Every finding on record at Camellia Health and Rehabilitation Center

Based on interviews, record reviews, review of the facility's abuse investigation file related to an allegation of physical abuse and misappropriation of resident property made by Resident Identifier (RI) #1, and review of facility's policies titled, Abuse Prevention Program and Resident-to-Resident Altercations, the facility failed to ensure staff identified, reported, and implemented protective measures in accordance with the facility's abuse policy following allegations of physical abuse and misappropriation of resident property. Specifically, the facility failed to ensure: 1) Employee Identifier (EI) #3, Licensed Practical Nurse (LPN), identified an allegation of potential abuse, implemented immediate protective measures, and immediately reported the allegation of abuse to the facility's Abuse Coordinator in accordance with the facility's abuse policy on 10/18/2022 around 9:00 PM when RI #1 reported to her that RI #2, his/her roommate, had put his/her hands on his/her neck and taken his/her telephone and television remote; and 2) EI #2, Director of Nursing (DON), identified an allegation of potential abuse and immediately reported the allegation of abuse to the facility's Abuse Coordinator in accordance with the facility's abuse policy on 10/26/2022 around 7:45 AM when it was reported to her that RI #8 was fighting RI #7, his/her roommate, and staff. Staff's failure to identify multiple allegations of abuse, failure to immediately report allegations of abuse to the Abuse Coordinator, and failure to implement immediate protective measures following allegations of abuse placed RI #1 and RI #7, two of five residents sampled for abuse, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. On 10/27/2022 at 6:10 PM, the Administrator, the Director of Nursing, and the Nursing Consultant were provided a copy of the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect, and Exploitation, at F607-Develop/Implement Abuse/Neglect Policies. The immediate jeopardy began on 10/18/2022 and continued until 10/28/2022 when the facility implemented corrective actions to remove the immediacy. After verifying the immediate actions had been implemented, the scope/severity level of F607 was lowered to an E level on 10/28/2022, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. Findings Include: Cross Reference F602 and F610. A review of the facility policy titled, Resident-to-Resident Altercations, with a revision date of December 2016, revealed: Policy Statement All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, Director of Nursing Services and to the Administrator. A review of the facility policy titled, Abuse Prevention Program with a revision date of April 2019, revealed: .Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property . Definitions 1. Abuse, is defined . the willful infliction of injury, deliberate act . with resulting physical harm, pain or mental anguish . Abuse or Neglect is to be reported immediately to the supervisor, who then will report to the Administrator. Policy Interpretation and Implementation As a part of the resident abuse prevention, the administration will: . 3. implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse . 8. Protect residents during abuse investigations; . 1) On 10/19/2022 the facility reported an incident via the Alabama Department of Public Health (ADPH) Online Incident Reporting System regarding an allegation made by RI #1 that RI #2, his/her roommate, had placed his/her hands on RI #1's neck and taken RI #1's television remote and telephone. On 10/20/2022 the facility submitted their Investigative Summary via the ADPH Online Incident Reporting System. The facility's report indicated that RI #1 reported to a staff member that RI #2 walked over to his/her side of the room, put his/her hand around his/her throat but did not choke him/her, took his/her remote to his/her TV and turned it down. Resident stated he/she informed his/her nurse (EI #3) who came into the room to check on him/her. (EI #3) failed to report the alleged incident . saying she did not believe his/her story. Resident reported . he/she was afraid to be in the room with his/her roommate and asked if he/she could go to another room . RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/25/2022 at 1:45 PM an interview was conducted with RI #1, who reported that around 8:00-9:00 PM a few nights prior (10/18/2022) his/her roommate, RI #2, walked over from his/her bed, took RI #1's television remote and telephone, then placed his/her hands on RI #1's neck and squeezed for approximately two to three seconds. RI #1 reported that he/she pushed RI #2 away. RI #1 stated that he/she felt scared after RI #2 squeezed his/her neck. RI #1 reported that he/she called the nurse, EI #3, and reported what happened. RI #1 was asked what EI #3 did after he/she told her what happened. RI #1 replied, nothing. RI #1 said he/she wanted the nurse to remove RI #2 from the room at that time, but she did not. RI #1 added that EI #3 found his/her belongings on RI #2's table. RI #1 said that he/she felt scared after the incident happened and was still scared after telling EI #3. RI #1 reported that he/she did not sleep well that night and was scared. RI #1 stated that he/she did not report the incident to anyone else until the next day, when he/she also reported the incident to EI #1, the Administrator/Abuse Coordinator. RI #1 said that some time after he/she reported the incident to EI #1, EI #1 moved RI #2, the roommate, to a different room. RI #1 stated that after the roommate was moved, he/she no longer felt scared and felt safe again. An interview was conducted on 10/25/2022 at 2:35 PM with Employee Identifier (EI) #3, Licensed Practical Nurse (LPN). EI #3 said on 10/18/2022, she and EI #7, a Certified Nursing Assistant (CNA), responded to RI #1's call light. EI #3 said when they got to the room, RI #1 alleged RI #2 had taken his/her TV remote and telephone. EI #3 confirmed when she was in the room, she saw RI #1's telephone on RI #2's over-the-bed table and RI #1's TV remote on the floor close to RI #2's bed. EI #3 also stated RI #1 reported to her that RI #2 placed his/her hands on RI #1's neck and tried to choke him/her. EI #3 said she returned RI #1's belongings, but did not report the allegations to anyone. EI #3 reported that she did not assess RI #1's chest or neck area. EI #3 said she turned and stepped toward RI #2's bedside and asked if he/she had choked RI #1, but RI #2 did not reply yes or no. EI #3 said she then left the room with EI #7, the CNA. EI #3 admitted she had not reported RI #1's allegations to anyone and did not separate the residents. EI #3 acknowledged she should have, and said that it was a mistake on her part. EI #3 stated she should have removed RI #2 from the room and reported to the Abuse Coordinator/Administrator. EI #3 was asked, what was the potential for harm to RI #1 when he/she was left in room over night with the roommate who RI #1 alleged had choked him/her. EI #3 replied, nothing else happened, but it could have happened again. EI #3 stated she should have done something more, but left the room and forgot about it. An interview was conducted on 10/25/2022 at 5:36 PM with EI #7, the CNA. EI #7 reported that EI #3 and she entered RI #1's room together. She said RI #1 accused RI #2 of taking his/her television remote and telephone, which she agreed was an allegation of misappropriation of property. When asked who she reported it to, EI #7 said EI #3 was taking the report from RI #1, and she was just there and overheard it. EI #7 denied hearing RI #1 allege anything about RI #2 placing hands on his/her neck. However, EI #7 said she did ask EI #3 if she heard the allegation about taking RI #1's television remote and telephone, and EI #3 told her she was going to call the DON or the Administrator/Abuse Coordinator. On 10/26/2022 at 8:42 AM an interview was conducted with EI #2, the DON. EI #2 reported that 10/19/2022 was her first day working in the facility. EI #2 stated EI #1 reported to her that RI #1 alleged RI #2 had placed his/her hands around RI #1's neck, and RI #1 felt threatened. EI #2 stated that EI #1 reported that the incident had occurred the evening before, and the nurse had not reported it. EI #2 reported that she and EI #1 went to RI #1's room. Upon entering the room, both RI #1 and RI #2 were in the room. While in the room, RI #1 reported that RI #2 had snatched the TV remote from RI #1 and put his/her hands around RI #1's neck. EI #2 was asked, when she left the room, was anyone instructed to stay with RI #1. EI #2 replied, no. EI #2 stated that RI #1 remained in the room all night because his/her allegation had not been addressed by EI #3 when RI #1 reported to her. EI #2 said RI #1 and RI #2 should have been separated when the allegation was initially reported. EI #2 said that leaving the residents in the room together after the allegations were initially made, was a failure to protect the resident. On 10/26/2022 at 10:50 AM an interview was conducted EI #13, CNA. EI #13 reported that she was assigned to provide care to RI #1 and RI #2 during the morning shift on 10/19/2022, the day after RI #1 initially made his/her allegations against RI #2. EI #13 confirmed that RI #1 and RI #2 remained in the same room and said no direction was given to staff to provide additional observations or supervision to either resident. EI #13 also indicated she was not made aware of RI #1's allegations that RI #2 had put his/her hands on RI #1's neck and took his/her television remote. EI #13 stated that RI #1 did report to her that he/she was sleepy on the morning of 10/19/2022 and did not want to go to therapy that morning, but did go later in the day. On 10/26/2022 at 11:35 AM an interview was conducted with EI #1, Administrator/Abuse Coordinator. EI #1 reported that on 10/19/2022 around 3:30 PM, RI #1 came to her office and reported an allegation that RI #2, his/her roommate, had come to RI #1's bed the previous night and put his/her hand around RI #1's neck. EI #1 reported that RI #1 also alleged that RI #2 took his/her television remote. Per EI #1, RI #1 also told her that he/she was afraid to be in the room with RI #2. EI #1 was asked when should she she should have been notified of the allegations made by RI #1. EI #1 replied, EI #3 should have notified her as soon as she became aware; however, according to EI #1, EI #3 told her she did not believe RI #1's allegations had occurred. EI #1 explained that, based on the facility investigation of the allegation, the facility failed to protect RI #1 from further mental distress, failed to protect RI #1 from further potential physical abuse, and failed to report the allegation timely to the Abuse Coordinator (herself) when staff first became aware of what RI #1 was alleging. 