54 PM on 7/2/2011 to respond to an incident of "assault and battery 3rd degree" at Brookview Healthcare Center. "R/O (responding officer) responding to Brookview Nursing Home and spoke with (Social Worker, SW). SW stated that an incident had occurred between suspect, who was a visitor at the home, and victim, who is a resident. A nurse (RN #1) observed suspect with his hand down victim's shirt fondling her breasts and that suspect also had his penis out in his hand trying to get victim to touch it. R/O spoke with both victim and suspect's families and determined that a charge of assault and battery 3rd degree would be appropriate. Suspect was booked into CCDC (Cherokee County Department of Corrections) and charged with assault and battery 3rd degree. Suspect placed on trespass notice at Brookview." Review of the facility's 5 Day Follow Up report sent to the State Certification Agency on 7/6/2011 revealed the interventions in place were "police were called and (Resident #1's family) will be pressing charges- (Suspect) was escorted off premises." The Immediate Corrective actions were "supervised visitations from Monday-Friday, hours 9-5." The interventions taken to prevent future occurrences were "monitoring visitors and observing and reporting behaviors." Review of the facility obtained witness statement from RN #1 revealed "I was coming out of a resident's room from washing my hands and noted (Resident #2's family member) with his hand down (Resident #1's) shirt stating "your titties feel warm." (Resident #2's family member) also had his penis out of his pants trying to get (Resident #1) to touch it. I approached (family member) and told him "No sir! We do not do this. You need to put it away and go on up the hallway." I then went to the dogwood unit and notified (Licensed Practical Nurse #1) of what I had heard and seen. This incident happened outside of room [ROOM NUMBER] on the Peach Unit. I was coming out of room [ROOM NUMBER] on Peach Unit." During a telephone interview on 7/11/2011 at 10:25 AM, RN #1 stated that she was coming out of room [ROOM NUMBER] when she observed Resident #2's family member with his hand down Resident #1's blouse fondling her breasts and also had his penis out. She stated that she approached him and told him to "put it away and go on down hallway." RN #1 stated that she then left the unit and reported the incident to the nurse on Dogwood (LPN #1). RN #1 stated that she saw the family member walking down the hallway but "didn't see what room he went into." RN #1 stated that LPN #1 then notified the supervisor. RN #1 then walked back to the Peach Unit. RN #1 stated that Resident #1 remained on the Peach Unit and was under supervision after the incident." Review of the facility obtained statement from RN #2 (weekend supervisor) revealed she was on the Magnolia Unit when LPN #1 approached her. RN #2 entered (Resident #2's room), an activity assistant was present in the room. RN #2 asked the AA to leave. RN #2 documented that she asked (Resident #2's family member) "what was going on, it was reported to me that some inappropriate behavior had taken place. The visitor said she used to be in the room with my wife. I told the visitor to sit right there and I would be right back...After talking with Peach Nurse that witnessed this behavior of this visitor and getting all the information including that this visitor was questioning why (Resident #1 changed rooms), I immediately went back to (Resident #2's) room with 2 witnesses and asked visitor to leave immediately and not to come back..." RN #1 stated that after she escorted the family member out of the building, she notified Social Services of the incident. During an interview on 7/11/2011 at 10:30 AM, RN #2 stated that LPN #1 reported the incident to her on 7/2/2011. RN #2 stated that once she was aware of the entire situation she immediately escorted the family member out of the building. She stated that it was reported to her by a family member that the police ordered that Resident #2's family member could not visit and the facility was to post a picture of him in the facility. RN #2 stated that no pictures were posted because the facility was allowing the family member to visit. RN #2 stated that the family member had not been back in the facility since 7/2/2011. During a telephone interview on 7/11/2011 at 10:55 AM, LPN #1 stated that RN #1 reported the incident that occurred on 7/2/2011. LPN #1 stated that she saw Resident #2's family member walk down the hallway past the desk and into Resident #2's room. LPN #1 stated that she asked the Activities Assistant to go into Resident #2's room and "make conversation." LPN #1 stated that she reported the incident to RN #2 and RN #2 escorted the family member out of the facility. During an interview on 7/11/2011 at 10 AM, the Social Services Assistant (SSA) stated that she was called at home and notified of the incident on 7/2/2011. She stated that she arrived at the facility 20 minutes later at approximately 10 AM. The SSA stated that she notified both Resident #1 and #2's family members. She stated that she called 911 at 10:45 AM. The SSA stated that the police officer spoke with both Resident #1 and #2's family members. She further stated that the officer offered a rape kit to Resident #1's family members and they declined. The SSA stated that Resident #1's family was pressing charges. The SSA stated that Resident #2's family member could visit the facility but would have to have supervised visits. She also stated that the police officer provided a picture of the family member to post. The SSA confirmed that no pictures were posted in the facility. The SSA stated she did not notify staff of the incident that occurred on 7/2/2011 and did not provide inservicing to all staff members. The SSA confirmed that no counseling had been provided to Resident #1 and no other