Every finding on record at Bryant Health and Rehabilitation Center

Based on observations, staff interviews, record review, and review of the facility policy titled Food Temperatures, the facility failed to accurately record food temperatures during meal service. Specifically, staff failed to properly calibrate the thermometer prior to taking temperatures for each food served to residents. The deficient practice resulted in inadequate verification that foods remained within the required temperature range for food safety which affected 67 residents receiving food from the kitchen. Findings include:Review of the facility's undated policy titled Food Temperature, documented, Policy: Foods will be maintained at proper temperature to insure food safety. and .3. The cook is responsible to see that all food is at the proper temperature.During an observation on 08/04/2026 at 12:45 PM, [NAME] AA was observed obtaining food temperatures using the same [Brand] thermometer. Prior to taking the temperature of the spaghetti, the thermometer displayed a reading of 89 F (degrees Fahrenheit). [NAME] AA sanitized the thermometer with a sanitizing wipe and immediately inserted the thermometer into the spaghetti. The spaghetti temperature was 157 F. [NAME] AA then removed the thermometer from the spaghetti and wiped the food residue from the thermometer stem with a napkin that was located on the preparation table and then used a fresh sanitizing wipe to wipe the thermometer stem and immediately inserted it into the mixed vegetables. Prior to inserting the thermometer into the mixed vegetables, the thermometer displayed a reading of 88 F. The cook repeated the cleaning process by wiping the thermometer stem with the same napkin located on the preparation table, followed by another sanitizing wipe. She then immediately inserted the thermometer stem into the pureed spaghetti. Prior to insertion, the thermometer displayed a reading of 88 F; the pureed spaghetti temperature was 169 F. Following the same cleaning process, cook AA used the thermometer to obtain the temperature of the pureed vegetables, which was 153 F.Interview regarding thermometer calibration with [NAME] AA stated, We press the button to calibrate it. Observation revealed the thermometer displayed temperatures of 88 F-89 F immediately prior to being inserted into each food item, however no actual calibration procedure was observed during the temperature-taking process.Interview on 08/05/2026 at 1:58 PM, the Dietary Manager (DM) was able to verbally articulate the proper procedure for checking steam table food temperatures. She stated that the thermometer should be cleaned, sanitized, calibrated, and allowed sufficient time to dry before being inserted into another food item. If the thermometer is not calibrated, it should be placed in a cup of ice water to bring the temperature to 0. The DM stated that written instructions for properly calibrating the thermometer were posted on the kitchen bulletin board for staff to reference. The DM confirmed that during the observed steam table temperature checks, [NAME] AA did not calibrate the thermometer between checking each food item. DM advised that it was her expectation that all staff receive education to include the proper procedure for calibrating the thermometer between testing each meal item on the steam table which ensured food temperatures meet applicable guidelines.During an interview on 08/05/2026 at 2:06 PM, the Administrator stated that staff were expected to be knowledgeable about activities occurring in and around the kitchen, including the proper procedures for monitoring food temperatures. The Administrator stated that the Dietary Manager (DM) was responsible for providing the necessary education and training. The Administrator stated that in-service training was provided to staff on relevant topics and that staff were expected to apply the knowledge and skills obtained through these training courses in their daily duties.

Based on observations, staff interviews, and review of the facility's policy titled, Waste Storage and Disposal, the facility failed to ensure the sanitary handling of garbage and refuse by allowing the door on the garbage dumpster to remain open when not in use. The deficient practice increased the risk of harboring pests and insects that affected all 67 residents.Findings Include:Review of the facility's policy titled Waste Storage and Disposal, dated 06/2016 documented Procedure: .5. Keep containers closed at all times when not in use.Observation on 08/02/2026 at 11:49 AM with the Dietary Manager (DM) revealed that the door of dumpster number 2 was opened and was confirmed by the DM. Observation on 08/03/2026 at 8:29 AM revealed that the door on dumpster number 1 was opened. Observation on 08/04/2026 at 7:55 AM revealed that the door on dumpster number 1 was opened. Observation and interview on 08/04/2026 at 8:55 AM with DM confirmed that the door on dumpster number 1 was opened. She stated it was her expectation that staff close the dumpster door after each use.Interview on 08/04/2026 at 12:52 PM with the Administrator revealed that she had been informed that the dumpster doors were left open. She stated that it was her expectation that the dumpster doors remain closed after each use and that it was the responsibility of the DM to ensure that staff consistently keep the dumpster doors closed.

Based on observation, staff interviews, and review of the facility's policy titled, Food Handling Procedures, the facility failed to maintain the cleanliness of the kitchen and ice maker. This deficient practice had the potential to place the 66 residents who received an oral diet at risk of foodborne illnesses. Findings Include: Review of the facility's undated policy titled, Procedures for Food Preparation, revealed the Policy section stated, Each facility should develop Hazard Analysis and Critical Control Point (HACCP) procedures to ensure foods produced and consumed will be safe. HACCP is a process control system that identifies critical points in the production and service of food items to prevent food safety and sanitation hazards. The Procedures section included, . 2. Identify critical control points at which procedures may result in a food safety hazard. Observation on 4/13/2025 at 9:52 am of the dishwasher revealed a fan with a black flaky substance located near the dishwasher and blowing air toward the clean dishes. Observation on 4/13/2025 at 10:20 am revealed the ice maker had a brown, flaky substance on the inside of the door. In an interview on 4/13/2025 at 10:25 am, the Dietary Manager (DM) revealed that the maintenance staff cleaned the ice maker at least two times a month. She confirmed the existence of the brown, flaky substance on the inside door of the ice machine. In a concurrent observation and interview on 4/16/2025 at 10:15 am, the DM confirmed the fan continued to have a black, flaky substance and was blowing air toward the clean dishes. In an interview on 4/16/2025 at 10:45 am, the Administrator stated that the ice maker should be cleaned monthly and as needed. The Administrator confirmed that a picture of the ice maker taken on 4/13/2025 revealed it was not clean.

Based on record review, staff interview, and review of the facility policy titled Lab Procedures and Other Services, the facility failed to obtain a urine analysis (UA) with Culture and Sensitivity timely as ordered by the physician for one of ten residents(R) (R5) reviewed. Findings include: A review of the facility policy titled Lab Procedures and Other Services, dated August 2021, revealed it was the standard of the facility to provide laboratory and diagnostic studies for all residents in compliance with Federal and State requirements. All tests will be completed as ordered, results obtained, and reported to the attending physician or Medical Director, and other members of the Interdisciplinary Team, as appropriate to assist in the management of the disease process. The General Guidelines section indicates the Licensed Nurse ensures lab is drawn/conducted in a reasonable time frame (unless stat (immediate) order). A review of the Health Status Note dated 10/19/2023 at 3:22 pm, noted R5 with altered mental status and complaints of burning when urinating. The Nurse Practitioner (NP) was made aware and new orders noted for UA with Culture and Sensitivity. The Health Status Note dated 10/19/2023 at 4:00 pm, documented an attempt to obtain a urine sample from the resident by in and out catheter was unsuccessful. Encouraged the resident to drink plenty of fluids and would pass on in report. There was no further documentation that staff attempted to obtain the urine specimen until 10/23/2023. There was also no documentation that the staff notified the physician of the failed attempt to obtain the UA on 10/19/2023. The Health Status Note dated 10/23/2023 at 11:26 am, indicated the Director of Nursing (DON) obtained the UA and it was taken to the local hospital for the UA and Culture with Sensitivity. According to the 10/24/2023 at 12:32 am Health Status Note, the resident was started on Bactrim DS (an antibiotic) as ordered for a urinary tract infection (UTI). On 10/26/2023 the resident was assessed by the NP for a follow-up related to the UTI who noted the resident was on Bactrim for UTI with final culture possible colonization. The NP noted to complete Bactrim and push fluids. The 10/27/2023 at 8:35 am a Situation, Background, Assessment, Recommendation (SBAR) form noted a change in condition with altered mental status with agitation and psychosis. It further noted the primary care provider was notified and gave orders to send the resident to the emergency room for evaluation. A review of the hospital record revealed the resident was admitted to the hospital on 10/27/2023. The 10/27/2023 hospital document titled History and Physical noted that diagnoses included UTI, advanced Alzheimer's disease, possibly end-stage, and bradycardia. During an interview with the DON on 1/8/2024 at 12:00 pm, she stated she found out during the morning meeting on 10/23/2023 that staff were having difficulty getting the urine for the UA and Culture with Sensitivity. She stated that was when she got the urine sample from the resident. She also stated staff should have notified the physician of having difficulty getting the urine sample.

Based on observations, staff and resident interviews, and review of the facilities policy titled, Infection Control Manual, the facility failed to maintain a safe, clean, and homelike environment. Specifically, the facility failed to maintain clean furniture for Resident (R#39) and linen for R#17. The deficient practice affected two of 36 resident rooms. This failure had the potential to place residents at risk for the use of an unsanitary environment and a potential for diminished quality of life. Findings Include: Review of the Infection Control Manual policy dated 06/2016 under section titled, Housekeeping revealed minimum cleaning requirements are as follows: Cleaning of resident rooms will be performed daily. Cleaning will include beds, call bells, chairs, floors, high dusting, doors, ledges, light fixtures, tables, and vacuuming of carpets. Further review of the policy under the Laundry subsection titled Replacing Soiled Linen with Clean Linen revealed: 1. Replace resident linen with clean and dry linen regularly. 1. Observations on 3/24/2023 at 8:39 a.m. and 1:15 p.m. revealed the couch adjacent to bed had a visible brown stain on the pillow cushion of unknown origin. Interview on 3/24/2023 at 1:15 p.m. with R#39 reported the couch was given to her by a nurse who worked at the facility. She reported she sits on the couch after she walks with therapy. Observations on 3/25/2023 at 9:15 a.m. and 12:15 p.m. revealed the couch adjacent to the bed has a visible brown stain on the pillow cushion of unknown origin. Review of Healthcare Services Group, Inc. Job Description revealed the following: Section 2: Position Summary-The light housekeeper is responsible for daily cleaning and sanitizing of patient room furniture, as well as sitting room and dining room furniture. Section 2A: Essential Functions of the Job-Cleans horizontal surfaces, cleans movable and stationary furnishings and fixtures: Dusts, spot cleans or washes, disinfect, when necessary, polishes where required. Review of [NAME] Health & Rehab Daily Work Routine-Light Housekeeper 8:00 a.m.-3:30 p.m. revealed a.m. walk through to include all resident rooms (Pull all over-flowing trash, identify, and fix spills or debris and fill any low supplies). Interview on 3/25/2023 at 11:50 a.m. with Housekeeping Account Manager revealed housekeeping was responsible for cleaning furniture. She reported they have a monthly project schedule they use as a guide to focus on target areas in addition to a daily work routine task list. Observation and Interview conducted on 3/26/2023 at 8:30 a.m. with Housekeeper AA confirmed and was aware of the brown stain on pillow cushion. She stated the stain was from a wound R#39 had on her bottom. The Housekeeper AA stated she had not cleaned it because it would not do any good because it happens every time R#39 sits on the couch. She further revealed they were not able to clean the pillow cushions because the cushion cover was un-removable and too large to go in the washing machine. Environmental rounds and Interviews on 3/26/2023 at 8:49 a.m. with the Housekeeping Account Manager and the Administrator, revealed both confirming the brown stain on the pillow cushion. The Administrator stated the chair belonged to her and that she had provided the chair for R#39 to use when out of bed. The administrator further revealed although this was a repeated issue, her expectations of staff to make every effort to clean it daily as needed. Interview on 3/26/2023 at 10:25 a.m. with the Housekeeping Account Manager reported she had spoken to the Regional Manager and was informed that housekeepers were not responsible for cleaning upholstered furniture. She reported that the Regional Manager stated that the nursing staff are responsible for cleaning any upholstery. Interview on 3/26/2023 at 10:35 a.m. with the Administrator reported although a joint effort, the housekeeping department was responsible for cleaning upholstery furniture and not nursing. She reported the Housekeeping/Laundry department was contracted with the facility and she plans to discuss the job responsibilities with the Regional Manager on Monday. She reported the chair cushion had been removed and was currently being washed. 45813 2. Record review revealed R#17 was admitted to facility on 6/4/2015 with diagnosis that include but not limited to paranoid schizophrenia, psychotic disorder with delusions due to known physiological condition and generalized anxiety disorder. Record review of current physician orders for R#17 revealed Hydroxyzine Pamoate Oral Capsule 25 MG (milligram) (Hydroxyzine Pamoate). Give one capsule by mouth two times a day for Itching and Bactroban Ointment 2 % (Mupirocin). Apply to Affected Areas topically everyday shift for Open Skin Areas. Record review of the most recent Minimum Data Set (MDS) quarterly assessment for R#17 dated 3/13/2023 revealed resident has a Brief Interview for Mental Status (BIMS) score of 14 indicating resident is cognitively intact. Resident requires extensive assistance x 1 physical assist with personal hygiene and has open lesions other than ulcers, rashes, cuts. Record review of the care plan for R#17 revealed a focus area that related to resident has a potential for skin breakdown. Resident frequently picks at his skin causing multiple sores. Interventions related to this problem included administering cream as ordered, avoid restrictive clothing , observe skin during care for any redness/breakdown and report to nurse/MD as indicated, redirect resident as needed when picking his skin. Observation on 3/24/2023 at 9:07 a.m. and 12:59 p.m. revealed resident lying in bed. The bed sheet had multiple blood stains. There is also a white paper towel on the bed stained with blood. R#17 stated that the sores on his legs bleed and cause blood stains. R#17 further states that he gets a cream applied but the open lesions that bleed and are not covered. Observation on 3/25/2023 at 9:04 a.m. and 12:03 p.m. revealed resident lying in bed. There is a paper towel stained with blood on the bed. There were blood stains on the bed sheets at the time of this observation. Interview on 3/25/2023 at 12:09 p.m. with Certified Nursing Assistant (CNA) DD revealed R#17 ambulates to bathroom independently. She stated that the resident does allow her to assist him with ADLs and change his linen and his bed. CNA DD stated R#17 has never refused care when she worked with him. CNA DD further revealed the resident picks at his skin every day therefore his linen should be changed at least daily or maybe every shift due to the open lesions on his skin. Interview on 3/25/2023 at 1:23 p.m. with Registered Nurse (RN) BB, revealed R#17 is noncompliant with care. RN BB stated resident fusses and yells at staff if they attempt to remove dirty stuff from the bed, including the blood-stained paper towels. She further revealed the resident refuses to allow staff to change his linen. RN BB stated that she is not aware if resident has ever been seen by a skin doctor, but the facility's doctor and Nurse Practitioner sees resident. RN BB stated that R#17 picks his skin because he thinks there are mites living in his skin. RN BB further stated that the staff had not reported a refusal of care today or on 3/24/2023. RN BB further stated that if a resident refuses care she is required to document the refusal of care in the electronic record. RN BB verified the blood stained linen and paper towel on R#17's bed and would get it changed. Interview on 3/26/2023 at 10:20 a.m. with Director of Nursing (DON) revealed that the staff is aware of resident's self-inflicted open areas on his skin. She further stated that this is being treated as behaviors and not a medical treatment. The DON stated that it is her expectation that if a resident refuses any care or services that the nurse speaks to the resident and if resident continues to refuse, the refusal is to be documented. Observation 3/25/2023 at 2:56 p.m. revealed resident lying in bed with clean sheets. Interview on 3/26/2023 at 11:14 a.m. with Administrator, she stated that typically the residents sheets are bloody from him always picking his skin but the staff should offer to change his linen.