2) RI #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of RI #8's Progress Notes dated 10/26/2022 revealed the following: . Effective Date: 10/26/2022 08:21 Type: Behavior Note Note Text: Staff was called to patient room for assist (assistance) due to resident fighting roommate and staff . On 10/26/2022 at 2:20 PM an interview was conducted with EI #2, DON. EI #2 was asked what happened that morning with RI #8. EI #2 reported that RI #8 was in the bed with and fighting his/her roommate, RI #7. EI #2 said around 8:00 AM on 10/26/2022 EI #8, the Director of Rehab, notified her that RI #8 was being combative with the roommate and staff. EI #2 said it took four staff members to remove RI #8 from RI #7's bed. When asked if she had reported the allegation of resident-on-resident abuse, EI #2 agreed that it would be considered an allegation of abuse, but said if that was the case, she would have to report every situation in which a resident becomes combative. An interview was conducted with EI #5, a CNA, on 10/26/2022 at 4:34 PM. EI #5 reported she was delivering RI #8's breakfast tray at the same time a laboratory technician was entering RI #7 and RI # 8's room. EI #5 said about 7:45-8:00 AM, she announced to RI #8, Here is your breakfast tray, and RI #8 then jumped out of the bed, went rushing towards RI #7's bed, and jumped down on top of RI #7. She added after RI #8 jumped on RI #7, he/she was moving to touch RI #7 all over, and then gripped RI #7's calves. EI #5 said RI #8 appeared to be disoriented and dazed, and other staff came in the room to assist with getting RI #8 out of RI #7's bed. On 10/26/2022 at 5:05 PM, an interview was conducted with EI #11, Director of Maintenance. EI #11 reported that on the morning of 10/26/2022, he was with EI #2, the DON, and EI #8, and heard a staff member say there were two residents fighting. EI #11 reported that when he arrived at the residents' room RI #8 was sitting on RI #7's bed. EI #11 said he assisted RI #8 back to his/her bed, and then went to EI #1, the Administrator/Abuse Coordinator, to let her know the situation was taken care of. EI #11 said he assumed that EI #1 knew what was going on and that other staff had reported it to her. On 10/26/2022 at 5:45 PM a follow-up interview was conducted with EI #2, the DON. EI #2 said she started to reported the incident to the Administrator/Abuse Coordinator at 2:20 PM on 10/26/2022. EI #2 stated she reported to EI #1 that there was an altercation between RI #8 and RI #7. On 10/26/2022 at 6:30 PM an interview was conducted with EI #1, Administrator/Abuse Coordinator. EI #1 reported she was initially made aware of the incident with RI #8 and RI #7 after 3:00 PM on 10/26/2022. EI #1 said that EI #2 told her that RI #8 was agitated and swinging at staff and was on RI #7's bed. EI #1 was asked when the incident should have been reported to her. EI #1 replied, it should have been reported when it occurred. EI #1 added, EI #2 and herself attended morning meeting at 10:00 AM that day and EI #2 did not mention it. EI #1 said if it was reported a resident was fighting another resident, it was an allegation of abuse and should have been reported to her immediately. This deficiency was cited as a result of the investigation of complaint/report number AL 133. ********** On 10/28/2022 the facility submitted the following acceptable Removal Plan: 1. The facility policy on Abuse and Neglect was reviewed by the Nurse Consultant on 10/27/22. The policy was updated to give detailed direction to immediately remove the perpetrator to protect the resident. The Guidance to Conducting an Abuse Investigation was also reviewed, and the document was updated to add the information and guidance to immediately remove the alleged perpetrator when an allegation of abuse occurs. 2. Adhoc QAPI was held on 10/27/22 to review the IJ tag and policy changes to the Guidance to conducting an Abuse Investigation and Abuse and Neglect policy. These revisions were approved by the QA committee. 3. The Director of Nursing received disciplinary action for failure to follow the abuse and neglect policy to identify and report alleged abuse on 10/27/22. 4. The Director of Nursing was in serviced on 10/27/22 by the Nurse Consultant on the abuse and neglect policy to ensure the DON can immediately identify abuse, neglect and the immediate actions taken to protect residents when an allegation of abuse is reported and report to the abuse coordinator. 5. Education began on 10/27/22 for all staff to include contract and agency staff on the abuse and neglect policy to ensure all staff know how to identify abuse and neglect, take immediate actions to protect the residents when an allegation of abuse is reported and how to report the allegation to the administrator. Staff were questioned if they had witnessed or had reported to them any abuse that has not reported. No staff member will be allowed to start the shift until education has been completed. All department managers Human Resource Director, Director of Nursing, Administrator, Unit Manager, Activity Coordinator, Central Supply, were trained to be a trained the trainer. Written information was provided to the trained members. An employee roster will be maintained of all employees who still require training. No staff will work with residents until they have received the in-service beginning on 10/28/22. 54 out of 102 employees have received education as 10/28/22. 54 employees that have received education have denied having knowledge of abuse that has not been reported. 6. On 10/28/22 all residents will be interviewed, and a questionnaire will be completed to assess their safety and to identify any other allegations that have not been reported. The assigned team members who conducted the interview are the guardian angel room round assignments. These staff members are part of the management team and received the training on 10/27/22 by the Nurse Consultant. Interviews will be reviewed by the Administrator and Nurse Consultant. No concerns were identified through the interviews. For any non-interviewable residents the family members were contacted to interview to see if there were any concerns. 7. An information guidance sheet will be placed at each nursing station to provide guidance to the staff on what actions to take when an allegation of abuse is reported. This document will give step by step instructions as outlined in the policy and guidance to conducting an abuse investigation. 8. Going forward the Administrator will report immediately to the Nurse Consultant the allegation of abuse and the immediate measures put in place to protect the resident. These measures will be documented on the summary report submitted to the ADPH. Going forward any allegations of abuse will be reported to the Nurse Consultant by the Administrator via phone or email at all times and monitored to ensure the perpetrator is immediately removed to protect and provide safety to the resident and it was investigated thoroughly. The Administrator will submit the investigative summary electronically prior to submission and the Nurse Consultant will review through for a complete investigation. 9. Subsequent QAPI meetings will be held to ensure the removal plan is followed. All investigations initiated and submitted will be reviewed for compliance by the QAPI committee. The Nurse Consultant or designee will monitor the QAPI minutes for compliance that the Administrator will send electronically after each meeting. See attached Quality Assurance and Performance Process document. ********** After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F607 was lowered to an E level on 10/28/2022, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, record reviews, review of the facility's abuse investigation file related to an allegation of physical abuse and misappropriation of resident property made by Resident Identifier (RI) #1, and a review of facility policies titled, Abuse Investigation and Reporting and Abuse Prevention Program, the facility failed to ensure Employee Identifier (EI) #1, the Abuse Coordinator/Administrator, conducted a thorough abuse investigation in accordance with the facility policy and immediately implemented protective measures on 10/19/2022 during the investigation when Resident Identifier (RI) #1 reported to her that his/her roommate, RI #2, had put his/her hands on RI #1's neck and taken his/her television remote and telephone on 10/18/2022 around 9:00 PM. This deficient practice placed RI #1, one of five sampled residents reviewed for abuse, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 10/27/2022 at 6:10 PM, the Administrator, the Director of Nursing, and the Nursing Consultant were provided a copy of the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect, and Exploitation, at F610-Investigate/Prevent/Correct Alleged Violation. The immediate jeopardy began on 10/18/2022 and continued until 10/28/2022 when the facility implemented corrective actions to remove the immediacy. After verifying the immediate actions had been implemented, the scope/severity level of F610 was lowered to a D level to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. Findings Include: Cross Reference F602 and F607. On 10/19/2022 the facility reported an incident via the Alabama Department of Public Health (ADPH) Online Incident Reporting System regarding an allegation made by RI #1 that RI #2, his/her roommate, had placed his/her hands on RI #1's neck and taken RI #1's television remote and telephone. A review of the facility policy titled, Abuse Investigation and Reporting with a revision date of April 2019, revealed: . Policy Statement All reports of resident abuse . misappropriation of resident property . shall be . thoroughly investigated by facility management. Policy Interpretation and Implementation Role of the Compliance Team: . 2. Protect the alleged victim from further abuse by identifying and removing the cause of danger. 3. Record statements and interviews of the resident, suspect (if one is identified) . and any circumstantial witnesses . Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: . b. Review the resident's medical record to determine events leading up to the incident . e. Interview the resident . 2. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in a private location . A review of the facility policy titled, Abuse Prevention Program, with a revision date of April 2019, revealed: . As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone . 6. Identify and assess all possible incidents of abuse; 7. Investigate . any allegations of abuse . 