psychosocial interventions had been provided to Resident #1 and no interventions were put in place for Resident #2. During a follow up interview on 7/11/2011, the SSA confirmed 911 was not called until 12:54 PM, three and a half hours after the incident. During an interview on 7/11/2011 at 11:15 AM, the Administrator stated that he was notified of the incident on 7/2/2011 via the SSA. He stated that Resident #2's family member was allowed supervised visits during normal working hours (Monday - Friday, 9-5). He also stated that he had not received any court documents and the restricted visits were still in place. The Administrator confirmed that the family member had not been back to the facility. The Administrator stated that the SSA was provided a picture of the family member to post, however he confirmed no pictures were posted. The Administrator stated that a picture would be posted at the nursing stations if the family member returned to the facility. During an interview on 7/12/2011 at 9:25 AM, the Attending Physician stated that she was not notified of the incident that occurred on 7/2/2011. The Physician stated that Resident #2's family had mentioned the incident to her in passing but stated again that the facility staff had not notified her of the incident. The Physician stated that the on call physician was notified on 7/2/2011. She stated that doctors did not come to the facility on the weekends and that if there were a concern then the resident would have been sent to the emergency room . The Physician also stated that the physicians relied on the nursing assessments and since the family refused the rape kit and the nurses reported that the resident was "ok" there would have been no need to send the resident to the emergency room . The Attending Physician stated that a healthcare provider had not assessed Resident #1. During an interview on 7/12/2011 at 10:30 AM, the On Call Physician confirmed that he was not notified of the incident until approximately 4 PM on 7/2/2011, six and a half hours after the incident occurred. He stated that it was reported to him that the entire incident was witnessed and the resident appeared to be "ok". He stated that a physical assessment had not been reported to him. He also stated again that he was not informed that the nurse observed the incident already in progress and had not witnessed the entire incident. The On Call Physician stated that if he was told the incident was not witnessed entirely then he would have ordered the resident to be sent to the emergency room . He also stated that he expected the nursing staff and the social service staff to provide counseling and for the healthcare provider to be involved. He further stated that he expected the staff to have notified 911 and the physician within the hour the incident occurred. The On Call Physician stated that the nursing staff should have placed the resident on the provider list to be seen by the physician on the next visit. During an interview on 7/12/2011 at 11:30 AM, the Medical Director stated that he was not notified of the incident until the Attending Physician briefly reported the incident on the evening of 7/11/2011. He stated that he should have been notified. The Medical Director stated that he expected the facility to have followed the no trespass ordered by the police to protect all of the residents. He stated that he also expected the facility to address the residents' psychosocial needs and provide counseling. The Medical Director stated that he also expected the healthcare provider(s) to have seen and assessed the resident or to have sent to the emergency room for evaluation. He also stated that the resident should have been placed on the provider list and the Attending Physician should have been notified of the incident. Cross Refers to F-157 as it related to the facility failure to timely notify the emergency services of alleged assault of a facility resident. Failed to timely notify the on call physician of the incident and failed to provide a thorough accounting of the incident. The facility failed to notify the resident's attending physician of the incident. Cross Refers to F-226 as it related to the facility failure to implement the policy on sexual abuse related to the protection of residents. Cross Refers to F-250 as it related to the facility failure to ensure that Resident's received the necessary social services following an allegation of sexual abuse. Cross Refers to F-251 as it related to the facility failure to employ a licensed social worker to provide the medically related social services to residents. Cross Refers to F-280 as it related to the facility failure to care plan interventions following an allegation of sexual abuse. Cross Refers to F-319 as it related to the facility's failure to provide necessary interventions to address the psychosocial needs of Resident #1 allegedly sexually abused on 7/2/2011 by Resident #2's husband. The psychosocial needs of Resident #2 related to the loss of the daily visits from her husband were not addressed. Cross Refer to F-490 as it related to the failure of the facility Administration to protect residents from further abuse and failed to assure all staff had knowledge of the incident. On 7/11/2011 at 4:35 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-251, F280, F-319, and F-490 at a scope and severity of "J". The findings related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse. On 7/2/2011 Resident #2's husband allegedly sexually abused Resident #1. The facility failed to put interventions in place to protect Resident #1 after the allegation and failed to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, and staff interviews, the Immediate Jeopardy was removed and citations F-157, F-223, F-226, F-250, F-251 F-280, F-319, and F-490 were lowed to a scope and severity of "D" as of 7/12/2011 at 2:00 PM.