Based on observation, interview and review of facility policy titled Medication Administration Guidelines, the facility failed to ensure nursing staff performed hand hygiene while administering medications to three of six sampled residents observed for medication administration (R#38, R#43, and R#52). Findings include: Observation of medication administration on 11/17/21 starting at 9:30 a.m. revealed Licensed Practical Nurse (LPN) BB did not sanitize or wash hands before, during, or after administering medications to R#38, R#43, or R#52. After medication was distributed to each resident, LPN BB returned to medication cart each time without performing hand hygiene by either washing hands or utilizing alcohol-based hand sanitizer. Interview with LPN BB on 11/17/21 at 9:45 a.m. confirmed that handwashing procedures were not adhered to during the above observations of medication administration. Interview with the Director of Nursing (DON) on 11/17/21 at 1:45 p.m. revealed that all staff are expected to follow infection control guidelines and policy and procedures during medication administration and while performing care to residents. Review of facility policy titled Medication Administration Guidelines dated August 2021 under General and Specific Guidelines on Administration of Medication by Routes revealed: A. General procedures completed before administering medication by routes: a. Staff must begin by washing their hands and assembling equipment necessary for administration; hand sanitizer may also be used following manufacturer's instructions.

Based on observations, record review, review of facility policy titled Medication Administration Guidelines, and staff interviews, the facility failed to ensure the medication error rate was less than 5%. A total of 34 opportunities were observed with three errors for three of six residents for an error rate of 8.82%. Findings include: 1. Observation of medication administration on 11/17/21 at 9:00 a.m. revealed Licensed Practical Nurse (LPN) BB obtained medication from the cart for R#43. LPN BB administered [MEDICATION(S)] 500 milligrams (mg), [MEDICATION(S)] 20 gm, [MEDICATION(S)] 20 mg, and [MEDICATION(S)] 10 mg whole and without being crushed, as ordered by the physician. Review of resident's medical record revealed R#43 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with LPN BB on 11/17/21 at 9:30 a.m. confirmed R#43 did have an active order for all medications to be crushed before administration and that the medications for R#43 should have been crushed before administering. The following two observations of medication administration started on 11/17/21 at 9:30 a.m. with LPN BB: 2. Observation of medication administration revealed LPN BB obtained medications from the cart for R#38 and administered the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . No other medications were administered at this time. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Observation of medication administration revealed LPN BB obtained medications from the cart for R#52 and administered the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . No other medications were administered at this time. Review of the MAR for R#52 revealed that nurse did not administer [MEDICATION(S)] 1 mg that was ordered for resident daily, during observation. Interview with LPN CC (Unit Manager) on 11/17/21 at 11:09 a.m. revealed the process for replacing medications is to first look in the emergency kit to ensure medication is available. If the medication that is needed in the emergency kit is available, there is a form that is to be completed that indicates what medication was used and how many are remaining. The form is then sent to the pharmacy to let them know that the emergency kit has been opened. If the medication that is needed is not available in the emergency kit the pharmacy is called to see when the medication can be delivered or if the medication can be called into the back up pharmacy to be picked up. Further interview revealed that if the medication is not available at the back up pharmacy, then the physician is notified to see if there can be an order to hold the medication or to change it to something else until the medication becomes available. Continued interview revealed that all nurses that are hired into the facility are educated on this process during orientation. Interview with LPN BB on 11/17/21 at 11:56 a.m. confirmed that the losartan 50 mg for R#38 and [MEDICATION(S)] 1 mg for R#52 was not available for administration. Continued interview also revealed that the process for retrieving medications for residents when they are not available on the cart is to go to the emergency kit located in the drug room. LPN BB confirmed that she did not utilize the emergency kit for replacement of the medications that were not available for distribution. Interview with the DON on 11/17/21 at 12:21 p.m. revealed that the process for obtaining medication when it is not available for administration is to first check the emergency kit to see if the medication is in there and the pharmacy should be notified. If the medication is not in the kit the physician is notified and an order is obtained to either hold the medication or another medication would be ordered until the missing medication is available. Further interview also revealed that the nurses are aware of this process, and they are expected to follow facility protocol. Review of facility policy titled Medication Administration Guidelines dated August 2021 under medication administration revealed: prior to administering medications, the resident must have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, staff interviews, and policy review titled Infection Prevention and Control Program, the facility failed to sanitize ice/water machine and failed to prevent possible cross contamination to clean laundry. This had the potential to effect 45 of 67 residents for the use of ice/water machine and 53 of 67 residents that the facility provided laundry services for personal clothing. Findings include: 1. An observation on 2/9/2020 at 12:50 p.m. revealed the ice/water machine dirty with brown substance at the bottom of tray. An observation on 2/10/2020 at 10:20 a.m. revealed the ice/water machine dirty with brown substance at the bottom of tray. Staff was observed getting ice from the ice/water machine at this time. On 2/10/2020 at 12:00 p.m. Resident (R) #42 was observed getting ice from the ice/water machine. A continued observation on 2/11/2020 at 9:27 a.m. revealed the ice/water machine remained dirty with brown substance at the bottom of tray. During an interview on 2/11/2020 at 4:33 p.m., Account Manager EE stated housekeeping staff are responsible for cleaning the ice/water machine daily with Virex (a one-step disinfectant cleaner and deodorant). She proceeded to clean the machine with the Virex and a white washcloth. A brown substance was noted on the washcloth after it was cleaned. During an interview on 2/11/2020 at 4:45 p.m., Licensed Practical Nurse (LPN) CC stated nurses do not get water or ice from the ice/water machine for residents but from the coolers. She stated that staff mainly uses it and it is occasionally used by residents who are able to operate the machine on their own. An interview on 2/12/2020 at 9:09 a.m. with Ice Machine Technician BB revealed the manufacturer recommends ice/water machine to be cleaned every six months. He stated he's not sure of how often it is to be cleaned in between service calls and they use a cleaning agent called Safe Clean Plus. He stated he was currently soaking the parts to the machine and that it had calcium build up on them. 2. During a tour of the laundry room and interview on 2/11/2020 at 9:04 a.m. with Laundry Staff DD and Account Manager EE, an opened soda can and tube of lotion was observed on the laundry folding table near clean clothing protectors. Laundry Staff DD and Account Manager EE acknowledged that personal items should not have been on the folding table where clean clothes and linens are folded to prevent cross contamination. Laundry Staff DD stated she is aware that personal items are not to be placed there and that the clean clothing protectors would be re-washed. An interview on 2/11/2020 at 4:59 p.m. with the Administrator revealed she was made aware by staff of the brown material that came from the ice/water machine and personal items near clean laundry. She has instructed and expect the housekeeping staff to clean the machine daily with warm water and store personal items in the designated areas. Review of the facility policy titled, Infection Prevention and Control Program dated 06/2016 documented: The facility strives to prevent transmission of infections and communicable diseases, development of nosocomial infection, and effectively treat and manage nosocomial and community acquired infections. The goal of the program is to identify and reduce the risks of acquiring and transmitting infections among residents, employees, volunteers, and visitors. The program includes a system to monitor and investigate infection trends. The program is developed based on nationally recognized organizational standards and procedures.

Based on observations and staff interview, the facility failed to ensure rooms had privacy curtains that provided total visual privacy for three of 37 rooms in which three residents resided (Room #'s 201, 207, and 204). Findings include: 1. During an observation on 2/9/2020 at 12 p.m. in room [ROOM NUMBER] there was a short privacy curtain for Bed B. 2. During observation of room [ROOM NUMBER] on 2/9/2020 at 3:38 p.m. there was a short privacy curtain between Bed A and Bed B. 3. Observation on 2/9/2020 at 11:25 a.m., 2/10/2020 at 10:42 a.m. and 3:55 p.m. revealed the resident in room [ROOM NUMBER] had no privacy curtain. A tour was conducted on 2/12/2020 from 2:55 p.m. until 2:59 p.m. with the House Keeping Supervisor who confirmed that there was a short privacy curtain in room [ROOM NUMBER] due to the curtain track being short. It was reported that housekeeping staff should be pulling the privacy curtains daily when in the room to check for stains and to assure that the curtains are the appropriate length. The Housekeeping Director was unaware of the short curtain in rooms [ROOM NUMBERS]; and the missing curtain in room [ROOM NUMBER]. The Housekeeping Supervisor initially reported that the previous Maintenance Director had been notified of the short privacy curtains and was supposed to order curtains. However, there was no documentation provided to support the order for new privacy curtains.