8. Protect residents during abuse investigation . RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Investigative Summary, dated 10/20/ , submitted via the ADPH Online Incident Reporting System, revealed no follow-up questions were asked regarding RI #1's allegation that RI #2 had taken his/her remote, no determination was made regarding RI #1's allegation that RI #2 had taken his/her remote, and there was no record of RI #2's interview or statement in the investigative file. On 10/25/2022 at 1:45 PM an interview was conducted with RI #1, who reported that around 8:00-9:00 PM a few nights prior (10/18/2022) his/her roommate, RI #2, walked over from his/her bed, took RI #1's television remote and telephone, then placed his/her hands on RI #1's neck and squeezed for approximately two to three seconds. RI #1 reported that he/she pushed RI #2 away. RI #1 stated that he/she felt scared after RI #2 squeezed his/her neck. RI #1 reported that he/she called the nurse, EI #3, and reported what happened. RI #1 was asked what EI #3 did after he/she told her what happened. RI #1 replied, nothing. RI #1 said he/she wanted the nurse to remove RI #2 from the room at that time, but she did not. RI #1 added that EI #3 found his/her belongings on RI #2's table. RI #1 said that he/she felt scared after the incident happened and was still scared after telling EI #3. RI #1 reported that he/she did not sleep well that night and was scared. RI #1 stated that he/she did not report the incident to anyone else until the next day, when he/she also reported the incident to EI #1, the Administrator/Abuse Coordinator. RI #1 said that some time after he/she reported the incident to EI #1, EI #1 moved RI #2, the roommate, to a different room. RI #1 stated that after the roommate was moved, he/she no longer felt scared and felt safe again. On 10/26/2022 at 8:42 AM an interview was conducted with EI #2, Director of Nursing (DON). EI #2 reported that she accompanied EI #1 to RI #1's room on 10/19/2022 between 3:00 and 4:00 PM. She reported that EI #1 and RI #1 discussed the allegation in the room. EI #2 reported she and EI #1 left the room to talk to other staff. EI #2 was asked, when EI #1 and her left the room, was anyone instructed to stay with RI #1. EI #2 said no. On 10/26/2022 at 10:50 AM an interview was conducted EI #13, CNA. EI #13 reported that she was assigned to provide care to RI #1 and RI #2 during the morning shift on 10/19/2022, the day after RI #1 initially made his/her allegations against RI #2. EI #13 confirmed that RI #1 and RI #2 remained in the same room and said no direction was given to staff to provide additional observations or supervision to either resident. EI #13 also indicated she was not made aware of RI #1's allegations that RI #2 had put his/her hands on RI #1's neck and took his/her television remote. EI #13 stated that RI #1 did report to her that he/she was sleepy on the morning of 10/19/2022 and did not want to go to therapy that morning, but did go later in the day. On 10/26/2022 at 11:25 AM an interview was conducted with EI #1, Administrator/Abuse Coordinator. EI #1 indicated that she was responsible for the investigation of abuse. EI #1 said on 10/19/2022 around 3:30 PM, RI #1 came to her office and reported that RI #2, his/her roommate, had come to RI #1's bed the previous night and put his/her hand around RI #1's neck. EI #1 reported that RI #1 also alleged that RI #2 took his/her television remote. According to EI #1, RI #1 told her that he/she was afraid to be in the room with RI #2. EI #1 reported that EI #2, RI #1, and herself went to RI #1's room and saw RI #2 on his/her bed. EI #1 said RI #1 was asked again what happened and reported the same as what he/she reported in the office and that the incident occurred about 9:00 PM on 10/18/2022. EI #1 said she walked over to RI #2's bed and asked if there was any truth to what RI #1 said and he/she denied it. EI #1 stated she did not ask RI #2 about the TV remote. EI #1 reported that EI #2 and herself left the residents' room, discussed options, and decided to move RI #2 to another room. EI #1 was asked, after RI #1 made the allegation known to her and before RI #2 was moved, how was RI #1 protected. EI #1 replied, no one was particularly assigned to observe the residents, but there were CNAs on the hall. EI #1 was asked, how much time passed between visiting the residents' room and RI #2 being moved. EI #1 replied, she was not sure of the exact time but within an hour. EI #1 was asked, what did the interview with RI #2 include. EI #1 replied, while in the room with RI #1, she asked RI #2 if RI #1's allegation was true, and he/she denied it. EI #1 continued, once RI #2 denied the allegation, she did not question him/her further. EI #2 was asked, why did she not interview or question RI #2 privately. EI #1 replied, she just did not. EI #1 was asked, why was RI #1 re-questioned in the presence of the alleged perpetrator. EI #1 replied that RI #1 had already been questioned and she was making EI #2, the DON, aware. When asked if there was any related information regarding RI #1's allegation that might not have been included in the facility's investigative report, EI #1 said her interview with RI #2 was not included because it was never documented. When asked if RI #1's allegations had been investigated thoroughly, RI #1 said she could have asked more questions to RI #2 about it. On 10/27/2022 at 9:40 AM a follow-up interview was conducted with EI #1 regarding the facility's policy on abuse investigations. EI #1 said the facility's abuse policy included a minimum amount of information to be collected during an abuse investigation as a guideline to follow for the investigations. EI #1 reported that when she interviewed RI #1 and RI #2 about RI #1's allegations, they were interviewed separately, but not in a private location. EI #1 said RI #2 was interviewed with RI #1 in the same room, but with the privacy curtain pulled. Regarding interviewing RI #1 about the incident in the room with RI #2 on the other bed, EI #1 reported the concern was privacy and confidentiality. EI #1 stated the interviews should have been done separately. EI #1 said talking to the residents together could have made RI #1 uncomfortable. EI #1 reported RI #2 was made aware of RI #1's allegations and then the two residents remained in the room together without a staff member assigned to monitor them. EI #1 added that she did not stay on the unit the whole time. EI #1 was asked, was the policy for investigating the abuse allegation followed. EI #1 replied, no. EI #1 reported the concern with not following the facility's abuse investigation policy for investigating allegations was the facility could not ensure it was done properly. EI #1 stated it was not followed because she did not have a copy of the policy and could not recall all that it included. On 10/27/2022 at 12:55 PM an interview was conducted with EI #4, Registered Nurse/Nurse Consultant. EI #4 reported that she reviewed the facility's investigation regarding RI #1 and RI #2. EI #4 said the best practice would be to separate the residents and interview them separately. EI #4 stated she was not there, but the residents should have been separated and not interviewed or questioned together. EI #4 reported that she was not aware that residents remained in the same room while preparing for the room change. This deficiency was cited as a result of the investigation of complaint/report number AL 133. ********** On 10/28/2022 the facility submitted the following acceptable Removal Plan: l. The facility policy on Abuse and Neglect was reviewed by the Nurse Consultant on 10/27/22. The policy was updated to give detailed direction to immediately remove the perpetrator or protect the resident. The Guidance to Conducting an Abuse Investigation was also reviewed, and the document was updated to add the information and guidance to immediately remove the alleged perpetrator when an allegation of abuse occurs. 2. AdHoc QAPI was held on 10/27/22 to review the IJ tag and policy revision. The revision was approved by the QAPI committee. 3. The nurse who failed to follow the requirements for reporting the allegation of abuse received disciplinary action on 10/19/22 for failure to protect the resident and report the occurrence. The administrator received disciplinary action for failure to follow the policy to protect the resident and conduct a thorough investigation. The Director of Nursing received disciplinary action for failure to follow the abuse and neglect policy to identify and report alleged abuse on 10/27/22. 4. The Administrator and Director of Nursing were in serviced on 10/27/22 by the Nurse Consultant on the updated abuse, neglect policy to protect the resident and the immediate actions that need to be taken to protect residents when an allegation of abuse is reported and how to complete a thorough investigation. 5. Education began on 10/27/22 for all staff to include contract and agency staff on the abuse and neglect policy to ensure all staff know how to identify abuse and neglect, take immediate actions to protect the residents when an allegation of abuse is reported and how to report the allegation to the administrator. Staff were questioned if they had witnessed or had reported to them any abuse that has not reported. No staff member will be allowed to start the shift until education has been completed. All department managers Human Resource Director, Director of Nursing, Administrator, Unit Manager, Activity Coordinator, Central Supply, were trained to be a trained the trainer. Written information was provided to the trained members. An employee roster will be maintained of all employees who still require training. No staff will work with residents until they have received the in service beginning on 10/28/22. 54 out of 102 employees have received education as of 10/28/22. 54 employees that have received education have denied having knowledge of abuse that has not been reported. 6. An information guidance sheet will be placed at each nursing station to provide guidance to the staff on what actions to take when an allegation of abuse is reported. This document will give step by step instructions as outlined in the policy and guidance to conducting an abuse investigation. 7. Subsequent QAPI meetings will be held monthly to ensure the removal plan is followed. All investigations initiated and submitted will be reviewed for compliance by the QAPI committee. The Nurse Consultant or designee will monitor the QAPI minutes for compliance that the Administrator will send electronically after each meeting. 