On the days of the Complaint and Extended Inspection based on record review, interview and review of the facility's policy on Abuse and Neglect, the facility failed to implement their Abuse Policy to protect Resident #1 who was allegedly sexually abused and to protect all residents at risk for sexual abuse. (One of one allegation of sexual abuse reviewed.) The findings included: On 7/2/2011 Resident #1 was allegedly sexually assaulted by another resident's spouse (Resident #2). The facility failed to put interventions in place to protect Resident #1 and failed to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. During an interview on 7/11/2011 at 11:15 AM, the Administrator stated that Resident #2's family member was allowed supervised visits during normal working hours (Monday - Friday, 9-5). The Administrator stated that the police provided a picture of the alleged perpetrator to post. He confirmed no picture was posted that a picture would be posted at the nursing stations only if the family member returned to the facility. During a follow up interview at 3:45 PM with the Social Services Assistant and the Administrator the SSA stated that she did not speak with all staff on all units regarding the incident on 7/2/2011. She stated that she had only spoken with the first shift nurses on the Dogwood unit. Both the Administrator and the SSA confirmed that staff were not aware of the incident and were not aware that the suspect was not allowed in the facility. Review of the facility's Abuse and Neglect Policy and Procedure revealed the following: "It is the policy of this facility that all residents have the right to be free from abuse that includes but is not limited to verbal, physical, sexual and mental abuse, corporal punishment and involuntary seclusion by a facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, friends or other individuals... Sexual Abuse includes but is not limited to sexual assault, sexual coercion, and sexual harassment... Protect the alleged victim from further abuse by identifying and removing the cause of the danger... When the abuse is detected GET THE FACTS, Physically assess the involved resident for injuries... Document the incident in the clinical record...All alleged violations... are reported immediately to The Director of Nursing, The Administrator, The resident's Attending Physician..." Cross Refers to F-157 as it related to the facility failure to timely notify the emergency services of alleged assault of a facility resident. Failed to timely notify the on call physician of the incident and failed to provide a thorough accounting of the incident. The facility failed to notify the resident's attending physician of the incident. Cross Refers to F-223 as it related to the facility's failure to put interventions in place to protect Resident #1 and to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Cross Refers to F-250 as it related to the facility failure to ensure that Resident's received the necessary social services following an allegation of sexual abuse. Cross Refers to F-251 as it related to the facility failure to employ a licensed social worker to provide the medically related social services to residents. Cross Refers to F-280 as it related to the facility failure to care plan interventions following an allegation of sexual abuse. Cross Refers to F-319 as it related to the facility's failure to provide necessary interventions to address the psychosocial needs of Resident #1 allegedly sexually abused on 7/2/2011 by Resident #2's husband. The psychosocial needs of Resident #2 related to the loss of the daily visits from her husband were not addressed. Cross Refers to F-490 as it related to the failure of the facility Administration to protect residents from further abuse and failed to assure all staff had knowledge of the incident. On 7/11/2011 at 4:35 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-251, F280, F-319, and F-490 at a scope and severity of "J". The findings related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse. On 7/2/2011 Resident #2's husband allegedly sexually abused Resident #1. The facility failed to put interventions in place to protect Resident #1 after the allegation and failed to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, and staff interviews, the Immediate Jeopardy was removed and citations F-157, F-223, F-226, F-250, F-251 F-280, F-319, and F-490 were lowed to a scope and severity of "D" as of 7/12/2011 at 2:00 PM.

NOT CORRECTED On the day of the follow up Complaint survey based on record review and interview the facility failed to implement their plan of correction related to medically related social services for 1 of 4 sampled residents. Resident #13 displayed suicidal ideation, and no interventions were put in place. The findings included: The facility admitted Resident #13 on 2/25/2008 with [DIAGNOSES REDACTED]. Record review on 8/10/2011 revealed a nurse's note dated 8/1/2011 at 5 PM that documented "Pt crying and yelling out making comments that she is going to kill herself. She just wants to die. (Attending Physician, Social Worker and family called.)" Review of the Physicians orders revealed the resident's Effexor was increased to 75 mg (milligrams) on 8/1/2011. Further record review revealed no other documentation related to the resident's suicidal ideation. Review of the Social Service Notes revealed an entry dated 8/9/2011 that did not include any reference to the suicidal ideation. No interventions were put in place related to Resident #13's behaviors. During an interview on 8/10/2011 at 4 PM, the Social Worker Director, the Social Worker Consultant, the Administrator and a Nurse Consultant all confirmed Resident #13's behaviors. The SW confirmed no notes were written in the resident's record related to the behaviors. All confirmed that no interventions were put in place related to Resident #13's behaviors/comments. The Nurse Consultant verified that all suicidal ideation should be taken seriously and the resident should be monitored and interventions should be implemented and documented. The Social Worker stated that she did see the resident on 8/1/2011 and speak with the family, however, she confirmed that she failed to document the encounter. The Social Worker also confirmed that no further monitoring or documentation was put in place for Resident #13's behaviors. A Plan of Correction (POC) related to F250 was submitted to the State Agency with a compliance date of 8/3/2011. Included in that POC was the following;..."The MDS (Minimum Data Set) Coordinators will review psychosocial needs of all residents that are requiring initial assessments, quarterly assessments, significant changes and scheduled care plan meetings. Daily review of unusual occurrences, grievances and 24 hour report sheets will be conducted by the IDT ( Interdisciplinary Team) and monitored for appropriate psychosocial follow-up. Inservices were provided for all staff of the expectations in providing psychosocial support for any resident exhibiting behaviors that would suggest the need for assessment. This inservice was provided by the Social Service Director and Administrator on 7-11-11. The Social Service Director will be responsible for providing scheduled educational inservices for all staff on a quarterly basis."