Based on record review and staff interview, the facility failed to ensure that two physicians signed a Physician order [REDACTED]. Findings include: A review of the Quarterly Minimum Data Sets dated [DATE] revealed a Brief Interview for Mental Status score of 99 indicating that the resident was unable to complete the interview with the staff assessment indicating that the resident had both short-term and long-term memory problems. A review of the Advanced Directives for R#39 revealed a POLST signed by only one physician and dated [DATE]. A review of the Physician order [REDACTED]. A review of the care plan revealed that R#39 had a care plan documenting request for a DNR, no Cardiopulmonary Resuscitation (CPR). An interview on [DATE] at 12:56 p.m. with the Social Service Director revealed that the resident was cognitively unable to make decisions. She confirmed that the POLST was signed on [DATE]. She also confirmed that there was only one physician signature and the resident does not have a Durable Power of Attorney for healthcare. She confirmed that there needed to be a concurring physician signature. An interview on [DATE] at 1:10 p.m. with the Director of Nursing revealed that she would expect for a resident who was not cognitively able to make decisions for themselves that the Advanced Directive would have a concurring physician signature. An interview on [DATE] at 2:52 p.m. with Licensed Practical Nurse/Unit Manager CC revealed that no residents have been resuscitated that had an Advanced Directive for DNR and no residents have not been resuscitated that had an Advanced Directive of Full Code.

Based on observation, interview and record review, the facility failed to ensure a clean, comfortable and homelike environment in five of 37 resident rooms that had a build-up of dust, stained privacy curtains, rusty medical furniture and an uncomfortably cool room temperature. Findings include: During an observation on 2/9/2020 at 2:28 p.m. in room [ROOM NUMBER] there were stained privacy curtains, missing paint from around the window, and there was a stained ceiling tile over Bed [NAME] During an observation on 2/9/2020 at 3:30 p.m. in room [ROOM NUMBER] there was dust noted on top of the concentrator, stained privacy curtain near Bed B, and rust on the base of the over bed table. During an observation on 2/9/2020 at 3:38 p.m. in the shared bathroom for rooms [ROOM NUMBERS] there was dust buildup in the vents, buildup on the rail in the bathroom, and the middle privacy curtain in room [ROOM NUMBER] was stained. During an observation on 2/9/2020 at 3:51 p.m. in the bathroom for room [ROOM NUMBER] there was a strong odor, the call light string was brown, there was rust on the over the toilet seat, there was missing paint from the ceiling near the vent, there was dust buildup in the vent, there was missing paint from the wall, a hole in the wall near Bed B, and rust on the base of the overbed table by Bed [NAME] An interview with resident (R)#48 on 2/10/2020 at 9:45 a.m. revealed that her room was freezing. An observation of the resident revealed that the resident was covered with a blanket and the room was uncomfortably cool. The observation also revealed that the resident's room had an individual heating unit in it that was not turned on. The resident stated that she told Maintenance that the knob on the heater had come off and he said that the knob had been removed because the heater was a fire hazard. The resident stated that she had been able to use the heater until the last few days, but they had now told her not to use it because of it being a fire hazard. An observation on 2/10/2020 at 11:10 a.m. revealed that the resident was sitting in her recliner in room [ROOM NUMBER] covered with a blanket. She stated that she had not gotten warm yet. Observation revealed that the room felt warmer at this time than it did earlier today. An observation on 2/12/2020 at 8:47 a.m. during a general tour with the Project Manager/ Interim Head of Maintenance FF and the Interim Head of Housekeeping EE in the shared bathroom for room [ROOM NUMBER]/209 confirmed that there was a dust build-up in the bathroom vent and build-up of brown substance on the handrail in the bathroom. The Head of Housekeeping EE also confirmed that the privacy curtain in the center of room [ROOM NUMBER] was stained. An observation on 2/12/2020 at 8:52 a.m. during a general tour with Project Manager/Interim Head of Maintenance FF and Interim Head of Housekeeping EE in room [ROOM NUMBER] confirmed a dust build-up on the oxygen concentrator, a stained privacy curtain, a dust build-up on the fan that was in use and rust on the base of over-bed table. An observation on 2/12/2020 at 9:00 a.m. during a general tour with Project Manager/Interim Head of Maintenance FF and Interim Head of Housekeeping EE in room [ROOM NUMBER] confirmed that the call light string in the bathroom was stained a yellow-brown color, there was rust on the raised toilet seat, there was missing paint near the vent in the bathroom, there was a hole in the wall in the resident's room on Bed B side with missing paint, the call light for Bed B had a build-up of debris and was stained, and there was rust on the base of the bedside table for Bed [NAME] An observation on 2/12/2020 at 9:02 a.m. during a general tour with Project Manager/Interim Head of Maintenance FF and Interim Head of Housekeeping EE in room [ROOM NUMBER] confirmed that the privacy curtain was stained. The Project Manager/Interim Head of Maintenance FF confirmed the yellowed ceiling tile over the resident's bed and confirmed that there was missing paint around the window frame. An observation on 2/12/2020 at 9:14 a.m. with Project Manager/Interim Head of Maintenance FF and Interim Head of Housekeeping EE in room [ROOM NUMBER] revealed a room temperature of 67 degrees Fahrenheit (F). Interview with the Head of Maintenance revealed that the temperature should be between 71 degrees F and 81 degrees F. A review of the log of temperatures in rooms revealed that the temperature was documented weekly as being checked in the Front Lobby, 100-hall, 200-hall and 300-hall but there was no documentation of temperatures being checked in resident rooms for the months of 11/25/19 through 2/6/2020. An interview on 2/12/2020 at 11:53 a.m. with the Project Manager/Interim Head of Maintenance FF confirmed that there was no documentation of temperatures being taken in resident rooms. He stated that the temperatures were to be documented weekly and were to include resident rooms. He stated that he wasn't sure why resident room temperature weren't checked.

Based on observation, staff interview and record review, the facility failed to ensure that the hair of two dependent residents (R) (#1 and #36) was kept clean of 33 sampled residents. Findings include: A review of the policy titled, Resident Hygiene: Bath and Shower Standard under subsection 9 stated that residents' hair was to be shampooed on each bath/shower day. 1. Observations on 2/9/2020 at 11:57 a.m., on 2/10/2020 at 9:37 a.m., and on 2/12/2020 at 11:05 a.m. revealed the hair of R#1 looked greasy. A review of the activity of daily living (ADL) sheets revealed that neither bathing nor the personal hygiene task specifically mentioned hair washing. A review of the care plan for the resident revealed that she required assistance with ADLs with documented interventions to anticipate and meet needs daily, total assistance of one person with bathing, dressing, personal hygiene, locomotion, toileting/incontinent care, eating and bed mobility. An interview on 2/12/2020 at 12:12 p.m. with the Certified Nursing Assistant (CNA) GG revealed that R#1 required total care. The CNA stated that the resident went to the shower one day a week and received bed baths the other days. She stated that shampooing of hair should be done when residents go to the shower. An observation and interview on 2/12/2020 at 12:22 p.m. with the Director of Nursing (DON) confirmed that the resident's hair was dirty and greasy looking. She stated that her expectation was that the resident's hair was to be washed when they go to the shower. 2. Observations of R#36 made on 2/9/2020 at 12:13 p.m., 2/10/2020 at 9:31 a.m., and 2/12/2020 at 11:26 a.m. revealed that the resident's hair looked greasy and dirty. A review of the ADL sheets for the resident revealed that neither bathing nor the personal hygiene task specifically mentioned hair washing. A review of the care plan revealed that the resident required assistance with ADLs with an intervention documented that she required total assistance by one person with bed mobility, eating, bathing, dressing, personal hygiene and toileting/incontinent care. There was a care plan documenting that the resident would refuse care at times, would hit at staff and yell or scream out at times. An interview on 2/12/2020 at 12:11 p.m. with CNA GG revealed that the resident required total assistance with most ADLs, and she received a shower on the 3 p.m. to 11 p.m. shift on Tuesday, Thursday and Saturday. An interview on 2/12/2020 at 12:20 p.m. with the DON confirmed that the resident's hair was dirty and greasy looking.

Based on observation, record review, review of the facility policy titled Respiratory System Management - Oxygen, Administration - Nasal Cannula, and staff interviews, the facility failed to follow a Physician's Order for two residents (R) (#21 and #65) reviewed of 7 residents receiving oxygen. Findings include: 1. Review of the medical record for R#21 revealed a [DIAGNOSES REDACTED]. Further review of the medical record revealed a Physician's Order for oxygen at 3 LPM (liters per minute) with a start date of 11/21/17. During observations on 2/9/2020 at 3:30 p.m., 2/10/2020 at 10:57 a.m. and at 4:25 p.m., and 2/11/2020 at 9:03 a.m. and 1:38 p.m. R#21's oxygen was infusing between 2 LPM and 2.5 LPM. During an observation and interview with Licensed Practical Nurse (LPN) AA on 2/11/2020 at 1:38 p.m. she confirmed R#21's oxygen not being administered at 3 LPM per the Physician's Orders. During an interview with the Director of Nursing (DON) on 2/12/2020 at 11:59 a.m., DON confirmed that nurses should check oxygen each shift to assure that they are being administered correctly. 2. Review of the medical record revealed R#65 with [DIAGNOSES REDACTED]. Review of Physician Order dated 1/18/2020 revealed that the oxygen will be set for 3 LPM. Observations of R#65 on 2/9/2020 at 11:22 a.m. and 12:35 p.m., 2/10/2020 at 9:34 a.m. and 10:25 a.m., and 2/12/2020 at 11:45 a.m. revealed R#65 was receiving oxygen at 2 to 2.5 LPM. During an interview and observation on 2/12/2020 at 11:45 a.m., LPN AA confirmed that R#65's oxygen was at 2 LPM. LPN AA reported that the oxygen should be at 3 LPM. LPN AA reported that she was responsible for ensuring the residents oxygen was correct. Review of the undated facility policy titled Respiratory System Management; Oxygen, Administration- Nasal Canula revealed: 1. Check the residents clinical record for the physician's order. 5. Turn the flow meter to the ordered flow rate.

Based on record review and staff interview, the facility failed to ensure that licensed/registered nursing staff administered medications per Physician order [REDACTED].#2) of three residents reviewed for medications from a census of 62 residents. Findings include: 1. Record review revealed that R A was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of his care plan revised 6/2/17 revealed that he had a history of [REDACTED]. Continued review of his care plan revised 1/2/19 revealed that he had a potential for adverse side effects due to his antidepressant with an intervention for licensed/registered nursing staff to administer medication as ordered by the physician. Review of the medical record for R A revealed current physician's orders [REDACTED]. Review of the Medication Administration Records (MARs) revealed that licensed/registered nursing staff failed to administer [MEDICATION NAME] for one day and [MEDICATION NAME] XL for two days in 2/2019; failed to administer [MEDICATION NAME] three times in 3/2019; and failed to administer [MEDICATION NAME] three days in 4/2019. Cross refer to F684. 2. Record review revealed that R#2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of her care plan revised 7/15/15 revealed that she was at risk for injury related to her [MEDICAL CONDITION] disorder with an intervention for licensed/registered nursing staff to give [MEDICAL CONDITION] medication as ordered by the doctor. Continued review of her care plan revealed that she refused medications at times. review of the resident's medical record revealed [REDACTED].) along with 100 mcgs to equal 188 mcgs. every day for [MEDICAL CONDITION] (6:00 a.m.); [MEDICATION NAME] 500 mg./10 cubic milliliters (mls.) three times a day for dementia with behaviors (also for [MEDICAL CONDITION]) (9:00 a.m., 1:00 p.m. and 5:00 p.m.); and [MEDICATION NAME] 300 mg./5 mls three times a day for [MEDICAL CONDITION] (9:00 a.m. and 9:00 p.m.) Review of the 2/2019 MAR indicated [REDACTED]. one day; failed to administer [MEDICATION NAME] three times a day for one day; and failed to administer [MEDICATION NAME] twice a day three times in 2/2019. Interview with the Director of Nursing (DON) on 5/7/19 at 4:00 p.m. revealed that there was no reason that licensed nursing staff should not administer the resident's medications as ordered and as care planned. She stated that the contracted Pharmacy delivered medications every night so medications should be available to administer the next day. Continued interview revealed that the nurses could also obtain certain medications from the Emergency (E) Kit kept in the Medication Room. Further interview revealed that medications could also be obtained from a local back-up pharmacy if needed. Cross refer to F684.