8. Going forward the Administrator will report immediately to the Nurse Consultant the allegation of abuse and the immediate measures put in place to protect the resident. These measures will be documented on the summary report submitted to the ADPH. Going forward any allegations of abuse will be reported to the Nurse Consultant by the Administrator via phone or email at all times and monitored to ensure the perpetrator is immediately removed to protect and provide safety to the resident and it was investigated thoroughly. The Administrator will submit the investigative summary electronically prior to submission and the Nurse Consultant will for review through for complete investigation. ********** After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F610 was lowered to a D level on 10/28/2022, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, record review, review of the facility's Confirmation of Receipt of Online Incident Report, and a review of a facility policy titled, Abuse Prevention Program, the facility failed to protect Resident Identifier (RI) #1 from misappropriation of his/her personal property by RI #2. On 10/18/2022 RI #2 took RI #1's television (TV) remote and telephone away without RI #1's consent. Later the same day, staff located RI #1's telephone on RI #2's over-the-bed table, and RI #1's TV remote was located on the floor between RI #1 and RI #2's beds, closer to RI #2's bed. Staff returned RI #1's belongings to him/her upon locating them. This affected RI #1, one of five residents sampled for abuse. Findings Include: Review of the facility's Confirmation of Receipt of Online Incident Report, dated 10/19/2022 at 5:20 PM, revealed RI #1 reported to the facility Administrator an allegation of misappropriation of his/her television remote by RI #2 on 10/18/2022. RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled, Abuse Prevention Program, with a revision date of April 2019, revealed: Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Definitions . 4. Misappropriation of Property, the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. RI #1 was interviewed on 10/25/2022 at 1:45 PM. RI #1 reported around 8:00 or 9:00 PM several nights prior, his/her roommate, RI #2, walked over to RI #1's bed, got his/her TV remote and telephone, then went back to his/her bed with RI #1's belongings. RI #1 stated he/she used the call light to inform the nurse his/her roommate had taken the telephone and TV remote. An interview was conducted on 10/25/2022 at 2:35 PM with Employee Identifier (EI) #3, Licensed Practical Nurse (LPN). EI #3 said on 10/18/2022, she and EI #7, a Certified Nursing Assistant (CNA), responded to RI #1's call light. EI #3 said when they got to the room, RI #1 alleged RI #2 had taken his/her TV remote and telephone. EI #3 confirmed when she was in the room, she saw RI #1's telephone on RI #2's over-the-bed table and RI #1's TV remote on the floor close to RI #2's bed. EI #3 said she returned both items to RI #1, but did not report the allegation to anyone. An interview was conducted on 10/25/2022 at 5:36 PM with EI #7, CNA. EI #7 said when she and EI #3 entered RI #1's room, RI #1 accused RI #2 of taking his/her TV remote and telephone. EI #7 acknowledged this would be considered misappropriation of resident property. An interview was conducted on 10/26/2022 at 11:25 AM with EI #1, Administrator/Abuse Coordinator. EI #1 reported that on 10/19/2022 around 3:30 PM, RI #1 came to her office and reported an allegation of physical abuse, as well as that his/her roommate took his/her TV remote. EI #1 stated she did not ask RI #2 about the remote. EI #1 was asked, what was it, when a resident took another resident's TV remote without permission. EI #1 replied, misappropriation of property. EI #1 reported the misappropriation of RI #1's remote was not addressed in her abuse investigation, because staff had already returned the items to RI #1 when they first located them. However, EI #1 agreed this should have been considered verified misappropriation of resident property. This deficiency was cited as a result of the investigation of complaint/report number AL 133.

Based on observations, interviews, and review of facility policies titled Respiratory Program Policy and Procedure and N95 Respirator Mask, the facility failed to ensure staff properly wore source control throughout the facility. Specifically, facility staff were observed wearing N95 respirators (masks) with the mask straps cut and tied to be worn behind the ears instead of around the head; N95 mask straps were observed hanging loosely instead of around the head; and N95 masks were observed not covering the nose and mouth. This had the potential to affect all residents and occurred during the COVID-19 pandemic. Findings include: A review of the facility policy titled, Respiratory Program Policy and Procedure, dated 05/11/2020, revealed, .Training: All required employees will receive training on the following topics .3. Capabilities and limitations of respiratory mask. 4. How to put on and remove the respiratory mask correctly. 5. How to inspect and check the seals of the respiratory mask .8. Users should understand that improper use, maintenance, and storage of respiratory masks may result in exposure that may lead to exposure to airborne disease . A review of the facility policy titled, N95 Respirator Mask, with no date, revealed, .The top strap (on single or double strap respirators) goes over and rests at the top back of your head. The bottom strap is positioned around the neck and below the ears . During an observation and interview on 01/04/2022 at 8:50 AM, the Certified Dietary Manager (CDM) was wearing an N95 mask with the straps cut, tied, and worn around the ears instead of over and around the head. The CDM indicated they were test fitted for the mask and they cut the straps for a better fit around the ears. During an observation and interview on 01/04/2022 at 8:55 AM, the Kitchen Manager was wearing an N95 mask with the straps cut, tied, and worn around the ears instead of over and around the head. The Kitchen Manager indicated they were test fitted for the mask and cut the straps for a more comfortable fit around the ears. During an observation and interview on 01/04/2022 at 8:58 AM, Employee Identifier (EI) #2, a Cook, was wearing an N95 mask with the straps cut, tied, and worn around the ears instead of over and around the head. EI #2 indicated she cut the straps because she could not get it over her head and the mask bruised her face. During an observation and interview on 01/04/2022 at 2:42 PM, the Maintenance Director was observed on the first floor wearing an N95 mask with the loops cut and tied behind their ears. The Maintenance Director indicated he cut and tied the straps around his ears because it was faster to put on and take off since he moved around the building. During an observation and interview on 01/05/2022 at 4:16 PM, EI #3, a Licensed Practical Nurse (LPN), was observed wearing an N95 mask with one strap around the back of the head and the other strap hanging below the chin, creating an improper fit and seal. EI #3 indicated she had been trained in N95 use and wore the mask in the way observed because, otherwise, it was too tight, and she could barely breathe. During an observation and interview on 01/06/2022 at 10:59 AM, the Kitchen Manager was wearing an N95 mask with the straps cut, tied, and worn around the ears instead of over the head. During an observation and interview on 01/06/2022 at 11:05 AM, EI #2 was wearing an N95 mask with the straps cut, tied, and worn around the ears instead of over the head. During an observation and interview on 01/06/2022 11:39 AM, EI #4, a Certified Nurse Aide (CNA), was standing in the dining room on the 3rd floor near Resident Identifier (RI) #70, RI #56, and RI #35, who were seated at a dining table. EI #4 wore an N95 mask pulled below the nose and then proceeded to walk into a hallway. EI #4 was also observed walking out of room [ROOM NUMBER], a resident's room, with the N95 mask pulled below the nose and walking into the hall. EI #4 identified she had been trained regarding how to properly wear the N95 mask and knew she was wearing the N95 mask improperly, but stated it hurt her ears bad to wear it properly. During an interview on 01/07/2022 at 8:16 AM, the Administrator indicated the correct way to wear the N95 mask involved putting one strap around the head at the base of the neck and the other strap around the head by the ears. The Administrator stated staff were not allowed to cut and/or tie the straps around the ears or pull the mask below the nose. The Administrator further indicated staff had been trained on how to properly wear N95 masks, noting the potential negative outcome of altering an N95 mask or not having a proper fit was potentially spreading COVID-19. Per the Administrator, four or five staff had tested positive for COVID-19 in the prior 14 days. During an interview on 01/07/2022 at 9:02 AM, the Maintenance Director indicated he was trained on how to wear an N95 mask. The Maintenance Director stated he knew the mask did not seal properly around his face, and the mask was not as effective when the head straps were altered. During an interview on 01/07/2022 at 9:13 AM, the CDM indicated she cut the straps of her N95 mask and was trained on how to properly wear the N95 mask. The CDM was unable to recall when the training was received. During an interview on 01/07/2022 at 9:14 AM, the Kitchen Manager indicated she received training on how to properly wear the N95 mask. During an interview on 01/07/2022 at 9:16 AM, EI #2 indicated she received training on how to properly wear the N95 mask. During an interview on 01/07/2022 at 9:43 AM, the Infection Preventionist (IP) indicated the correct way to wear the N95 mask was to put the straps over and behind the ears and neck and cover the nose and mouth. The IP further indicated staff had been trained on how to wear an N95 mask and that staff were not allowed to cut the straps on the N95 mask or wear the mask hanging down. Per the IP, the potential negative outcome of improperly wearing an N95 mask included the spread of infectious disease. During an interview on 01/07/2022 at 1:36 PM, the IP indicated unit managers and all department heads were to monitor for infection control practices. The unit managers and department heads conducted quality assurance rounds for everything and looked for proper mask use, observed staff entering and exiting rooms, and observed glove use and anything else related to infection control. The IP further indicated that it was the IP who was ultimately responsible for ensuring compliance, noting she was in training but had an Infection Preventionist certificate and completed daily audits when rounds were made. The IP was asked why staff were improperly wearing the N95 masks, and the IP stated, Staff choosing to do just what they want to do. During an interview on 01/07/2022 at 1:49 PM, the Administrator indicated that she and the Director of Nursing (DON) were ultimately responsible for ensuring compliance with infection control practices, but she tried to empower the department heads to enforce rules and relied on the department heads to correct issues because she could not be everywhere. The Administrator further indicated audits were completed during walking rounds and delegated to department heads to ensure compliance so that any issue was reported, up the ladder. The Administrator was asked why she thought staff were improperly wearing the N95 mask and she stated, Lack of concern.