On the days of the Complaint and Extended Inspection based on interviews and review of the employee files, the facility failed to employ a qualified social worker. The facility did not have a licensed social worker on staff. The findings included: Review of the employee file for the Social Services Assistant revealed she did not have a current and/or active license. Review of the employee file for the newly hired Social Services Director revealed she was not a licensed Social Worker. During an interview on 7/11/2011 at 3:45 PM, the Administrator confirmed neither the Social Services Assistant nor the Social Service Director had a current license for Social Work. The Administrator confirmed the facility was greater that 120 beds and did not have a licensed social worker on staff nor have the oversight of a social services consultant. Cross Refers to F-157 as it relates to the facility failure to timely notify the emergency services of alleged assault of a facility resident. Failed to timely notify the on call physician of the incident and failed to provide a thorough accounting of the incident. The facility failed to notify the resident's attending physician of the incident. Cross Refers to F-223 as it relates to the facility failure to put interventions in place to protect Resident #1 and to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Cross Refers to F-226 as it relates to the facility failed to implement the policy on sexual abuse related to the protection of residents. Cross Refers to F-250 as it relates to the facility failed to ensure that Resident's received the necessary social services following an allegation of sexual abuse. Cross Refers to F-280 as it related to the facility failure to care plan interventions following an allegation of sexual abuse. Cross Refers to F-319 as it relates to the facility's failure to provide necessary interventions to address the psychosocial needs of Resident #1 allegedly sexually abused on 7/2/2011 by Resident #2's husband. The psychosocial needs of Resident #2 related to the loss of the daily visits from her husband were not addressed. Cross Refers to F-490 as it relates to the failure of the facility Administration to protect residents from further abuse and failed to assure all staff had knowledge of the incident. On 7/11/2011 at 4:35 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-251, F280, F-319, and F-490 at a scope and severity of "J". The findings related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse. On 7/2/2011 Resident #2's husband allegedly sexually abused Resident #1. The facility failed to put interventions in place to protect Resident #1 after the allegation and failed to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, and staff interviews, the Immediate Jeopardy was removed and citations F-157, F-223, F-226, F-250, F-251 F-280, F-319, and F-490 were lowed to a scope and severity of "D" as of 7/12/2011 at 2:00 PM.

NOT CORRECTED On the day of the Follow Up Complaint survey based on record review and interview the facility failed to follow their plan of correction related to care plan revisions for 1 of 4 sampled residents. Resident #13's care plan was not updated related to the suicidal ideation. The findings included: The facility admitted Resident #13 on 2/25/2008 with [DIAGNOSES REDACTED]. Record review on 8/10/2011 revealed a nurse's note dated 8/1/2011 at 5 PM that documented "Pt crying and yelling out making comments that she is going to kill herself. She just wants to die. (Attending Physician, Social Worker and family called.)" Review of the Care Plan revealed the care plan was updated on 8/1/2011 with an increase of [MEDICATION NAME], however, the suicidal ideation was not added to the care plan nor were any interventions. A Plan of Correction (POC) related to F280 was submitted to the State Agency with a compliance date of 8/3/2011. Included in that POC was the following;..."The MDS (Minimum Data Set) Coordinators will review psychosocial needs of all residents that are requiring initial assessments, quarterly assessments, significant changes and scheduled care plan meetings. Daily review of unusual occurrences, grievances and 24 hour report sheets will be conducted by the IDT ( Interdisciplinary Team) and monitored for appropriate psychosocial follow-up. Inservices were provided for all staff of the expectations in providing psychosocial support for any resident exhibiting behaviors that would suggest the need for assessment. This inservice was provided by the Social Service Director and Administrator on 7-11-11. The Social Service Director will be responsible for providing scheduled educational inservices for all staff on a quarterly basis." During an interview on 8/10/2011 at 4 PM, the Social Worker Director, the Social Worker Consultant, the Administrator and a Nurse Consultant all confirmed Resident #13's behaviors and confirmed that the care plans were not updated with the resident's behaviors and new interventions.