Based on observation, review of the Long Term Care Pharmacy Services and Procedures Manual (Policy #1 and Policy #7), record review and resident and staff interview, the facility failed to ensure that licensed and registered nursing staff administered medications as ordered by the Physician for three residents (R) (R A, R#2 and R#3). The census was 62 residents. Findings include: Review of the Long Term Care Facility Pharmacy Services and Procedures Manual (dated (YEAR)): Policy # 1.0 Providing Pharmacy Products and Services, revealed that during normal business hours, facility staff may contact pharmacy by phone or fax. After normal business hours, facility staff should contact pharmacy by phone to page the on-call pharmacist. Review of Policy # 7.0 Medication Shortages/Unavailable Medications revealed that upon discovery that there is an inadequate supply of a resident's medication, facility staff should immediately initiate action to obtain the medication from pharmacy. If medication shortage is discovered during normal pharmacy hours, the facility nurse should call pharmacy to determine status of order. If the medication has not been ordered, the nurse should place the order or reorder for the next scheduled delivery. If the next available delivery causes delay or missed dose in the resident's medication schedule, the nurse should obtain the medication from the Emergency Medication Supply to administer the dose. If the medication is not available in the Emergency Medication Supply, the nurse should notify pharmacy and arrange for an emergency delivery. If a medication shortage is discovered after normal pharmacy hours, the nurse should obtain the medication from the Emergency Medication Supply. If the medication is not available in the Emergency Medication Supply, the nurse should call pharmacy's emergency answering service and request to speak with the pharmacist on duty to arrange emergency delivery or use an emergency (back-up) third party pharmacy. If an emergency delivery is unavailable, the nurse should contact the attending physician to obtain orders/directions. If the nurse is unable to obtain a response from the attending physician in a timely manner, the nurse should notify the nursing supervisor and the Medical Director for orders/direction making sure to explain the circumstances of the medication shortage. When a missed dose is unavoidable, the nurse should document the missed dose and the explanation for such missed dose on the MAR/TAR and in the nurse's notes per facility policy. Such documentation should include a description of the circumstances of the medication shortage, a description of pharmacy's response upon notification and action(s) taken. 1. Record review revealed that R A was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 15 indicating that he was alert and oriented. Review of his care plan revised 6/2/17 revealed that he had a history of [REDACTED]. Continued review of his care plan revised 1/2/19 revealed that he had a potential for adverse side effects due to his antidepressant with an intervention for licensed/registered nursing staff to administer medication as ordered by the physician. On 5/7/19 at 11:01 a.m., R A was sitting in his recliner in his room. The resident did not exhibit any adverse signs or symptoms related to his medications. R A stated at that time that he felt that he had not received his diabetic medications because his blood sugar levels were high. He stated that the physician had adjusted his medications but, his blood sugar levels were still high. Review of the medical record for R A revealed current physician's orders [REDACTED].) twice a day for [MEDICAL CONDITION] (9:00 a.m. and 9:00 p.m.). Review of the 2/2019 Medication Administration Record [REDACTED]. Continued review of the MAR indicated [REDACTED]. There was no indication that staff followed up with pharmacy on the status of the [MEDICATION NAME]. Continued review of the 2/2019 MAR indicated [REDACTED]. Review of the Nurse's Medication Notes revealed that Code B was documented under the reason the [MEDICATION NAME] was not administered on those days but, there was no indication that staff followed up with pharmacy about the status of the medication. Review of the 3/2019 MAR indicated [REDACTED]. There was no documentation for the reason the [MEDICATION NAME] was not administered on 3/4/19 at 9:00 p.m. or on 3/5/19 at 9:00 p.m and no indication that staff followed up with pharmacy about the status of the [MEDICATION NAME]. Review of the 4/2019 MAR indicated [REDACTED]. Review of the Nurse's Medication Notes dated 4/22/19 at 9:00 a.m. revealed that Code B-med reordered was documented under the reason the [MEDICATION NAME] was not administered. There was no documentation for the reason the [MEDICATION NAME] was not administered on 4/23/19 and 4/24/19 and no indication that staff followed up with pharmacy about the status of the [MEDICATION NAME]. Review of the medical record for R A revealed that he did not have any complications due to staff failure to administer his medications as the physician ordered. On 5/7/19 at 4:15 p.m., review of the Emergency Medication Supply (E-kit) Medication List with the DON revealed that [MEDICATION NAME] XL 25 mg, [MEDICATION NAME] 200 mg and [MEDICATION NAME] 20 mg were in the E-kit. 2. Record review revealed that R#2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed that she was severely cognitively impaired. Review of her care plan revised 7/15/15 revealed that she was at risk for injury related to her [MEDICAL CONDITION] disorder with an intervention for licensed/registered nursing staff to give [MEDICAL CONDITION] medication as ordered by the doctor. Continued review of her care plan revealed that she refused medications at times. On 5/7/19 at 12:12 p.m., R#2 was sitting in her wheelchair in the hall. She was clean and without odors. She did not exhibit any adverse signs or symptoms related to her medications. review of the resident's medical record revealed [REDACTED].) along with 100 mcgs to equal 188 mcgs. every day for [MEDICAL CONDITION] (6:00 a.m.); [MEDICATION NAME] 500 mg/10 milliliters (mls.) three times a day for dementia with behaviors (also for [MEDICAL CONDITION]) (9:00 a.m., 1:00 p.m. and 5:00 p.m.); and [MEDICATION NAME] 300 mg./5 mls twice a day for [MEDICAL CONDITION] (9:00 a.m. and 9:00 p.m.) Review of the 2/2019 Medication Administration Record [REDACTED]. Licensed nursing staff did administer [MEDICATION NAME] 100 mcgs. to the resident. Continued review of the 2/2019 MAR indicated [REDACTED]. Further review of the 2/2019 MAR indicated [REDACTED]. Continued review of the 2/109 MAR indicated [REDACTED]. Review of the medical record for R#2 revealed that she had [MEDICAL CONDITION] on 2/21/19, 2/25/19 and 3/1/19. The Physician was notified and [MEDICATION NAME] administered as ordered. The physician increased the [MEDICATION NAME] to three times a day on 2/25/19. On 5/7/19 at 4:15 p.m. review of the E-kit Medication List with the DON revealed that the E-kit contained [MEDICATION NAME] 88 mcgs and 100 mcgs. The E-kit did not contain [MEDICATION NAME] or [MEDICATION NAME]. An interview with the resident's attending Physician on 5/8/19 at 10:57 a.m. revealed that he did not think that the resident's [MEDICAL CONDITION] on 2/21/19 was caused by the missed doses of [MEDICATION NAME] on 2/20/19. He stated at that time that the missed doses of [MEDICATION NAME] on 2/9/19, 2/10/19 and 2/11/19 would not cause the resident's [MEDICAL CONDITION] on 2/21/19 due to the time interval between the missed doses of [MEDICATION NAME] and the [MEDICAL CONDITION]. 3. Record review revealed that R#3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed that she was severely cognitively impaired. On 5/7/19 at 12:00 p.m., the resident was lying in a low bed with her eyes closed. She was clean, neat and without odors. The resident did not exhibit any adverse signs or symptoms related to her medications. Review of the medical record for R#3 revealed that she had current Physician order [REDACTED].½ tablet (2.5 mg) at bedtime (9:00 p.m.) for overactive bladder. Review of the 2/2019 Medication Administration Record [REDACTED]. Review of the Nurse's Medication Notes revealed that licensed/registered nursing staff documented Code B as the reason the medication was not administered on each of those days. However, there was no indication that staff followed up with pharmacy on the status of the medication. Review of the 3/2019 MAR indicated [REDACTED]. Review of the Nurse's Medication Notes revealed that licensed nursing staff documented Code B as the reason the medication was not administered on 3/2/19, 3/6/19, 3/7/19, 3/8/19, 3/13/19 and 3/14/19. There was no documentation for the reason the [MEDICATION NAME] was not administered on 3/9/19, 3/10/19, 3/11/19 or 3/12/19 and there was no indication that staff followed up with pharmacy about the status of the medication. Continued review of the 3/2019 MAR indicated [REDACTED]. Review of the Nurse's Medication Notes revealed that licensed nursing staff documented Code B-faxed pharmacy for the reason the medication was not administered. Further review of the 3/2019 MAR indicated [REDACTED]. Review of the Nurse's Medication Notes revealed that there was no documentation for the reason the medication was not administered on 3/1/19. Continued review revealed that licensed nursing staff documented on 3/2/19 and 3/3/19 that pharmacy faxed. On 3/4/19 and 3/5/19, licensed nursing staff documented awaiting pharmacy. Review of the 4/2019 MAR indicated [REDACTED]. Review of the Nurse's Medication Notes revealed that licensed nursing staff documented on 4/23/19 that the medication was not available, pharmacy notified. There was no documentation for the reason the medication was not administered on 4/24/19, 4/25/19, 4/26/19 or 4/27/19 and no indication that staff followed up with pharmacy about the status of the medication. Review of the E-kit Medication List with the DON on 5/7/19 at 4:15 p.m. revealed that [MEDICATION NAME] 20 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 10 mg and [MEDICATION NAME] 5 mg were in the E-kit. Review of the medical record for R#3 revealed that she did not have any complications related to staff failure to administer medications as ordered by the physician. An interview with Licensed Practical Nurse (LPN) AA on 5/7/19 at 9:25 a.m. revealed that a medication for a resident was rarely unavailable. She stated that if a medication was unavailable she would obtain it from the E-kit. If it was not in the E-kit, she would notify pharmacy and call the physician to obtain an order for [REDACTED]. An interview with LPN BB on 5/7/19 at 9:40 a.m. revealed that about once per week, a medication was not in the medication cart. Continued interview revealed that the medication was usually in the E-kit. Further interview revealed that if the medication was not in the E-kit, she would notify the pharmacy and the physician. An interview with LPN CC on 5/7/19 at 3:25 p.m. revealed that it was not often that medications were not in the medication cart. Continued interview revealed that if a medication were not available, she would call the pharmacy to send the medication by the night courier. Further interview revealed that she could also notify the local pharmacy if a medication was not available. She stated at that time that [MEDICATION NAME] was an over-the-counter (OTC) medication that could easily be purchased from the local pharmacy without delay. Continued interview revealed that there really was no reason a medication should not be available for two or more days. An interview with LPN DD on 5/7/19 at 3:40 p.m. revealed that about once per week a medication will not be available. Continued interview revealed that she would check the E-kit for the medication. If the medication was not in the E-kit, she would notify the pharmacy to reorder the medication. She stated at that time that she would complete a Reorder Sheet, fax it to pharmacy and leave a copy for the Director of Nursing (DON) to follow-up the next morning on the status of the medication. Further interview revealed that she would notify the physician who may order another medication or order staff to hold the medication until it was available. Continued interview revealed that pharmacy delivered medications every night except Sunday. An interview with the Director of Nursing (DON) on 5/7/19 at 4:00 p.m. revealed that there was no reason that licensed nursing staff should not administer the resident's medications as ordered and as care planned. She stated that the contracted Pharmacy delivered medications every night so medications should be available to administer the next day. Continued interview revealed that the nurses could also obtain certain medications from the Emergency (E) Kit kept in the Medication Room. Further interview revealed that medications could also be obtained from a local back-up pharmacy if needed. Continued interview revealed that the nurses had not notified her that medications were unavailable for greater than one day. She stated at that time that if the nurses had notified her that the medications were not in the medication cart and they were too busy with their medication administration to retrieve the medications themselves, she would have obtained the medications from the E-kit, called the contracted pharmacy to send them that night or gone to the local pharmacy to obtain the medications.