Based on record review, interview, and review of facility policies titled Depression - Clinical Protocol, Behavioral Assessment, Intervention, and Monitoring and Antipsychotic Medication Use, the facility failed to ensure Resident Identifier (RI) #51, who received antipsychotic and antidepressant medications, was monitored for behaviors and/or side effects of precribed medications. This affected RI #51, one of four sampled residents receiving an antipsychotic medication and one of two sampled residents receiving an antidepressant medication. Findings include: Review of the facility's Depression - Clinical Protocol policy and procedure, revised in November of 2018, revealed: .Monitoring and Follow-Up .The staff and physician will monitor the resident/patient carefully for side effects of any medications used to treat a mood disorder as well as interactions between antidepressants and other classes of medications . Review of the facility's Behavioral Assessment, Intervention and Monitoring policy and procedure, revised in December of 2016, revealed: .Management .10. When medications are prescribed for behavioral symptoms, documentation will include .h. Monitoring for efficacy and adverse consequences . Monitoring . 4. The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications . 5. If antipsychotic medications are used to treat behavioral symptoms, the IDT [interdisciplinary team] will monitor their indication . a. The IDT will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, or recurrent falling. Review of the facility's Antipsychotic Medication Use policy and procedure, revised in December of 2016, revealed: .Policy Interpreation and Implementation . 16. The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications . RI #51 was admitted to the facility on [DATE]. RI #51's diagnoses included [CONDITION(S)] With Behavioral Disturbance, [CONDITION(S)] Disorder, [CONDITION(S)], and Major Depressive Disorder. RI #51's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2021, revealed RI #51 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS revealed the resident had exhibited no indicators of [CONDITION(S)] and had exhibited no behaviors. Per the MDS, RI #51 required extensive assistance or was dependent upon staff for most Activities of Daily Living (ADLs). The MDS indicated RI #51 had received antipsychotic and antidepressant medication during seven of seven days prior to the ARD and received antipsychotic medication on a routine basis. A review of RI #51's January 2022 Physician Orders, revealed the following orders with an order date of 10/15/2021: [MEDICATION(S)] (Zyprexa; antipsychotic) 2.5 milligrams (mg) in the evening for [CONDITION(S)] disorder and [MEDICATION(S)] (Cymbalta; antidepressant) Delayed Release 30 mg by mouth daily for depression. The Care Plan regarding RI #51's [CONDITION(S)] medication use, dated 11/22/2021, indicated behavior monitoring per facility protocol and observation for signs and symptoms of drug toxicity, adverse effects, intolerance, or drug interaction would be conducted by staff. The Care Plan regarding RI #51's potential for altered thought processes related to [CONDITION(S)] With Behavioral Disturbance, [CONDITION(S)] Disorder, [CONDITION(S)], and Major Depressive Disorder, dated 10/14/2021, indicated the resident would be monitored for effects of the medications administered. There was no documentation in RI #51's electronic or paper health record indicating staff monitored RI #51 for target behaviors and/or monitored for side effects of the antipsychotic and antidepressant medications. On 01/06/2022 at 5:19 PM, the Director of Nursing was interviewed. She stated RI #51 had not been monitored for behaviors and/or side effects of the antipsychotic or antidepressant medications since admission. She stated behavior and side effect monitoring should be documented on RI #51's Medication Administration Record (MAR) but no physician orders had been written for such monitoring, which would have resulted in the monitoring being added to the MAR.

Based on interviews, record review and review of facility policies titled Documentation, Accidents and Incidents and Pain Management, the facility failed to ensure: 1) an incident involving Resident Identifier (RI) #3 was documented in RI #3's medical records; and 2) a licensed nurse documented on the Medication Administration Record (MAR) the effectiveness of a PRN (as needed) Acetaminophen (Tylenol) administered to RI #2; further, licensed nurses failed to accurately document on RI #2's pain assessment scale if the resident was experiencing pain or not. These deficient practices affected RI #2 and RI #3; two of three residents sampled for documentation of an incident in the residents' medical records; and documentation on the residents' MARs. Findings include: 1) The undated facility policy titled Documentation, revealed the following: The purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., for continuity of care, treatment decisions . Procedure 1. Chart all pertinent changes in the resident's condition, reactions to treatments . as well as routine observations . 12. Personnel will be expected to document timely, accurately, and completely . The undated facility policy titled Accidents and Incidents, revealed the following: Important Points: 1. All accidents and incidents must be recorded on an Incident Report Form and if a resident is involved, documented in the medical record by the Charge nurse . RI #3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #3's medical record revealed the resident was seen in emergency room of a local hospital on 08/14/2020 at 4:43 PM. On 06/11/2021 at 3:34 PM, the surveyor conducted an interview with Employee Identifier (EI) #16, a Laundry Worker. The surveyor asked EI #16 did she observe RI #3 in the smoking/patio area on 08/14/2020. EI #16 said yes. EI #16 said she and EI #17, the Certified Nursing Assistant (CNA)/Staffing Coordinator, ran to the smoking/patio area and asked RI #3 if he/she was okay. EI #16 said RI #3 was lying on his/her back and not responding. EI #16 said EI #17 ran in the building and called for the nurses to come to the patio stat. EI #16 said the nurses came to the patio/smoking area and checked RI #3 out and the ambulance arrived. On 06/11/2021 at 4:33 PM, the surveyor conducted an interview with EI #17, the CNA/Staffing Coordinator. The surveyor asked EI #17 did she observe RI #3 in the smoking/patio area on 08/14/2020. EI #17 said yes. EI #17 said RI #3 was lying on his/her back. EI #17 said she ran to the smoking/patio area and asked RI #3 if he/she was okay. EI #17 said she told someone to call 911, asked EI #16 to stay with the resident and she (EI #17) called a stat code. EI #17 said some of the charge nurses responded, RI #3 was assessed; and the ambulance came and took RI #3 out. On 06/12/2021 at 1:02 PM, the surveyor conducted a telephone interview with EI #18, the Licensed Practical Nurse (LPN) assigned to care for RI #3 on the 2:00 PM to 10:00 PM shift on 08/14/2020. EI #18 said he became aware RI #3 was observed on the ground in the smoking/patio area when someone called and informed him. EI #18 said he went downstairs and RI #3 was lying on the ground on his/her back and had a pulse and respirations. When asked if he documented the incident in the nurses notes, EI #18 said he thought he had. The surveyor asked EI #18 what type information should be documented in the nurses notes when an incident occurs. EI #18 said, what happened, what care was rendered, who was notified and if the resident was sent out. When asked why it would be important to document these things in the nurses notes, EI #18 said because it tells what happened to the resident. A review of RI #3's medical records revealed there was no documentation in the nurses notes indicating RI #3 was involved in an incident on 08/14/2020. On 06/13/2021 at 10:57 AM, the surveyor conducted an interview with EI #2, the Director of Nursing (DON). EI #2 said she became the DON back in October of 2020 (after the incident involving RI #3) but she was familiar with RI #3. EI #2 said the incident should have been documented in RI #3's nurses notes. When asked what should [NAME] been documented in the nurses notes, EI #2 said the entire incident that happened. EI #2 said who was called when staff came down, who called 911, who assessed the resident, the vital signs and the doctor and family being notified. The surveyor asked EI #2 what was the importance of nurses documenting in the nurses notes. EI #2 said it shows that treatment was provided to the resident and notifications were done. On 06/14/2021 at 1:02 PM, the surveyor conducted a telephone interview with EI #19, the former DON. When asked who documented the incident involving RI #3 in the nurse notes, EI #19 said she was not sure but it would have been the responsibility of the charge nurse. The surveyor asked EI #19 why was it important to document in the nurses notes when an incident occurs. EI #19 said because that was your complete proof of everything that happened. EI #19 said when incidents occur, you need to document and chart anything that happens. EI #19 said documenting also shows the care that was given to or for the resident. 2) The undated facility policy titled Pain Management, revealed the following: . Procedure . 