NOT CORRECTED On the day of the survey based on record review and interview the facility failed to implement their plan of correction related to behavior monitoring and interventions for 1 of 4 sampled residents. Resident #13 had suicidal ideation. There was no monitoring or interventions put in place related to the suicidal ideation. The findings included: The facility admitted Resident #13 on 2/25/2008 with [DIAGNOSES REDACTED]. Record review on 8/10/2011 revealed a nurses note dated 8/1/2011 at 5 PM that documented "Pt crying and yelling out making comments that she is going to kill herself. She just wants to die. (Attending Physician, Social Worker and family called.)" Review of the Physicians orders revealed the resident's [MEDICATION NAME] was increased to 75 mg (milligrams) on 8/1/2011. Further record review revealed no other documentation related to the resident's suicidal ideation. Review of the Social Service Notes revealed an entry dated 8/9/2011 that did not include any reference to the suicidal ideation. No interventions were put in place related to Resident #13's behaviors. Review of the Behavior Monitoring Sheets for 8/2011 revealed increased agitation, restlessness and anxiety were monitored behaviors. No suicidal type behaviors/comments were added to the monitoring sheets. During an interview on 8/10/2011 at 4 PM, the Social Worker Director, the Social Worker Consultant, the Administrator and a Nurse Consultant all confirmed Resident #13's behaviors. All confirmed that no interventions were put in place related to Resident #13's behaviors/comments. The Nurse Consultant verified that all suicidal ideation should be taken seriously and the resident should be monitored and interventions should be implemented and documented. The Social Worker stated that she did see the resident on 8/1/2011 and speak with the family, however, she confirmed that she failed to document the encounter. The Social Worker also confirmed that no further monitoring or documentation was put in place for Resident #13's behaviors. A Plan of Correction (POC) related to F319 was submitted to the State Agency with a compliance date of 8/3/2011. Included in that POC was the following;..."The MDS (Minimum Data Set) Coordinators will review psychosocial needs of all residents that are requiring initial assessments, quarterly assessments, significant changes and scheduled care plan meetings. Daily review of unusual occurrences, grievances and 24 hour report sheets will be conducted by the IDT ( Interdisciplinary Team) and monitored for appropriate psychosocial follow-up. Inservices were provided for all staff of the expectations in providing psychosocial support for any resident exhibiting behaviors that would suggest the need for assessment. This inservice was provided by the Social Service Director and Administrator on 7-11-11. The Social Service Director will be responsible for providing scheduled educational inservices for all staff on a quarterly basis."

On the days of the Complaint and Extended Inspection, Substandard Quality of Care and/or Immediate Jeopardy was identified related to the failure of the facility's Administration to put interventions in place to protect Resident #1, allegedly sexually abused on 7/2/2011; to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. The findings included: On 7/2/2011 the husband of Resident #2 allegedly sexually abused Resident #1. The facility's Administration violated the no trespass police order and notified the suspect's family that supervised visits would be arranged. The Administration failed to put interventions in place to protect Resident #1. Inservices for staff related to the incident and interventions to protect all residents at risk for sexual abuse were not addressed by the Administration. During an interview on 7/11/2011 at 11:15 AM, the Administrator stated that he was notified of the incident on 7/2/2011 by Social Services. He stated that Resident #2's husband would be allowed supervised visit during normal working hours (Monday - Friday, 9-5). He also stated that he had not received any court documents and the restricted visits were in place. The Administrator stated that the police provided the facility a picture of the family member to post, however he confirmed no pictures were posted. The Administrator stated that a picture would be posted at the nursing stations only if the family member returned to the facility. During a follow up interview at 3:45 PM with the Social Services Assistant and the Administrator the SSA stated that she did not speak with all staff on all units regarding the incident on 7/2/2011. She stated that she had only spoken with the first shift nurses on the Dogwood unit. Both the Administrator and the SSA confirmed that staff were not aware of the incident and were not aware that the suspect was not allowed in the facility. Cross Refers to F-157 as it relates to the facility failure to timely notify the emergency services of alleged assault of a facility resident. Failed to timely notify the on call physician of the incident and failed to provide a thorough accounting of the incident. The facility failed to notify the resident's attending physician of the incident. Cross Refers to F-223 as it relates to the facility failure to put interventions in place to protect Resident #1 and to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Cross Refers to F-226 as it relates to the facility failed to implement the policy on sexual abuse related to the protection of residents. Cross Refers to F-250 as it relates to the facility failed to ensure that Resident's received the necessary social services following an allegation of sexual abuse. Cross Refers to F-251 as it relates to the facility failure to employ a licensed social worker to provide the medically related social services to residents. Cross Refers to F-280 as it related to the facility failure to care plan interventions following an allegation of sexual abuse. Cross Refers to F-319 as it relates to the facility's failure to provide necessary interventions to address the psychosocial needs of Resident #1 allegedly sexually abused on 7/2/2011 by Resident #2's husband. The psychosocial needs of Resident #2 related to the loss of the daily visits from her husband were not addressed. On 7/11/2011 at 4:35 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-251, F280, F-319, and F-490 at a scope and severity of "J". The findings related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse. On 7/2/2011 Resident #2's husband allegedly sexually abused Resident #1. The facility failed to put interventions in place to protect Resident #1 after the allegation and failed to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, and staff interviews, the Immediate Jeopardy was removed and citations F-157, F-223, F-226, F-250, F-251 F-280, F-319, and F-490 were lowed to a scope and severity of "D" as of 7/12/2011 at 2:00 PM.