Based on observation, staff interview, the facility policy title Food Storage and Labeling, the facility failed to ensure foods items were label and food processing equipment were maintained in clean sanitary manner. This had the potential to effect 67 residents. Findings include: Observation on 9/5/17 at 11:17 am revealed a meat slicer partially covered with saran wrap and not completing covering the blades, sitting on counter with white crumb like particles. Interview with the Dietary Manager DM at the time of the observation revealed blades did not have to be completed covered per instruction of the facility Register Dietician RD. She reported that her RD informed dietary staff that only the slicer blade need to be covered. She verified that the saran wrap did not covered the blade and the entire meat slicer. Observation 9/5/17 at 11:19 am revealed the following dry goods items with no open and expiration date -oatmeal and rice in separate large plastic storage containers.DM at time of interview revealed that her expectation is that all food items in the dry storage area should be properly labeled. She stated that her staff received in-service training on labeling and storage throughout the year and on their hire date. Observation on 9/5/17 at 11: 23 a.m. of walk in refrigerator revealed several partial open packages of cheese with no open date and without an expiration date. Observation on 9/5/17 at 11:33 a.m. of one reach in refrigerator revealed the following 3 food items, a bag of tilapia fish, a box of sausage patties, and a box of biscuits. All boxed food items were not completely sealed and were opened. Continued observation revealed that there was not an open date and there was not an expiration date on the 3 items. At the time of the observation, the DM stated that staff should have completely covered and sealed the boxes and should have labeled these items. Observation on 9/5/17 at 11:26 a.m. revealed one ceiling vent fan covered with thick dark greyish substances blowing towards the clean dishes merging from the dishwasher on a counter attached to the dishwasher. Continued observation revealed one ceiling vent covered with thick dark greyish, web substance positioned above the dishwasher and attached counter. DM verified that the greyish substances coating the fan and ceiling vent as dust. She stated that maintenance staff is responsible for cleaning the fan and the vent. She stated that maintenance staff cleans the fan and vent monthly. Interview with the Administrator on 9/5/17 at 1:25pm stated her expectations are that dietary staff and maintenance clean ceiling vent and fan in the kitchen area based on the cleaning schedule.

Based on observation, review of the Centers for Disease Control (CDC) Hand Hygiene in Healthcare Settings, review of the facility's Nursing Procedural Manual and staff interview, the facility failed to ensure that nursing staff washed/sanitized their hands after touching residents/residents' equipment during one (1) of two (2) meal services on two (2) of three (3) halls (100 hall and 200 hall). The facility census was 67. Findings Include: Review of the Infection Control Manual reveals that the facility will follow the Center for Disease Control (CDC) guidelines for handwashing. Review of the CDC Hand Hygiene in Healthcare Settings revealed that hand hygiene included washing hands with soap and water and using an alcohol-based hand sanitizer. Cleansing the hands reduced the spread of potentially deadly germs to patients and reduced the risk of healthcare provider colonization or infection caused by germs acquired from the patient. Alcohol-based hand sanitizers were the most effective products for reducing the number of germs on the hands. Soap and water were recommended for cleaning visibly dirty hands. Alcohol-based hand sanitizers were the preferred method for cleaning hands that were not visibly dirty. Hands should be cleansed before and after having direct contact with a patient's intact skin and after contact with inanimate objects in the immediate vicinity of the patient. 1. On 9/5/17 12:50 p.m. Certified Nursing Assistant (CNA) BB was observed on hall 100 taking a meal tray from the meal cart, carry it into Resident (R) 105A, set the tray on the bedside table in front of the resident and open the milk carton. CNA BB then reached into her pocket and pulled out a tissue, wiped her nose then opened the straw placing it into the milk carton. She then placed utensils from the tray onto the plate. CNA BB did not wash/sanitize hands prior to taking the meal tray from the meal cart, enter resident's room, set up the meal tray, before or after cleaning nose with a tissue, or upon leaving the room. CNA BB did not wash/sanitize hands before taking another tray from the meal cart and take it into R 109A, set the tray down on the bedside table, open the milk carton, open the straw and place it in the milk, and picked up utensils from the tray and place them onto the plate. CNA BB did not wash/sanitize hands at any time before or after setting up the resident's meal tray, or upon leaving the resident's room. CNA BB came out of R 109A, again CNA BB took a tissue from her pocket, wiped her nose and did not wash or sanitize hands, and began to assist a resident sitting in a geriatric chair (geri chair) with her meal that was already sitting on the table in front of the resident. 9/7/17 1:15 p.m. Interview with Infection Control nurse reveals that it is expected that all staff, including CNA's and nursing staff, sanitize or wash their hands before and after resident contact as well as before and after setting up a meal tray, after coming in contact with blood or body fluids, after removing gloves, and entering or leaving a resident room. Infection Control nurse also states she expects all staff to wash/sanitize hands after use of the toilet, before and after meals, and as needed. Infection Control nurse states she expects, for those residents who cannot get out of bed, a wash cloth be offered to them to clean their hands before and after meals and, if continent, before and after being assisted to the restroom. 2. Observation on 9/5/17 at 1:30 p.m. revealed Certified Nursing Assistant (CNA) AA observed passing trays on 200 Hall. CNA AA was observed picking up trays off the food cart, touching the cart, and passing and placing trays on resident bedside tables on the hall without using hand sanitizer or washing her hands. She was observed to be in violation of cross containmation and potential for food borne illness when she began assisting R#6 in bed A with positioning without washing her hands prior to assisting R#31 in bed B with her meal. Continued observation revealed CNA AA touching R#6's arms, clothes, bed linen, bed rails and walking over to R#6 without washing her hands. After CNA AA assisted R#6, she started to feed R#31.

Based on observation and staff interview, it was determined that the facility failed to provide effective housekeeping and maintenance services to maintain a sanitary, orderly and comfortable interior for three (3) of three (3) halls, the front lobby, and one (1) of on (1) shower rooms. Findings include: Front lobby: Observation on 3/17/16 at 7:20 a.m. of the front lobby revealed a table with the finish missing off the top in multiple areas. The baseboards had the finish missing on all the baseboards. Further observation revealed an arm chair with the upholstery torn on both arms of the chair, one love seat with three torn areas on each arm, one love seat with one torn area on the left arm of the and the right arm with two torn areas. 300 Hall: Observation on 3/17/16 at 7:25 a.m. the baseboards and hand rails throughout the hall were observed to have the finish missing. Observation of the storage room door, the soiled linen room door and laundry door had black discolored areas on the doors near the bottom. Observation revealed a ceiling tile near the laundry room door was cracked, discolored ceiling tiles were observed near the fire doors, the ceiling tiles between room 300 and 301 had black discolored areas, the ceiling tile across from room 301 was protruding out from the ceiling and the metal strips between the ceiling tile had brown discolored areas along the ceiling on the 300 hall. Observation revealed a discolored ceiling tile outside room 302, the ceiling tile near the sprinkler head was discolored, the ceiling tile between room 303 and 304 was discolored. Observation outside of room 304 and 305 revealed two (2) discolored ceiling tiles. Missing paint was observed on the ceiling vent across from room 301 and on the walls across from the dining room and along the 300 hall. Observation revealed black discolored areas on the walls near the dining room. The fire doors had the finish missing on both sides of the door. Observation of the area at the end of the 300 hall revealed approximately eleven (11) ceiling tiles with brown/ black discolored areas, a cracked ceiling tile outside the Social Service office and discolored metal strips between the ceiling tiles near the edges next to the windows. 300 Hall Resident rooms: Observation on 3/15/16 at 10:30 a.m., in room 304, a hole in the wall was present next to the left side of the bed. Observation on 3/15/16 at 10:21 a.m., in room 302, three (3) ceiling tiles were discolored. Observation further revealed the finish was worn off the night stands for the A and B beds. Observation on 03/14/2016 at 10:58 a.m. and 3/15/16 10:15 a.m., in room 301, a twelve (12) inch square of paint was missing behind the C bed. Observation further revealed the bathroom door vent cover was loose and hanging. The floor molding was observed pulling away from the wall under the sink in the room. Two (2) vents in the room were observed to have black build up present. Observation on 3/15/16 at 10:28 a.m. in the 300/301 bathroom, a loose air vent on the inside of the bathroom door leading to room 301. 100 Hall: Observation on 3/17/16 at 7:40 a.m. the baseboards and the hand rails in the hall were observed to have the finish missing along the entire hall. There was a cracked ceiling tile outside room 101, a discolored ceiling tile between rooms 100 and 102, a cracked ceiling tile protruding inward between room 103 and 105, a ceiling tile outside room 110 protruding down and a brown discolored ceiling tile near room 110. 100 Hall Resident rooms: Observation on 03/14/2016 at 10:54 a.m. revealed in Room 114 Bathroom the raised toilet had rust on it and for A-bed resident with the finish missing on the bedside table causing it to be rough. Observation on 03/14/2016 at 10:56 a.m. revealed in Room 109 the fire sprinkler head had a heavy coat of dust and a buildup of dust in the air vent. In the bathroom for Room 109 a dried black/brown substance was observed on the inside of the toilet lid. Observation on 03/14/2016 at 10:54 a.m. revealed that in Room 107 resident bathroom there was a strong urine odor, dust build-up in the bathroom vent, and bathroom ceiling tiles and vent with black residue. In Room 107- A there was a build-up of dust in the vent in the bedroom. Observation on 03/14/2016 at 10:56 a.m. of a random Geri chair parked on 100- hall revealed that the vinyl was ripped on the back of the cha 200 Hall: Observation on 3/17/16 at 7:45 a.m. a ceiling tile outside the Director of Nurses (DON) office had a quarter size piece missing and had a black discoloration present. The ceiling tile outside of room 203 had a black discoloration, the vent in the ceiling had a black discoloration in the vents and on all four (4) sides of the vent. The therapy door had a black discolored area on the bottom part of the door. The baseboards and hand rails along the hall have the finish missing. 200 Hall Resident rooms: Observation on 3/14/16 at 12:57 p.m. in room 211 B, the ceiling tile has a brown stain. Observation on 3/14/16 at 2:57 p.m. in the 211 bathroom, there was a gap between the wall and vent on the wall. A brown discolored area was present around the base of the toilet. Observation on 3/14/16 at 2: 15 p.m., in room 208, there was missing paint on the built in drawers. The baseboards next to the bathroom were observed to have missing paint. The bedroom door was observed to have a black discolored area on the outside of the door. The bedside table beside B bed had the finish missing on the top and had rough edges. Observation on 3/14/16 at 2:15 p.m. in the 208/210 bathroom, the ceiling vent was discolored with grayish/ black areas present. Observation revealed paint was missing on the wall over the sink area. The bathroom sprinkler head in the ceiling had brown areas present and the paper towel holder had brown discolored areas present. Observation on 3/14/16 at 2:30 p.m., in room 209, a piece of the baseboard was missing from behind the door to the room and the remaining baseboard was observed to have a white discolored area. The built in drawers had pieces of white stickers on the drawers with writing on them. Observation further revealed the door frame was missing paint. Observation on 3/14/16 at 2:30 p.m., in the 207/209 bathroom, the inside of the bathroom door had a black discolored area. The bathroom wall under the sink had a gap present between the baseboard and the wall. Observation revealed the ceiling tile was discolored and the ceiling vent had black discolored areas present. The handles next to the toilet were observed to have white paint on the handles. Observation on 3/14/16 at 3:34 p.m.in room 207, the chair next to B bed had discolored areas on the upholstery and the finish missing off of the chair arms. The ceiling tiles near the clock and ceiling light had discolored areas and the ceiling tile over the door was discolored. Observation on 3/14/16 at 1:33 p.m., in room 205, the ceiling vent over B bed had black discolored areas present on the vent. Observation of the ceiling revealed fourteen (14) discolored ceiling tiles Observation on 3/14/16 at 1:33 p.m. in the 203/205 bathroom, a white discolored area was observed on the blue wall over the faucet/ sink. Observation on 3/14/16 at 1:23 p.m., in room 206, baseboards were observed to have black discolored areas present. The outside of the bathroom door had black marks present. Observation revealed the door to the room had black marks on the outside and on the B bed closet door. Inside of the door to the room was observed to have streaked areas as if it was being painted. Observation on 3/14/16 at 1:23 p.m., in the 204/206 bathroom, four discolored ceiling tiles were observed. The inside of the bathroom door had black discolored areas present. Observation on 3/14/16 at 1:10 p.m., in room 202, the door to the room was observed to have black discolored areas on the outside of the door on the bottom part of the door Observation revealed the door had missing paint on the door edges near the door knob hardware. The built in dresser had missing paint on all four drawers. The ceiling tile over the built in dresser was observed to be cracked. Missing paint was observed on the wall near the A bed. The fall mat for the A bed had multiple torn areas on the top of the mat. Observation further revealed the A bed bedside table was missing finish on the top and had rough edges. Observation on 3/14/16 at 12:22 p.m., in room 200, the ceiling tile near the vent was cracked. The door to the room had black discolored areas present on the outside of the door. Observation revealed the fall mat had ripped areas on the top and sides of the mat. The chair next to a bed was observed to have torn upholstery on the side of the chair. The privacy curtain next to the wall for B bed had six black discolored areas present on the outside of the privacy curtain and two black discolored areas on the inside of the curtain. The privacy curtain between A and B bed was observed to have yellow stains. Observation revealed missing paint on the baseboard next to B bed and near the bathroom. The walls next to B bed and the bathroom were observed to have black discolored areas on the walls. Observation further revealed the bathroom door frame had missing paint and pieces of wood like material on area near the hardware. Observation on 3/14/16 at 12:22 p.m. in the 200/202 bathroom, the light fixture in the ceiling was observed to have insects inside the fixture. The wall over the bathroom sink was observed to have white discoloration (caulk) present. The inside of the bathroom door had black discolored areas on the bottom of the door. Observation on 3/14/16 at 12:51 p.m. in room 201, the built in drawers had missing paint on four of the drawers and three drawers had brown discolored areas presen. The four drawer chest between the B and C bed had a broken drawer that was hanging down between the B and C bed. Observation further revealed a chair with tape on the arm. The wall behind the sink faucet was observed with missing pieces of plaster. The paper towel holder next to the sink in the room had rusted areas. Observation further revealed eight discolored ceiling tiles. Observation on 3/14/16 at 12:51 p.m., in the 201 bathroom brown discolored areas were present on the floor tiles. Observation on 3/17/16 from 1:00 p.m. to 2:00 p.m. with the Maintenance Director while in room 201, R25 stated the room had stained ceiling tiles that bothered her. Shower room: Observation on 3/17/16 at 12:22 p.m., the shower room had four missing tile pieces in the shower floor with no loose tile observed. The metal shelf under the mirror had brown discolored areas present. Interview on 3/16/16 at 3:10 p.m., ) Licensed Practical Nurse (LPN), BB revealed environmental issues are put in the maintenance book which is kept at the nurses station and the maintenance supervisor checks the book several times a day. Interview on 3/16/16 at 3:30 p.m., with the Maintenance Supervisor and Administrator regarding how environmental issues are identified the Maintenance Supervisor revealed the staff writes identified issues in the maintenance log and he checks the book two to three times a day. The Administrator revealed the facility does Angel rounds every day in the morning and department heads are assigned to certain rooms to check. She further revealed the results of the Angel rounds are discussed in the morning meeting with maintenance to address. The Maintenance Supervisor revealed he has not done environmental rounds since he started working at the facility full time the beginning of May. Interview on 3/16/16 3:30 p.m. the Administrator revealed the plan is for two rooms to be deep cleaned per day and preventive maintenance will be done at that time She further revealed the facility was without a full time Maintenance man for approximately a month and a half. The Administrator revealed painting , discolored ceiling tiles , furniture, door frame repairs , floor mats and torn geriatric chairs are all currently in Quality Assurance Performance Improvement. The plan was requested with dates to be completed. Observation on 3/17/16 from 2:00 p.m. until 3:00 p.m. with the Maintenance Supervisor of the 100, 200, 300 halls, the shower room and the identified resident rooms listed above the Maintenance Supervisor confirmed the above listed concerns. During tour missing screens were observed and confirmed by the Maintenance Supervisor in rooms 205,209 and 212. The Maintenance Supervisor revealed that ceiling tiles need to be replaced, painting finished, and repairs done and replace loose rails around the toilets and revealed he will be doing each room thoroughly. Observation on 3/17/16 at 2:55 p.m., of the front lobby, the Administrator confirmed the above listed concerns. The Administrator revealed no fall mats were presently on order and she would be ordering one in March. She further revealed no furniture was on order. On 3/17/16 at 5:30 p.m. the Administrator revealed the environmental issues identified on the Quality Assurance Performance Improvement Plan were identified the end of February in preparation for the hiring of a full time Maintenance man in May. She further revealed all identified issues on the action plan would be corrected by 5/1/16. The Administrator revealed the Maintenance supervisor started painting in the front lobby to the nurse ' s station and had done most of the 200 hall and 200 hall rooms. She further revealed he would then start the 100 and the 300 hall and dining room. The Administrator confirmed no ceiling tiles, furniture or fall mats were currently on order.