6. For residents whose pain regimen includes prn pain medication, the charge nurse will assess the resident's pain with each request for pain medication and will document the effectiveness of each dose given . RI #2 was admitted to the facility on [DATE]. RI #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #2's March 2021 MAR revealed on 03/19/2021, RI #2 was administered Tylenol 325 mg two tablets at 11:50 AM. There was no documentation under the NURSE'S MEDICATION NOTES on the back of the MAR as to why the medication was administered or the effectiveness of the medication. On 06/15/2021 at 10:10 AM, the surveyor conducted an interview with EI #12, the LPN administering RI #2 the PRN Tylenol. EI #12 stated if a PRN medication was administered, it would be documented on the PRN space on the MAR. EI #12 acknowledged she did administer RI #2 a pain pill at 11:50 AM on 03/19/2021. When asked where the effectiveness of the Tylenol would be documented, EI #12 said in the nurses notes or on the back of the MAR. EI #12 said she did not see where she had documented the effectiveness of the Tylenol given to RI #2 on the back of the MAR or in the nurses notes. The surveyor asked EI #12 why would it be important to document the effectiveness of a PRN medication given. EI #12 said you want to make sure the medication worked, make sure the resident is okay and did not need anything stronger. On 06/15/2021 at 2:03 PM, the surveyor conducted an interview with EI #2. The surveyor asked EI #2 when nurses administer PRN medications what should be documented. EI #2 said the time the medication was administered, the route given and on the back of the MAR what is being asked about the medication and the effectiveness. When asked why it was important to document the effectiveness of a medication, EI #2 said with the Tylenol it would be important to see if the pain was relieved. EI #2 said if not relieved the nurse would call the physician. RI #2's March 2021 MAR revealed RI #2 was being assessed for pain daily at 6:00 AM, 2:00 PM and 10:00 PM. Instructions for completing the pain assessment scale were as follows: PAIN ASSESS QSHIFT (every shift): PAIN Y/N IF Y, LEVEL OF PAIN (0-10 0=NO PAIN, 10=WORST PAIN IMAGINABLE . Further review of the MAR revealed the licensed nurses working the 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM shifts were documenting with their initials that the pain assessment was done instead of using the Y or N according to the instructions of the pain assessment scale. On 06/15/2021 at 10:10 AM, the surveyor conducted an interview with EI #12, the LPN assigned to care for RI #2 on the 6:00 AM to 2:00 PM shift. When asked what was the purpose for conducting a pain assessment, EI #12 said it was to make sure the resident was free from pain. EI #said you would document at the end of the shift that the pain assessment had been done. The surveyor asked EI #12 when she documented on RI #2's pain assessment scale at the end of her shift, how was she to document, with a Y or N or with her initials. EI #12 said with a Y or N. EI #12 said looking at the March 2021 MAR she documented that the pain assessment had been done by using her initials instead of the Y or N. On 06/15/2021 at 2:41 PM, the surveyor conducted an interview with EI #13, the LPN assigned to care for RI #2 on the 2:00 PM to 10:00 PM shift. When asked what was the purpose for conducting a pain assessment, EI #13 said it was to monitor whether someone was in pain and treat them as needed. EI #13 said pain assessments are usually documented at the end of the shift. The surveyor asked EI #13 when she documented on the pain assessment scale at the end of the shift, how did the assessment indicate nurses were to document, using a Y or N or their initials. EI #13 the Y or N. When asked why she used her initials on the pain assessment scale and not the Y or N, EI #13 said the nurses had always just used their initials. On 06/15/2021 at 2:03 PM, the surveyor conducted an interview with EI #2, the DON. The surveyor asked EI #2 how were the nurses expected to complete the pain assessments. EI #2 said it was on the MAR and the nurse should read how it says to complete the assessment and document the level of pain as 0-10 or whatever the resident tells the nurse it is. When asked should the nurses be documenting Y or N or their initials. EI #2 said the Y or N and the number of the pain. EI #2 said reading the pain assessment scale on the MAR is self explanatory as what should be documented. This deficiency was cited as a result of the investigation of complaint/report number AL 401.

Based on observation, review of resident records and review of facility policies titled, Administering Oral Medications and Handwashing/Hand Hygiene, the facility failed to ensure Employee Identifier (EI) #10, a Registered Nurse (RN) cleansed his hands between residents and after removing gloves during medication administration for Resident Identifier (RI) #13, RI #14, RI #15, RI #16, RI #17 and RI #18; six of 11 residents observed for medication administration. Findings include: A review of the facility policy titled, Administering Oral Medications revealed, . The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Steps in the Procedure 1. Wash your hands. 4. Unlock the medication cart. 5. Select the drug from the unit dose drawer or stock supply. 16. Allow the resident to swallow oral tablets or capsules . 22. Discard all disposable items into designated containers. 23. Perform hand antisepsis. A review of the facility policy titled, Handwashing/Hand Hygiene with a revised date of August 2015 revealed, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.7. Use an alcohol-based hand rub . or, alternatively, soap . and water for the following situations: . c. Before preparing or handling medications; . m. After removing gloves; . 9. The use of gloves does not replace hand washing/hand hygiene. Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. On 06/15/2021 beginning at 4:02 PM, EI #10, a RN was observed administering medications to RI #13 through RI #18. EI #10 prepared and administered RI #13's medications, then returned to the medication cart. EI #10 did not wash his hands or use alcohol-based hand rub (ABHR), before preparing medications for RI #14. EI #10 entered the room, observed that RI #14 was not in the room, returned to medication cart and disposed of RI #14's medications. Then without washing his hands or using ABHR, EI #10 prepared medications for RI #15. After preparing medications for RI #15, EI #10 put on a clean pair of gloves, removed a straw from the wrapper, put the straw into a shake in a carton, held the shake with one hand and the straw with the other gloved hand while RI #15 drank all of the shake. EI #10 then threw out the empty shake container, pulled back RI #15's covers, checked RI #15's catheter by placing both hands on RI #15's genital area then touched the catheter tubing checking it for kinks, touched the catheter bag checking the urine in the bag. EI #10 then removed his gloves and washed his hands. EI #10 returned to the medication cart and prepared medications for RI #16. After administering medications to RI #16, EI #10 returned to the medication cart, and did not wash his hands or use ABHR. He then removed keys from his pocket, unlocked the medication cart, picked up a medication cup, touching the outside of the cup, turned pages of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Carrying a cup of water and straw in one hand and medication cup with pills in the other, handed RI #17 the medication cup. RI #17 took the medications and drank from the straw. EI #10 returned to the medication cart and signed off the medications given. EI #10 did not wash his hands or use ABHR. EI #10 turned several pages of MAR book, removed keys from his pocket, unlocked the cart, opened a drawer, picked up a medication cup touching the outside of the cup and prepared the medication for RI #18. EI #10 picked up a bottle of liquid medication, poured 30 milliliters into the medication cup and placed the bottle back into the drawer. EI #10 then put on a pair of clean gloves, poured a cup of water, unwrapped a straw touching it with a gloved hand. Carried the medication and cup of water and placed it on RI #18's table. RI #18 picked up the medication cup and took the medication. EI #10 removed the gloves, disposed of gloves in RI #18's room and returned to the medication cart, signed off the medication given on the MAR. EI #10 did not wash his hands or use ABHR. EI #10 then pushed the medication cart to the nurses' station, closed the MAR book and said all done. On 06/15/2021 at 5:37 PM, an interview was conducted with EI #10. EI #10 was asked, when should a nurse administer medications without cleansing their hands between residents. EI #10 replied, never. EI #10 was asked, when did he cleanse his hands during medication administration observation. EI #10 replied, he washed them before starting and after dealing with RI #15's catheter and when he finished the medication pass. EI #10 stated he gave five residents medications and washed his hands three times. EI #10 was asked, what was the potential risk to the residents when the nurse administering medications failed to cleanse their hands between each resident. EI #10 replied, the transfer of germs. EI #10 was asked, what should a nurse cleanse their hands with during medication administration. EI #10 replied, hand sanitizer between each resident and wash with soap and water. EI #10 was asked, what should a nurse do after removing gloves. EI #10 replied, wash their hands. EI #10 was asked, what did he fail to do after removing gloves. EI #10 replied, wash his hands. EI #10 was asked, what was the risk to the residents when nurse failed to washed their hands after removing gloves. EI #10 replied, transfer of bacteria and germs. On 06/15/2021 at 5:42 PM, an interview was conducted with EI #3, the Infection Control Nurse. EI #3 was asked, how should the nurse sanitize their hands during medication administration. EI #3 replied, with hand sanitizer and if visibly soiled wash them with soap and water. EI #3 was asked, when should the nurse wash their hands during medication administration. EI #3 replied, cleanse their hands before medication pass starts, and before preparing medications and wash or sanitize after administering them. EI #3 was asked, what should happen before the nurse administers medications to a different resident. EI #3 replied, they should sanitize their hands. EI #3 was asked, if this was not done what could this be considered. EI #3 replied, an infection control issue and a violation of infection control policy. This deficiency was cited as a result of the investigation of complaint/report number AL 401.