On the day of the complaint inspection based on observations, record reviews, interviews and review of the facility's Abuse and Neglect policy, the facility failed to assure 3 of 5 sampled residents were free from neglect. Resident #1 and #3's dressings were not changed per the physician's orders [REDACTED]. Resident #2's wound was observed to have a yellow center with dried blood. The findings included: Resident #1 sampled as a result of an incident reported by the facility on 11/24/2010 that indicated the facility substantiated neglect against Licensed Practical Nurse (LPN) #1 for failure to change Resident #1's dressings as ordered. The facility admitted Resident #1 on 5/5/2006 with [DIAGNOSES REDACTED]. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a short-term and long-term memory problem with severely impaired cognitive skills for daily decision-making. The Annual MDS coded Resident #1 as totally dependent for hygiene, bathing and toileting. Resident #1 was coded as needing extensive assistance with transfers, dressing and eating. No behaviors were coded as occurring during the assessment period. Review of the facility's Five-Day Follow-Up Report dated 11/24/2010 indicated the facility substantiated neglect against LPN #1 for failure to change Resident #1's dressings as ordered. The interventions that were in place prior to the incident were "abuse and neglect addressed 10/1/2010 by staff development coordinator." The interventions taken by the facility to prevent future abuse were "facility continues to stress no tolerance for abuse or neglect. Reeducation of staff on abuse/neglect." LPN #1's facility obtained statement dated 11/23/2010 indicated that she worked 7 AM to 7 PM the weekend of 11/20/2010 and 11/21/2010. LPN #1 documented that she "had done all of my treatments. I done (sic) some extra tx (treatment) on the opposite hall, and stayed over on Sunday night to make sure I had all of my tx done. I remember gathering the notes I wrote and the tx cart and going down the hall. I do recall doing the skin prep and the applying of the [MEDICATION NAME] to the resident's right foot and toes. I unintentionally must have looked over the inner ankle. I could have been thinking about the regular dressing I normally do on 7 p-7 a. I do understand that's no excuse." LPN #3's facility obtained statement dated 11/22/2010 stated, "On 11-22-10, I removed a foam drsg (dressing) and a bordered guaze from Res. (resident) coccyx and Rt (right) inner ankle. Both drsgs were dated 11-19-10." Review of the care plan revealed "Altered Skin Integrity" as a problem area. Interventions and approaches included "Tx (treatments)/dressings as ordered, Routine body audits, observe skin with care." Review of the Nurses' Progress Notes dated 11/19/2010 indicated a "tx to right foot continued, odor to right foot." On 11/20/2010 at 1:10 AM, "tx cont(inued) to R foot. Strong odor noted. Black areas noted on R foot." The next nurse's note dated 11/23/2010 documented [MEDICATION NAME] sprinkles were ordered for the wound bed. Review of the Weekly Skin Evaluations revealed the resident's skin was assessed on 11/13/2010 with Right Foot and Sacrum receiving treatments. On 11/20/2010, the resident was assessed as having "right foot dark toes and underneath. Draining with odor...treatment continued." On 11/27/2010 the right foot with toes were "black with odor." Review of the physician's orders [REDACTED]." The coccyx wound was to be cleaned with normal saline and "apply santyl and cover with foam dressing everyday and as needed." Review of the MAR from November 2010 revealed on 11/20/2010 and 11/21/2010, LPN #1 initialed the MAR indicated [REDACTED]. The facility admitted Resident #2 on 11/17/2010 with [DIAGNOSES REDACTED]. Observation of Resident #2 on 12/20/2010 revealed the resident laying in bed. The resident had a [MEDICATION NAME] dressing on her lower right leg dated 12/06/2010. The wound bed was observed to be yellow with dried blood observed under the [MEDICATION NAME]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the medical record revealed no documentation related to the wound. The Unit Manager confirmed the presence of the yellow wound bed and dried blood. She assessed the wound after the surveyor brought the wound to the facility's attention and then provided appropriate treatment for [REDACTED]. The facility admitted Resident #3 on 03/05/2010 