Based on observation, interview and review of the policy the facility failed to prevent the potential for food-borne illness during the preparation of food for fifty-two (52) out of a total of seventy-one (71) residents with two (2) residents having PEG tubes and nineteen (19) residents being on pureed diets from a total sample of 34 residents and failed to maintain an Infection Control Program that demonstrated ongoing surveillance, recognition, investigation and control of infections to help prevent the development and spread of infection. Findings include: 1. Observation on 03/17/2016 at 1:17 p.m. revealed that the Assistant Activity Director was sitting at a table in the Activity Area mixing up ingredients (flour, sugar, etc.) to make cookies. Observation continued to reveal that the Assistant Activity Director has long hair, beard and moustache and he had no hair net on or facial hair containment device. He was observed wearing gloves and then observed answering phone with gloves on and touched hair while talking on phone. He then proceeded to lay phone on table and touched the face of the phone and then returned to stirring ingredients without changing gloves or washing/sanitizing hands and proceeds to reach into sugar bag with same gloves on. He then moved his hair behind his ear and proceeded to knead the ingredients with his hands with the same gloves on. Interview on 03/17/2016 at 1:28 p.m. with the Assistant Activity Director reveals that he is making Key Lime Pie Cookies for St. Patrick's Day for the residents. Observation revealed that Activity Director was mixing ingredients with gloved hands with gloves that have not been changed after touching multiple dirty objects. During the interview the Assistant Activity Director stated he had not noticed that he touched his phone and hair with his gloved hands and did not realize that he needed to have on a hair or beard net. Interview with Administrator on 03/17/2016 at 1:36 p.m. confirmed that the touching of food items after touching phone and hair was an area of concern and she stated that she would have Assistant Activity Director trash these items and start over. 2. Review of the Infection Control log revealed there were monthly Infection Prevention and Control reports review revealed that for the months of 8/15/15, 9/15/15, 10/15/15,11/15/15 and 12/15/15 there was no evidence any infection control surveillance. Interview with the Director of Nursing on 3/17/16 at 2:45 p.m., she confirmed there was no documentation the infection control surveillance had been done from 8/15/15 to 12/15/15. She stated that she did not know how the previous staff did the infection control program.

Based on observation, interview and policy review the facility failed to provide a safe environment for smoking as defined by their policy for five (5) of five (5) residents that smoke by not providing a fire blanket and failed to provide a safe environment in five (5) out of twenty-two (22) rooms (44, 114, 109, 302/303) related to unsecured handrails/grab bars. Findings include: 1. Observation of resident # 85 on 03/14/2016 at 2:39 p.m. smoking with a smoking apron on with supervision being provided by resident's husband. Staff were in smoking area for less than 10 minutes and came out to the smoking area after resident began smoking and left before the resident was through smoking. Observation on 03/15/2016 at 2:20 p.m. showed that resident # 85 husband was at the facility and that they were in the smoking area. Resident had a smoking apron on and there were currently staff members outside with the resident. Observation on 03/15/2016 at 3:45 p.m. showed resident # 85 smoking with one other resident in the designated smoking area. Both residents observed to have smoking aprons on and staff was outside supervising the residents. Observation on 03/16/2016 at 9:18 a.m. showed resident smoking under supervision of staff and she is wearing a smoker's apron. Observation on 03/16/2016 at 3:15 p.m. showed that resident # 85 was in the designated smoking area with two visitors with one of the visitors being her husband. She was observed to have a smoking apron on. Observation on 03/16/2016 at 3:33 p.m. showed that the residents were smoking outside with staff supervision and had smoking aprons on. No fire blanket observed. Interview on 03/16/2016 at 3:35 p.m. with the Administrator showed that she confirmed concern about smoking without a fire blanket. Interview on 03/16/2016 at 5:57 p.m. with the Administrator showed that resident # 85 ' s spouse had been observed for a period of time and observation had shown that he consistently exhibited safe behavior while smoking with resident #85. Administrator stated he places the smoking apron on resident every time he smokes with resident, resident had never had burns on clothes or injury while smoking. The Administrator went on to state during the interview that family supervision would be based on situation by situation and would be made after observing family safety awareness. Review on 03/17/2016 at 1:59 p.m. of Facility Policy showed that to provide a safe smoking environment that residents are to be provided with a smoking apron, and there was to be a fire blanket and a fire extinguisher. Observation showed on 03/17/16 at 1:00 p.m. that there was no fire blanket. 2. Observations of hand rails in resident rooms revealed the following: Observation on 3/14/16 at 10:27 a.m., the assist bar on the left side of #44's bed was loose. Observation on 03/14/2016 at 10:40 a.m. showed that in Room 114 there was a loose handrail/grab bar in the bathroom. Observation on 03/14/2016 at 10:33 a.m. showed that in Room 109 the handrail/grab bar in the bathroom was loose. Observation on 3/14/16 at 1:02 p.m. of the room 211 bathroom revealed the grab bars surrounding the toilet were not stable. Observation on 3/15/16 at 10:27 a.m. of the 302/303 bathroom revealed the grab bar next to the toilet was loose. Interview on 3/17/16 from 2:00 p.m.to 3:00 p.m. the bars around the toilet in the 211 bathroom were observed to be loose. The Maintenance Supervisor confirmed the bars were loose but stated if he tightened them anymore the ceramic toilet might crack. He stated he needed to find a different type of rails for around the toilet because they loosen with use. Interview on 3/16/16 at 3:30 p.m. with the Administrator and Maintenance Supervisor regarding the grab bars they revealed the system in place to identify loose grab bars is angel rounds which are done daily. The Administrator revealed that since loose grab bars were identified this week, weekly audits are being done of all the grab bars. She further revealed that she was not aware of any loose grab bars prior to being notified by surveyors of the loose grab bars. Stated that effective this week audits are being done of all the grab bars. Review of the angel round sheets of observations revealed the absence of grab bars being assessed in the bathrooms for 109/111, 114, 211 and 302/303. Interview on 3/17/16 at 12:55 p.m. the Administrator confirmed that the angel round sheet does not list grab bar under observation but stated if there is concern it would be listed on the sheet.

Based on record review and staff interview, the facility failed to have an effective Quality Assurance process that developed and implemented effective interventions and determined the effectiveness of any interventions that were developed. This effected ten (10) residents ( #3, #5, #20, #31, #58, #61, #64, #70, #81, #84) from a sample of thirty two (32) residents. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for those ten (10) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of August 10, 2011 and continued through February 23, 2012, at which time a plan was implemented by the facility to remove the immediate jeopardy situation. The facility's Administrator and Director of Nursing were informed of this Immediate Jeopardy on January 22, 2012 at 3:30 p.m. Findings include: Interview on 02-24-12 at 1:20 p.m. with the Administrator revealed that the facility has a Quality Assurance meeting every three (3) month but that concerns with falls was not a part of their present QA program. Continued interview revealed that the facility has an Interdisciplinary Team (IDT) that meets weekly to discuss falls. However, there was no evidence that this information was taken to the Quality Assurance Committee.. Cross Refer to F323 The immediate and serious threat to resident health and safety was determined to be removed on February 23, 2012, when the facility had completed the following steps: A. On February 23, 2012, the facility submitted a Falls Management Program that included, implementation of the development of an admission/readmission care plans with appropriate interventions, Fall risk evaluation to be completed with admission, quarterly and significant change MDS assessments, falls interventions will be included on the daily care guide, and resident and family education related to falls and falls management as appropriate. Responses to falls will include immediate assessment of resident and resident environment, the charge nurse may implement immediate interventions such as resident alarms, notification of CNAs of fall interventions and review of the fall at the morning meeting with the Interdisciplinary Team. B. On February 22, 2012, all residents with falls in the last three months were identified, care plans were reviewed to identify interventions related to fall prevention and falls management, assessed residents and resident rooms to ensure that interventions were in place, and checked all alarms to ensure they were functioning properly C. On February 23, 2012, All charts of residents identified as at risk for falls were reviewed with comparison of intervention identified to the interventions in place and recorded on the daily care guide. D. On February 23, 2012, all residents in the facility had a falls risk assessment completed. A falls/injury prevention log was developed to identify interventions and will be maintained by the Director of Nurses. Developed a tool to document daily testing of alarms. E. On February 23, 2012 Inserviced 51 employees on new falls management program. The remaining 7 nursing employees were scheduled to receive the training prior to returning to work. F. On February 22, 2012 The DON was designated to have responsibility for oversight of the program. This oversight includes quarterly reports to the Quality Assurance Committee. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 23, 2012. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. Therefore, the non-compliance continues but the scope and severity level is reduced to an "E" level.