Based on interviews, record review and review of a facility policy titled Change in a Resident's Condition or Status, the facility failed to notify Resident Identifier (RI) #2's physician and responsible party when RI #2 experienced [CONDITION(S)]-like activity on 03/17/2021. This deficient practice affected RI #2; one of three residents sampled for notifications. Findings include: Review of a facility policy titled Change in a Resident's Condition or Status, with a revised date of 05/2017, revealed the following: Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition . Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): . d. significant change in the resident's physical . condition . 4. a nurse will notify the resident's representative when: .b. There is a significant change in the resident's physical . status . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . RI #2 was admitted to the facility on [DATE]. RI #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 100 MG (milligrams) CAPSULE GIVE 1 CAPSULE BY MOUTH EVERY DAY SEIZURES . RI #2's Departmental Notes revealed the following: . 3/17/2021 4:00 AM Role: NURSING . AT 0400 AM, I WAS CALLED TO (RI #2's) ROOM AND I NOTICED THAT (HE/SHE) WAS HAVING A PETIT MAL [CONDITION(S)]. (RI #2) WAS LYING IN BED AND THE BED WAS IN THE LOWEST POSITION. (HE/SHE) WAS SHAKING MILDLY AND DROOLING FROM (HIS/HER) MOUTH. THE [CONDITION(S)] LASTED FOR APPROXIMATELY 2 MINUTES. I STAYED WITH (RI #2) UNTIL THE SHAKING STOPPED. (HE/SHE) WAS CLEANED AROUND THE MOUTH. (HE/SHE) WAS TURNED AND REPOSITIONED TO BE CLEANED. AFTERWARDS, (RI #2) RETURNED BACK TO SLEEP. (HE/SHE) WAS IN A FOWLERS POSITION. THERE WAS NO FURTHER [CONDITION(S)] ACTIVITY . This Departmental Note was made by Employee Identifier (EI) #14, the Licensed Practical Nurse (LPN) assigned to care for RI #2 on 03/17/2021 during the 10:00 AM to 6:00 PM shift. On 06/13/2021 at 11:45 AM, the surveyor conducted a telephone interview with EI #14. When asked about RI #2, EI #14 recalled a time when he was working with RI #2 that the Certified Nursing Assistant (CNA) called him into the room and when he got there he saw RI #2 shaking like he/she was having a [CONDITION(S)] that lasted two to three minutes. When asked if he had ever seen RI #2 have a [CONDITION(S)] before, EI #14 said no. The surveyor asked EI #14 what should the nurse do when a resident has a [CONDITION(S)]. EI #14 said keep the resident safe, keep the bed low, keep the side rails up and stay with the resident while they are having the [CONDITION(S)]. When asked if he informed his supervisor or notified the doctor or family about RI #2 having a [CONDITION(S)], EI #14 said no. EI #14 said he did inform the oncoming nurse of the [CONDITION(S)]. When asked should the supervisor, physician and responsible party have been notified, EI #14 said he probably could have notified them since this was the first time he had seen RI #2 have a [CONDITION(S)]. On 06/15/2021 at 9:38 AM, the surveyor conducted an interview with EI #11, RI #2's physician. The surveyor asked EI #11, if RI #2 experienced a [CONDITION(S)] what would he expect the nurse to do. EI #11 said he would expect the nurse to let him know. EI #11 said any time something goes on that they (he and the Nurse Practitioner) was not aware of, they should be made aware. When asked what would he had done if he had been made aware of RI #2's [CONDITION(S)] like activity, EI #11 said he or the Nurse Practitioner would have examined RI #2 and done follow-up to see what was going on with RI #2. On 06/15/2021 at 2:03 PM, the surveyor conducted an interview with EI #2, the Director of Nursing (DON). When asked what the nurses were expected to do when a resident had a [CONDITION(S)], EI #2 said they should make sure they protect the resident while the resident was having the [CONDITION(S)], time the [CONDITION(S)], notify the physician and if any orders were given to implement those orders. On 06/16/2021 at 2:04 PM, the surveyor conducted a telephone interview with RI #2's responsible party. RI #2's responsible party said she had never been informed RI #2 had a [CONDITION(S)]. This deficiency was cited as a result of the investigation of complaint/report number AL 401.

Based on record review, interview, review of a facility Resident Incident Report and review of a facility policy titled Lifting Machine, Using a Portable, the facility failed to ensure a Certified Nursing Assistant (CNA) used two staff members when transferring Resident Identifier (RI) #4 from bed to chair using a mechanical lift on 10/15/2020. This deficient practice RI #4, one of five sampled residents reviewed for falls. Findings include: A review of an undated facility policy titled Lifting Machine, Using a Portable revealed: Purpose The purpose of this procedure is to help lift residents using a manual lifting device. General Guidelines The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedure. If not, two nursing assistants will be required to perform the procedure. RI #4 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] and Muscle Weakness. A review of RI #4's Physicians Orders List revealed: . start date 6/4/20 Hoyer lift for transfers . A review of RI #4's care plan revealed, . At risk for falls RT (related to) left side [CONDITION(S)] . Care Plan Goal fall risk will be minimized with reduction interventions . 2 staff assist for transfers . start date 4/25/2020 . Hoyer lift for transfers . start date 4/25/2020 . A review of RI #4's undated Resident Status Sheet revealed: . Locomotion . Hoyer with 2 assist . RI #4's Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 08/31/2020 revealed the resident was totally dependent on 2 plus people for transfers. RI #4's Resident Incident Report indicated on 10/15/2020 at 10:30 AM, the resident fell from the Hoyer lift while being transferred by Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA). The report further indicated RI #4 was not injured. On 06/11/2021 at 11:20 AM, an interview was conducted with EI #4, a CNA. EI #4 was asked about the incident that occurred on 10/15/2020 involving RI #4 and the use of the Hoyer lift. EI #4 replied, she was transferring RI #4 from the bed to a chair. EI #4 stated RI #4 was moving around in the lift sling and shaking it. EI #4 stated the lift tilted and RI #4's top part of his/her body slipped out of the sling. According to EI #4, RI #4 is care planned to be transferred by two staff. When asked who assisted her with the transfer of RI #4 on 10/15/2020, EI #4 said no one. During a follow-up interview on 06/13/2021 at 6:59 PM, EI #4 was asked if she was trained to use two staff members anytime a Hoyer lift was used to transfer a resident. EI #4 replied, she guessed so. On 06/11/2021 at 10:58 AM, an interview was conducted with EI #6, a Licensed Practice Nurse (LPN). EI #6 was asked about the incident that happened on 10/15/2020 involving RI #4. EI #6 replied, there was a CNA that came to her and told her that the lift had leaned over and the resident had leaned over to the side. EI #6 was asked what she did when told that. EI #6 replied she went to talk to RI #4, she thought he/she was in a geri chair. EI #6 was asked what injuries did RI #4 have. EI #6 replied, there were no apparent injuries and RI #4 did not tell her that he/she was hurt and that she thought RI #4 told her that the CNA dropped him/her. EI #6 was asked what else did she do. EI #6 replied, called the doctor, the family, reported the incident to the nursing supervisor, assessed the resident, took the resident's vital signs, filled out an incident report. EI #6 was asked, at the time of the incident, what did RI #4's care plan say how he/she should be transferred. EI #6 replied, mechanical lift with two people. All mechanical lifts require two people. EI #6 was asked how did CNAs know what a resident is care planned for. EI #6 replied, it was on the resident care guide in the Activities of Daily Living (ADL) book. EI #6 was asked, what was the risk to the resident when not transferred as the care plan indicated. EI #6 replied, the resident could fall. EI #6 further stated residents must be transferred according to what the care plan stated or the resident could get hurt. On 06/14/2021 at 4:47 PM, EI #3, the Assistant Director of Nursing (ADON) was asked, what was found to be the cause of RI #4's fall. EI #3 replied, improper use of a mechanical lift, using one staff and not two staff members. This deficiency was cited as a result of the investigation of complaint/report number AL 401.