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 12/20/2010 revealed the resident lying in bed. The Resident had a Medi-honey strip on the lateral aspect of her lower leg. The Medi-honey was not covered with a [MEDICATION NAME] pad nor was the strip dated. The resident had a dressing on her left foot dated 12/17/2010. Review of the MAR indicated [REDACTED]. Another order for Medi-Honey to the top of the left foot and to cover with a [MEDICATION NAME] pad and to change daily. The treatments were last initialed as done on 12/17/2010. The Unit Manager confirmed that the dressings had not been changed since 12/17/2010. She assessed the wounds and performed the prescribed treatments. During a telephone interview on 12/20/2010, LPN #2 stated that she worked weekends from 7 PM to 7 AM. She stated that she was working the weekend of 12/18 and 12/19/2010. LPN #2 confirmed that she was assigned to Resident's #2 and #3. She stated that she did not change the dressing on Resident #3's foot on either 12/18 or 12/19. She stated that she "just didn't do it." LPN #2 stated that she was aware of the orders to change the dressings daily. LPN #2 also stated that if she noticed the dressings were not changed per the physician's orders [REDACTED]. She stated that she would not notify the unit manager or the Director of Nurses. LPN #2 stated she was aware that Resident #2 had a dressing on her right leg but did not notice that it was dated 12/06/2010. LPN #2 stated that she was unaware of any dressing changes for Resident #2's right leg. Three other LPN's were asked if they checked orders daily. All answered "yes." All 3 LPN's stated that during their daily assessments of the residents they check the dressings. All 3 stated that if the dressing was not changed per the physician's orders [REDACTED]. Three CNA's were interviewed; all three stated that they would notify the nurse immediately if a dressing was not in place or if there were any skin concerns. During an interview on 12/20/2010, the Director of Nurses (DON) stated that LPN #1 failed to change Resident #1's dressing as ordered. The DON stated that the LPN signed the treatment record. LPN #3 on 11/22/2010 reported to the unit manager that the dressings had not been changed. LPN #1 was suspended and an investigation was completed. Upon completion of the investigation it was determined that LPN #1 neglected Resident #1 and she was immediately terminated. Resident #1's dressings were immediately changed and her wounds assessed. The DON stated that all residents with dressings were assessed on 11/22/2010 with no other abnormal findings. The DON stated that weekly wound rounds were conducted with the DON as the lead and the unit managers. She stated that wound team evaluated the wounds including measurements and assured the treatments were appropriate. She stated that the floor nurses were responsible for changing the dressings on a daily basis. If there were any changes in the wounds, then the physician would be notified as well as a member of the wound team (a unit manager of the DON). The DON also confirmed the dressings on Resident #3's left leg and foot had not been changed since 12/17/2010. The DON confirmed the physician's orders [REDACTED]. The DON also confirmed that the dressing on Resident #2's right leg was dated 12/06/2010. She confirmed that the wound bed was yellow with dried blood. She stated that the dressing should have been changed on 12/11/2010 and 12/18/2010. The DON stated that anytime an allegation of abuse or neglect is made an inservice would be conducted that was mandatory for all staff. An inservice was conducted on Abuse and Neglect on 11/23/2010 regarding the allegation on 11/22/2010. Review of the inservice conducted on 11/23/2010 revealed that 13 nurses signed the attendance log and 20 CNA's signed the log. Review of the facility's employment record indicated that 41 nurses were employed and 72 CNA's were employed. The DON confirmed that not all licensed staff members attended the inservice. Review of the facility's policy on "Abuse and Neglect" revealed that "it is the policy of this facility that all residents have the right to be free from abuse that includes but is not limited to verbal, physical, sexual and mental abuse... Abuse also includes those practices and omissions, neglect and misappropriation of resident property that left unchecked, lead to abuse. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness."