Based on observations, record review and staff interview the facility failed to reassess the effectiveness of interventions and review and revise the plan of care in an attempt to prevent further falls for residents with multiple falls. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for eight (8) residents (#3, #5, #20, #58, #61, #64, #70 and #81) from a sample of thirty two (32) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of 08/09/2011 and continued through February 23, 2012, at which time a plan was implemented by the facility to remove the immediate jeopardy situation. The facility's Administrator and Director of Nursing were informed of this Immediate Jeopardy on January 22, 2012 at 3:30 p.m. Findings include: 1. Review of the medical record for resident #5 revealed that the resident is [AGE] years old with [DIAGNOSES REDACTED]. Review of the nurses notes revealed that the resident had nine (9) falls between 2/05/11 and 2/94/12. Review of the Minimum Data Set (MDS) assessments for this resident revealed that the resident was assessed for falls on the annual assessments dated 2/10/11 and 1/31/12 and on the quarterly assessments dated 5/09/11, 8/04/11, and 11/02/11. Review of the Care Area Assessments (CAAs) completed with each annual survey revealed that falls were to be care planned. Review of the resident care plan dated 3/03/08 revealed potential to fall associated with limited mobility and cognitive deficits. Goal: will have no injury requiring hospitalization due to a fall through next review. Approaches: put eyeglasses in place when resident is awake; use wheel chair to transport resident; extensive assist with one (1) with transfers; non-ambulatory; Bed in lowest position for safety; latch and safety knob on bathroom door; encourage resident to call for assistance; scheduled toileting program; bed and chair alarm to wheel chair for safety. Continued review revealed no evidence that the resident had been reassessed for the effectiveness of the interventions or that the care plan had been revised or updated since 3/03/08. Review of the Interdisciplinary Team (IDT) notes dated 2/08/2012 revealed that the IDT met to discuss the resident's current condition and plan of care. Continued review revealed that the team noted that the resident had a bed and chair alarm for safety. Review of the Falls Risk Assessment evaluation sheets dated 11/20/10, 2/12/11, 8/4/11 and 1/31/12 revealed that the resident scored between 12 and 18, representing a High risk for falls. Observation on 2/22/12 at 10:32 a.m. revealed the resident asleep in a wheelchair in her room. Chair and bed alarms in place and on; Latch at the top of the bathroom door was not latched; safety knob on the bathroom doorknob; and a floor mat folded and propped against the top of the bed. Interview on 2/22/12 at 10:35 a.m. Certified Nursing Assistant (CNA) "EE" revealed that the resident used to have a seat belt, but the resident would take it off so she does not have it anymore. The bed and chair alarms are checked daily to make sure they are working properly and there is a latch on the bathroom door. Continued interview revealed that the bathroom door was supposed to be latched at all times but she had forgotten to latch it after assisting the resident's roommate with toileting. A second interview at 10:42 a.m. revealed that there is a CNA information book with an information sheet for each resident. Review of the CNA information sheet for resident #5 revealed no information related to falls. Review of the physician's orders [REDACTED]. Observation on 2/23/12 at 2:08 p.m. revealed resident resting in bed. CNA placing floor mat beside the bed and call light in resident's reach. CNA reminded resident to use the button to call for assistance before trying to get out of bed. Resident was assessed on the annual MDS assessment dated [DATE] with a Brief Inventory of Mental Status (BIMS) score of 1 indicating that the resident was cognitively impaired. Observation on 2/24/12 at 9:05 am revealed resident asleep sitting in her wheelchair in her room with chair alarm. 2. Resident #3 is a [AGE] year old admitted [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident was unable to complete the Brief Inventory of Mental Status (BIMS) indicating cognitive impairment. Further review of the MDS revealed the resident had one (1) fall with no injury since the previous quarterly assessment and required extensive assistance with one person physical assist for transfers and toileting. Review of the nurses notes revealed that the resident had two (2) falls, 12/26/11 and 1/07/12. Review of the care plan dated 12/12/2005 revealed the resident was at risk for injury related to history of falls. History of fractured ankle. Goals: Resident will have no injurious falls requiring hospitalization thru the next review. Interventions: Observe for use of walker. Retrieve when necessary and give to her when ambulating. Evaluate shoes for non-skid surface as needed and notify family when new ones are needed. Extensive assistance of one (1) person with transfers. Low bed with alarms and mat for safety. Keep call light within easy reach and answer promptly. Assist with Activities of daily living (ADL) performance as needed. Observe gait for steadiness or other changes, uses walker. Keep pathways clear. Provide good lighting. Assist with toileting as needed especially when having loose bowel movements. Provide adequate hydration. Encourage to call for assistance. Handwritten, undated revisions to care plan: Out of order sign on bathroom door to discourage resident from getting up to bathroom unassisted. Extensive assistance of one person with locomotion in wheelchair. Limited assistance of one person with ambulation with walker. Out of bed in wheelchair with blue cushion to elevate legs for comfort and safety. There was no evidence that the care plan had been revised to include interventions to prevent further falls. Interview with the Director of Nursing (DON) and minimum data set (MDS) coordinator on 2/24/12 at 8:10 a.m. and review of the care plan with these staff members revealed there is no way to determine when the handwritten interventions were added, since they were not dated. The DON and MDS coordinator further revealed that care plans are updated at the time of the weekly interdisciplinary team (IDT) meetings or as needed. Continued interview revealed that falls are discussed at the weekly IDT meetings. Review of the record revealed the last IDT meeting note for resident #3 was 8/3/11. 3. Review of the medical record for resident #58 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nurses notes revealed that the resident had three (3) falls from 10/06/11 through 02/04/12. Review of the quarterly MDS assessments dated 11/08/11 and 2/06/12 revealed that the resident was assessed at risk for falls. Review of the Falls Risk assessments dated 08/08/11,11/08/11 and 02/06/12 revealed that the resident scored 13, 11 and 11 representing a high risk for falls. Review of the resident care plan dated 08/16/11 revealed that the care plan had not been revised or updated to reflect interventions to prevent further falls and/or injury. Interview with Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator "BB" on 02/22/12 at 2:00 p.m. revealed that she had not revised or updated the resident care plan since 8/16/11. Interview with the Director Of Nursing (DON) on 02/22/12 at 2:10 p.m. revealed that anytime someone adds anything to the care plan it should be dated. Interview with Administrator on 02/22/12 at 3:33 p.m. revealed that when changes are made to the care plan they are dated unless they are added the day the care plan is completed. 4. Review of the medical record for resident #61 revealed that the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the nurses notes revealed that the resident had two (2) falls, 10/12/11 and 02/18/12. Review of the Falls Risk Assessment forms dated 9/6/11 and 10/1/11 revealed that the resident scored 16 and 14 respectively representing a high risk for falls. There was no evidence that any other falls risk assessment had been done. Review of the resident's care plan dated 9/13/11 revealed that the resident was care planned for falls at admission and the care plan had been updated on 10/23/11 for limited assistance with transfers and ambulation of one (1) person. There was no evidence that the care plan had been updated or revised to reflect interventions to prevent further falls and/or injury. Interview with the Director of Nursing (DON) on 02/21/12 at 2:45 p.m. revealed that the resident did have a fall which was unwitnessed on 10/12/11 from her recliner but that the resident no longer uses the recliner and that the resident's son has since removed it. Continued interview revealed that the DON concurred that no interventions are on the care plan for the resident falls. Observation on 02/22/12 at 10:40 a.m. revealed the resident in her room sitting in the recliner, that had been alleged as removed by the family, chair watching television. 5. Review of the medical record for resident # 81 revealed that the resident was admitted to the facility on [DATE] after a hospitalization for exacerbation of [MEDICAL CONDITIONS] and with other [DIAGNOSES REDACTED]. Continued review revealed that the resident required skilled nursing and rehab services, is alert with periods of confusion with a BIMS score of two (2) and able to make her needs known. She ambulates by wheelchair with assistance from staff. She requires oxygen therapy continuously and does have periods of low oxygen saturation levels. The resident has a chair alarm in place and a history of two (2) falls with injury since her admission to the facility. She receives [MEDICATION NAME] therapy daily. Review of the nurses notes revealed that the resident had two (2) falls, 01/21/12 and 02-01-12. Review of the Falls Risk assessments dated 09/13/11 and 12/17/11 revealed that the resident scored 18 representing a high risk for falls. Review of the resident care plans revealed a care plan for falls dated 9/20/11 with an update/revision dated 1/24/12 for non skid strips to the floor in the room. There was no evidence that the care plan was revised or updated to reflect interventions related to falls and [MEDICATION NAME] therapy and no interventions to reflect interventions to prevent further falls after the fall on 2/01/12. Review of the Certified Nurses Aide (CNA) Care Plan revealed that the resident had the following Safety Precaution/Restraints in place: Bed Alarm, Chair Alarm, Hip protectors. None of these interventions were included on the residents care plan. Interview with LPN MDS/Care Plan Coordinator "BB" on 02/22/12 at 11:05 am revealed that resident are care planned on admission for risks for falls and then updated as different interventions are put into place. 6. Review of the medical record for resident #70 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed that the resident was assessed as alert with confusion with a BIMS score of six (6) and required extensive assistance of one (1) person with Activities of Daily Living (ADLs). Review of the nurses notes revealed that the resident has had five (5) falls since admission in December 2011. Review of the Fall Risk assessment dated [DATE] revealed that the resident scored thirteen (13) representing a high risk for falls. Review of the resident care plans revealed a care plan for risk for falls dated 12/08/11. There was no evidence that the care plan had been revised or updated to reflect interventions to prevent further falls and/or injury. Review of the CNA Care Plan revealed that the resident had the following Safety Precaution/Restraints in place: Bed Alarm. 7. Review of medical record for resident #20 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nurses notes revealed that the resident had two (2) falls 12/04/11 and 02/20/12. Review of the Fall Risk assessments dated 08/08/11, 1/08/11 and 2/06/12 revealed the resident scored 13, 11, and 11 respectively representing a high risk for falls. Review of the quarterly MDS assessment dated [DATE] revealed that the resident was assessed for falls. Review of the care plan dated 08/16/11 revealed that the resident was care planned for risk for falls related to history of falls. There was no evidence that the care plan had been revised or updated to reflect interventions to prevent further falls and/or injury 8. Review of medical record for resident #64 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nurses notes revealed that the resident had three (3) falls from 12/03/11 thru 02/12/12 as follows: Review of the Fall Risk assessments dated 11/11/11 and 02/15/12 revealed that the resident scored 8 and 16 respectively. The score of 16 represents a high risk for falls. Review of the resident care plan dated 03/08/10 revealed that the resident was care planned at risk for falls. The care plan was updated 11/17/11 to offer the wheelchair if resident is weak or fatigued. There was no evidence that the care plan had been revised or updated to reflect new interventions to prevent further falls and/or injury after the 2/15/12 fall. The immediate and serious threat to resident health and safety was determined to be removed on February 23, 2012, when the facility had completed the following steps: A. On February 23, 2012, the facility submitted a Falls Management Program that included, implementation of the development of an admission/readmission careplan with appropriate interventions, Fall risk evaluation to be completed with admission, quarterly and significant change MDS assessments, falls interventions will be included on the daily care guide, and resident and family education related to falls and falls management as appropriate. Responses to falls will include immediate assessment of resident and resident environment, the charge nurse may implement immediate interventions such as resident alarms, notification of CNAs of fall interventions and review of the fall at the morning meeting with the Interdisciplinary Team. B. On February 22, 2012, all residents with falls in the last three months were identified, care plans were reviewed to identify interventions related to fall prevention and falls management, assessed residents and resident rooms to ensure that interventions were in place, and checked all alarms to ensure they were functioning properly C. On February 23, 2012, All charts of residents identified as at risk for falls were reviewed with comparison of intervention identified to the interventions in place and recorded on the daily care guide. D. On February 23, 2012, all residents in the facility had a falls risk assessment completed. A falls/injury prevention log was developed to identify interventions and will be maintained by the Director of Nurses. Developed a tool to document daily testing of alarms. E. On February 23, 2012 Inserviced 51 employees on new falls management program. The remaining 7 nursing employees were scheduled to receive the training prior to returning to work. F. On February 22, 2012 The DON was designated to have responsibility for oversight of the program. This oversight includes quarterly reports to the Quality Assurance Committee. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 23, 2012. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. Therefore, the non-compliance continues but the scope and severity level is reduced to an "E" level.

Based on observation, record review, staff interview and review of the Falls Policy, the facility failed to ensure that adequate supervision was provided to prevent and/or reduce falls, and have a defined system of communicating the needs of residents at risk for falls to nurse aides to ensure interventions were known and implemented for seven (7) residents ( #3, #5, , #31, #58, #61, #70, and #81), from a sample of thirty-two (32) residents. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for those ten (10) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of August 10, 2011 and continued through February 23, 2012, at which time a plan was implemented by the facility to remove the immediate jeopardy situation. The facility's Administrator and Director of Nursing were informed of this Immediate Jeopardy on January 22, 2012 at 3:30 p.m. Findings include: 1. Review of the medical record for resident #5 revealed that the resident is [AGE] years old with [DIAGNOSES REDACTED]. Review of the nurses notes revealed that the resident had nine (9) falls between 2/05/11 and 2/04/12 as follows: -02/05/11-5:30 p.m.-Resident trying to get dressed for bed unassisted-fell backwards-chair alarm did not sound because resident had removed/silenced it-fractured right radial neck. -2/19/11-2:30 p.m.-resident sitting at bedside on the floor,-no injury -6/27/11-5:00 a.m.-resident observed sitting on floor at bedside-no injury -8/03/11-10:55 p.m.-resident observed sitting on floor in room-no injury -8/09/11-10:30 a.m.-resident came out of bathroom and attempted to sit in the wheelchair, wheels were not locked and resident fell to floor, resident had chair alarm but will turn it off-no injury -10/22/11-9:30 a.m.-resident observed on the floor in the bathroom-resident has removed the chair alarm-no injury -11/21/11-1:00 a.m.-resident observed sitting on the bathroom floor in front of the toilet-no injury -12/09/11-1:15 a.m.-resident observed sitting on the floor at bedside-no injury -02/04/12-8:25 p.m.-resident observed sitting on foot rest of wheelchair-stated slipped out of the chair-no injury Review of the Minimum Data Set (MDS) assessments for this resident revealed that the resident was assessed for falls on the annual assessments dated 2/10/11 and 1/31/12 and on the quarterly assessments dated 5/09/11, 8/04/11, and 11/02/11. Review of the Falls Risk Assessment evaluation sheets dated 11/20/10, 2/12/11, 8/4/11 and 1/31/12 revealed that the resident scored between 12 and 18, representing a High risk for falls. Observation on 2/22/12 at 10:32 a.m. revealed a latch at the top of the bathroom door was not latched and a floor mat was folded and propped against the top of the bed. Interview on 2/22/12 at 10:35 a.m. with Certified Nursing Assistant (CNA) "EE" revealed that the resident used to have a seat belt, but the resident would take it off so she does not have it anymore. Review of the physician's orders [REDACTED]. Observation on 2/23/12 at 2:08 p.m. revealed the CNA reminding the resident to use the button to call for assistance before trying to get out of bed. Resident was assessed on the annual MDS assessment dated [DATE] with a Brief Inventory of Mental Status (BIMS) score of indicating that the resident was cognitively impaired. 2. Review of the medical record for resident # 81 revealed that the resident was admitted to the facility on [DATE] after a hospitalization for exacerbation of Chronic Obstructive Pulmonary Disease (COPD) and with other [DIAGNOSES REDACTED].Continued review revealed that the resident requires skilled nursing and rehab services, is alert with periods of confusion with a BIMS score of two (2) and able to make her needs known. She ambulates by wheelchair with assistance from staff. She requires oxygen therapy continuously and does have periods of low oxygen saturation levels. The resident has a chair alarm in place and a history of two (2) falls with injury since her admission to the facility. She receives Coumadin therapy daily. Review of the nurses notes revealed that the resident had two (2) falls as follows: -01/21/12-2:00 a.m.-resident observed sitting on the floor beside the wall in her room with active bleeding to the right index and middle finger. Fingers were cut on a sharp corner of the wall -02-01-12-12:30 p.m.-resident observed sitting on the floor beside her wheelchair in her room-skin tear to left lower elbow and discoloration to right wrist. Review of the Falls Risk assessments dated 09/13/11 and 12/17/11 revealed that the resident scored 18 representing a high risk for falls. 3. Review of the medical record for resident #70 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed that the resident was assessed as alert with confusion with a BIMS score of six (6) and required extensive assistance of one (1) person with Activities of Daily Living (ADLs). Review of the nurses notes revealed that the resident has had five (5) falls since admission in December 2011 as follows: -12/20/11-10:00 a.m.-resident was being assisted out of bed by Physical Therapist when he kept sliding and was assisted to a sitting position on the floor-no injury -01/03/12-7:00 p.m.-resident observed sitting on the floor on his bottom-was getting off the bed to go to the bathroom and slid to floor-no injury -01/06/12-9:30 a.m.-resident was observed on the floor in his room sitting on his buttocks-no injury -01/12/12-12:45 a.m.-resident's bed alarm sounded after resident had called to nurses station for assistance to commode-resident got out of bed unassisted and sat on floor-no injury -02/07/12-1:40 a.m.-resident called for help to bedside commode-when CNA entered room, resident observed on the floor by the bed-no injury Review of the Fall Risk assessment dated [DATE] revealed that the resident scored thirteen (13) representing a high risk for falls. 4. Review of the medical record for resident #58 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nurses notes revealed that the resident had three (3) falls from 10/06/11 through 02/04/11 as follows: -10/06/11-2:55 p.m.-resident fell while trying to get out of recliner in his room-no injury -01/01/12- 9:50 a.m.-resident observed lying on his right side on the floor near the dresser and under the bedside table with head up-skin tear to right forearm -02/04/12- 8:55 p.m.-resident observed on floor, stated he was coming out of the bathroom, fell and hit his left arm on the bed. Left arm with bruising and swelling. Review of the quarterly MDS assessments dated 11/08/11 and 2/06/12 revealed that the resident was assessed at risk for falls. Review of the Falls Risk assessments dated 08/08/11,11/08/11 and 02/06/12 revealed that the resident scored 13, 11 and 11 representing a high risk for falls. 5. Review of the medical record for resident #61 revealed that the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the nurses notes revealed that the resident had two (2) falls as follows: -10/12/11-5:00 p.m.-resident was observed on the floor under the bedside table-electric recliner at full up position-no injury -2/18/12-8:20 p.m.-resident observed on the floor-no injury Review of the Falls Risk Assessment forms dated 9/6/11 and 10/1/11 revealed that the resident scored 16 and 14 respectively representing a high risk for falls. There was no evidence that any other falls risk assessment had been done. Interview with the Director of Nursing (DON) on 02/21/12 at 2:45 p.m. revealed that the resident did have a fall which was unwitnessed on 10/12/11 from her recliner. Interview with the Director Of Nursing (DON) on 2/21/12 at 3:39 p.m. revealed that the facility does not have a Falls Management Program. Interview with DON on 02/22/12 at 9:15 a.m. revealed that the Certified Nursing Assistants (CNA) have their own flow sheets which are kept in a book and when a resident has a fall, the nurse is suppose to update the CNA on the fall of the resident. Interview with the DON on 2/22/12 at 12:15 p.m. revealed that the 3 to 11 shift supervisor is responsible for checking for proper functioning of all bed and chair alarms on a daily basis. When asked about a log documenting that the devices were checked and functioning, the DON revealed that no log is kept verifying that the alarms are checked. 6. Resident #3 is a [AGE] year old admitted [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident was unable to complete the Brief Inventory of Mental Status (BIMS) indicating cognitive impairment. Further review of the MDS revealed the resident required extensive assistance with one person physical assist for transfers and toileting. Review of the nurses notes revealed that the resident had two (2) falls as follows: -12/26/11-resident was leaving the facility with a family member when she fell , landing on her bottom- discoloration to upper sacrum. -1/07/12-resident was observed lying on her right side on the floor between the bed and wheelchair, after an attempt to get out of the wheelchair unassisted. Review of the Fall Risk Assessment revealed the resident was assessed for falls on 3/17/11, 6/15/11, 9/7/11, and 12/5/11. The scores ranged from 19 to 21, indicating the resident was at high risk for falls. Interview with Certified Nursing Assistant "EE" on 2/24/12 at 8:00 a.m. revealed the resident is hard of hearing and does not use her call light; she hollers out when she want to go to the bathroom. . 7. Resident #31 is a [AGE] year old admitted [DATE] with Diagnoses: [REDACTED]. Review of the medical record revealed the resident had a fall on 1/19/12 at 5:15 p.m.: The CNA was transferring her from the recliner to the wheelchair, the resident lost her balance while turning and the CNA lowered her to the floor. Interview with LPN "CC" on 2/20/12 at 3:00 p.m. revealed resident #31 had a fall on 1/26/12 when she lost her balance and started to slip. The CNA lowered her to the floor. There were no injuries. Review of the resident's admission minimum data set ((MDS) dated [DATE] revealed the resident the Brief Inventory of Mental Status (BIMS) score was 5, indicating she is severely cognitively impaired. Further review of the MDS revealed the resident requires extensive assistance with two or more people for physical assist for transfers and toilet use. Additional record review revealed documentation in the Interdisciplinary Progress Notes that the resident required assistance of two (2) persons with toileting and transfers. Interview with LPN "DD" on 2/22/12 at 10:00 a.m. revealed the nurses give report to the CNAs at the change of shift if there are any changes to any of the residents. There are notebooks on a cart between the nurses' station and the Social Service Director's office that the CNAs use to determine how to care for the residents. Review of the CNA care plan (Daily Care Guide) revealed they contain information regarding the resident's vision, dental, hearing, speech; the assistance required for activities of daily living, risk for pressure ulcer, safety precautions/restraints; splints/positioning device; and special instructions. Review of the undated Daily Care Guide used by CNAs - kept in the "Information Sheets" notebooks - revealed the resident required extensive assistance of two (2) people for transfers and toileting. There was no documentation of the chair alarm. Interview with Certified Nursing Assistant on 2/24/12 at 8:00 a.m. revealed the resident is able to use her call light but sometimes just yells out when she needs help. The CNA further revealed that she usually just walks the resident to the bathroom by herself. The immediate and serious threat to resident health and safety was determined to be removed on February 23, 2012, when the facility had completed the following steps: A. On February 23, 2012, the facility submitted a Falls Management Program that included, implementation of the development of an admission/readmission care plans with appropriate interventions, Fall risk evaluation to be completed with admission, quarterly and significant change MDS assessments, falls interventions will be included on the daily care guide, and resident and family education related to falls and falls management as appropriate. Responses to falls will include immediate assessment of resident and resident environment, the charge nurse may implement immediate interventions such as resident alarms, notification of CNAs of fall interventions and review of the fall at the morning meeting with the Interdisciplinary Team. B. On February 22, 2012, all residents with falls in the last three months were identified, care plans were reviewed to identify interventions related to fall prevention and falls management, assessed residents and resident rooms to ensure that interventions were in place, and checked all alarms to ensure they were functioning properly C. On February 23, 2012, All charts of residents identified as at risk for falls were reviewed with comparison of intervention identified to the interventions in place and recorded on the daily care guide. D. On February 23, 2012, all residents in the facility had a falls risk assessment completed. A falls/injury prevention log was developed to identify interventions and will be maintained by the Director of Nurses. Developed a tool to document daily testing of alarms. E. On February 23, 2012 Inserviced 51 employees on new falls management program. The remaining 7 nursing employees were scheduled to receive the training prior to returning to work. F. On February 22, 2012 The DON was designated to have responsibility for oversight of the program. This oversight includes quarterly reports to the Quality Assurance Committee. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 23, 2012. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. Therefore, the non-compliance continues but the scope and severity level is reduced to an "E" level.