On the day of the complaint inspection based on observations, interviews and record reviews, the facility failed to provide the necessary care and services to 3 of 5 sampled resident's wounds. Resident #1 and #3 did not have their dressings changed as ordered. Resident #2 had a dressing on her right lower leg dated 12/6/2010; the dressing was observation on 12/20/2010. The findings included: The facility admitted Resident #1 on 5/5/2006 with [DIAGNOSES REDACTED]. Resident #1 sampled as a result of an incident reported by the facility on 11/24/2010 that indicated the facility substantiated neglect against Licensed Practical Nurse (LPN) #1 for failure to change Resident #1's dressings as ordered. Review of the facility's Five-Day Follow-Up Report dated 11/24/2010 indicated the facility substantiated neglect against LPN #1 for failure to change Resident #1's dressings as ordered. On 11/22/2010 LPN #3 removed dressings from Resident #1's coccyx and right inner ankle dated 11/19/2010; daily dressing changes were ordered. LPN #1's facility obtained statement dated 11/23/2010 indicated that she worked 7 AM to 7 PM the weekend of 11/20/2010 and 11/21/2010. LPN #1 documented that she "had done all of my treatments. I done (sic) some extra tx on the opposite hall, and stayed over on Sunday night to make sure I had all of my tx done. I remember gathering the notes I wrote and the tx cart and going down the hall. I do recall doing the skin prep and the applying of the [MEDICATION NAME] to the resident's right foot and toes. I unintentionally must have looked over the inner ankle. I could have been thinking about the regular dressing I normally do on 7 p-7 a. I do understand that's no excuse." LPN #3's facility obtained statement dated 11/22/2010 stated, "On 11-22-10, I removed a foam drsg (dressing) and a bordered guaze from Res. (resident) coccyx and Rt (right) inner ankle. Both drsgs were dated 11-19-10." Review of the physician's orders [REDACTED]." The coccyx wound was to be cleaned with normal saline and "apply santyl and cover with foam dressing everyday and as needed." Review of the MAR from November 2010 revealed on 11/20/2010 and 11/21/2010, LPN #1 initialed the MAR indicated [REDACTED]. The facility admitted Resident #2 on 11/17/2010 with [DIAGNOSES REDACTED]. Observation of Resident #2 on 12/20/2010 revealed the resident laying in bed. The resident had a [MEDICATION NAME] dressing on her lower right leg dated 12/6/2010. The wound bed was observed to be yellow with dried blood observed under the [MEDICATION NAME]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the medical record revealed no documentation related to the wound. The Unit Manager confirmed the presence of the yellow wound bed and dried blood. She assessed the wound after the surveyor brought the wound to the facility's attention and then provided an appropriate treatment for [REDACTED]. The facility admitted Resident #3 on 3/5/2010 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 12/20/2010 revealed the resident lying in bed. The Resident had a Medi-honey strip on the lateral aspect of her/his lower leg. The Medi-honey was not covered with a [MEDICATION NAME] pad nor was the strip dated. The resident had a dressing on her left foot dated 12/17/2010. Review of the MAR indicated [REDACTED]. Another order for Medi-Honey to the top of the left foot and to cover with a [MEDICATION NAME] pad and to change daily. The treatments were last initialed as done on 12/17/2010. The Unit Manager confirmed that the dressings had not been changed since 12/17/2010. She assessed the wounds and performed the ordered treatments. During a telephone interview on 12/20/2010, LPN #2 stated that she worked weekends from 7 PM to 7 AM. She stated that she was working the weekend of 12/18/2010 and 12/19/2010. LPN #2 confirmed that she was assigned to Resident's #2 and #3. She stated that she did not change the dressing on Resident #3's foot on either 12/18 or 12/19. She stated that she "just didn't do it." LPN #2 stated that she was aware of the orders to change the dressings daily. LPN #2 also stated that if she noticed the dressings were not changed per the physician's orders [REDACTED]. She stated that she would not notify the unit manager or the Director of Nurses. LPN #2 stated she was aware that Resident #2 had a dressing on her right leg but did not notice that it was dated 12/06/2010. LPN #2 stated that she was unaware of any dressing changes for Resident #2's right leg. During an interview on 12/20/2010, the Director of Nurses stated that LPN #1 failed to change Resident #1's dressing as ordered. The DON stated that the LPN signed the treatment record. The nurse on 11/22/2010 reported to the unit manager that the dressings had not been changed. She stated that the floor nurses were responsible for changing the dressings on a daily basis. If there were any changes in the wounds, then the physician would be notified as well as a member of the wound team (a unit manager of the DON). The DON also confirmed the dressings on Resident #3's left leg and foot had not been changed since 12/17/2010. The DON confirmed the physician's orders [REDACTED]. The DON also confirmed that the dressing on Resident #2's right leg was dated 12/06/2010. She confirmed that the wound bed was yellow with dried blood. She stated that the dressing should have been changed on 12/11/2010 and 12/18/2010.