Based on interviews, record review and review of a facility policy titled Facility 24 Hour Report, the facility failed to obtain an x-ray of Resident Identifier (RI) #2's right knee when the physician ordered the x-ray on 03/19/2021. The facility further failed to ensure the licensed nurses communicated from shift to shift the x-ray was pending. RI #2's x-ray was not obtained until 03/22/2021, three days after the x-ray was ordered. This deficient practice affected RI #2; one of 18 sampled residents. Findings include: Review of an undated facility policy titled Facility 24 Hour Report, revealed the following: Policy: It is the policy of this facility to record relevant information onto a 24 Hour Report Form in order to promote effective communication and continuity of care. Policy Explanation and Compliance Guidelines: 1. A report will be completed daily for a 24 hour period and maintained with the charge nurse. 2. Each nurse with responsibility for a resident is responsible for recording any new, relevant information about a resident onto the shift report form. Examples include, but are not limited to: . g. New orders . 3. Each nurse is responsible for reviewing the information on the shift report at the beginning of his/her shift to identify and prioritize resident needs. RI #2 was admitted to the facility on [DATE]. RI #2's Departmental Notes revealed the following notes made by Employee Identifier (EI) #12, a Licensed Practical Nurse (LPN): . 3/19/2021 11:37 AM . WHILE GIVING (HIM/HER) AM (morning) CARE CNA (CERTIFIED NURSING ASSISTANT) REPORTED WHEN SHE TRIED (TRIED) TO PICK UP (HIS/HER) LEG UP RESIDENT WAS MAKING FACES THAT IT WAS PAIN. ASSESSMENT RT. (RIGHT) KNEE IS SWOLLEN AND TENDER TO TOUCH. REPORT TO SUPERVISOR AND CALL TO M.D. (MEDICAL DOCTOR) . 3/19/2021 11:51 am . TYLENOL 325 MG (MILLIGRAM) X2 (TIMES 2) GIVEN FOR RT KNEE PAIN. PLACE CALL TO M.D. OFFICE NEW ORDER RECEIVED FOR X-RAY TO RT KNEE . RI #2's PHYSICIAN'S TELEPHONE ORDERS, dated 03/19/2021, documented the following: OK for X-Ray to (R) (right) knee (swollen & (and) pain) . RI #2's Departmental notes written by EI #12, the LPN that received the x-ray order for RI #2 on 03/19/2021 during the 6:00 AM to 2:00 PM shift, revealed the following: . Addendum 3/23/2021 10:28 AM PORTABLE DIAGNOSTIC STATED WOULD BE OUT MONDAY TO DO X-RAY . On 06/11/2021 at 1:37 PM, the surveyor conducted an interview with EI #12. EI #12 said she was made aware RI #2 was having pain to his/her right knee when the Certified Nursing Assistant (CNA) was doing morning care for RI #2. EI #12 said the CNA came to get her and said when RI #2 was touched in certain ways, RI #2 said ouch. EI #12 said when she did her an assessment RI #2's right leg, it was warm and tender to touch. When asked what she did at that time, EI #12 said she called the doctor and was told to get an x-ray. EI #12 said she called the radiology company concerning the x-ray. The surveyor asked EI #12 was the x-ray done on 03/19/2021 on her shift. EI #12 said no it was not. EI #12 said when she called the person at the x-ray company she spoke with someone who said they could not send anybody then, but they would send someone. EI #12 said person she spoke with asked if the x-ray was STAT and she informed them the doctor had not ordered it STAT. EI #12 said she thought the x-ray would have been done on the next shift on the same day because that was what was normally done before COVID. EI #12 said when an x-ray is needed she puts that information on the 24 hour report so the next shift will know it is pending. EI #12 said she thought she had put that on the 24 hour report. When asked after 03/19/2021, when she had cared for RI #2 again, EI #12 said on 03/22/2021. EI #12 said the x-ray results must have come back that evening because she worked that morning and did not recall any results being back. The surveyor asked EI #12 who would be responsible for following up to ensure x-ray results are done as ordered. EI #12 said every shift until the results are received. When asked should a resident needing an x-ray for a swollen right knee have to wait from 03/19/2021 to 03/22/2021 to have the x-ray done, EI #12 said no, they should not have to wait. EI #12 said the facility could not send RI #2 out unless there was an order. When asked did she see (when looking at the nurses notes) where anyone attempted to call the doctor after 03/19/2021, pertaining to not being able to obtain the x-ray for RI #2, EI #12 said no. On 06/12/2021 at 8:24 PM, the surveyor conducted a telephone interview with EI #20, the LPN assigned to care for RI #2 on 03/20/2021 and 03/21/2021 on the 2:00 PM to 10:00 and 10:00 PM to 6:00 AM shifts. The surveyor asked EI #20 what was the procedure nurses followed when a resident had an x-ray ordered. EI #20 said you would call the x-ray company and tell them who needed an x-ray done and the company would come out and complete the x-ray. When asked what should happen from shift to shift if the x-ray was pending, EI #20 said the nurses report it to the oncoming shift and place the order on the 24 hour report. The surveyor asked EI #20 who was the 6:00 AM to 2:00 PM nurse when she worked on 03/20/2021 and 03/21/2021. EI #20 said she thought it was EI #14. When asked was she ever informed by EI #14 RI #2 had an x-ray pending, EI #20 said no. EI #20 said she did not recall anything about RI #2 having a pending x-ray. The surveyor asked EI #20 did she recall seeing that an x-ray was pending for RI #2 on the 24 hour report. EI #20 said she did not recall if she looked at the 24 hour report, but it should have been on the 24 hour report if RI #2 had a pending x-ray. On 06/13/2021 at 9:17 AM, the surveyor conducted an interview with EI #21, a Registered Nurse (RN) Supervisor. When asked when she was made aware RI #2 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #21 said the nurse who receives the order calls the x-ray company and sets up for the x-ray to be done. EI #21 said the nurse needs to make sure the x-ray company comes and does the x-ray. EI #21 said when the nurse leaves they are going to report to the next shift if the x-ray company did not come. When asked how is it communicated from shift to shift that an x-ray result was pending, EI #21 said the nurses write it on the 24 hour report and report off to the oncoming nurse. EI #21 said the nurses also write the results are pending in the nurses notes. The surveyor asked EI #21 why did EI #12 write an addendum in the nurses notes on 03/23/2021 that she placed a call to Portable Diagnostics and they said they would be out on Monday (03/22/2021) to do RI #2's x-ray. EI #21 said she did not know. The surveyor asked EI #21 should EI #12 have shared this information with the oncoming nurse and supervisor. EI #21 said most definitely. When asked should a resident having an x-ray ordered have to wait three days for the x-ray to be obtained, EI #21 said no. EI #21 said if the x-ray company could not come to do the x-ray the resident could be sent to the hospital to have it done. On 06/13/2021 at 10:57 AM, the surveyor conducted an interview with EI #2, the Director of Nursing (DON). The surveyor asked EI #2 when was she first made aware RI #2 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #2 said she thought it was the day EI #12 said a CNA was giving RI #2 care and informed EI #12 RI #2 acted like he was in pain. EI #2 said RI #12 was going to call RI #2's physician and get an order and notify them of what was going on. When asked why the x-ray was not done on 03/19/2021, EI #2 said when she asked EI #12 about that, EI #12 said she called the x-ray company and they said they could not come that day. The surveyor asked EI #2 what process did the facility have in place for ensuring nurses were aware any pending results, such as x-rays. EI #2 said that was communicated when the nurse gave report and the nurses should document on the 24 hour report about the order for the x-ray. The surveyor asked EI #2 why EI #12 documented the addendum on 03/23/2021 in RI #2's nurses notes. EI# 2 said after she and EI #3, the Assistant Director of Nursing (ADON) reviewed the nurses notes they did not see where EI #12 had documented what she told them about the x-ray company not being able to come on 03/19/2021. When asked, looking at the nurses notes from 03/19/2021 to 03/22/2021, did she see any mention where the x-ray results for RI #2 were pending, EI #2 said no. The surveyor asked EI #2 where would there be evidence RI #2's x-ray was pending. EI #2 said that would be on the 24 hour report (EI #2 informed the surveyor she would get the 24 hour reports for the surveyor). When asked should EI #12 have shared with the oncoming shift nurse (EI #14) RI #2's x-ray results were pending. EI #2 said yes. EI #2 said each shift should have been reporting to the oncoming shifts that the x-ray results were pending. When asked should a resident have to wait three days (after orders had been given to obtain an x-ray) for the x-ray to be done, EI #2 said no. The surveyor asked EI #2 was there a delay in RI #2 receiving treatment and services when his/her x-ray was not obtained as ordered. EI #2 said yes because the nurses could have called the physician to let him know the x-ray could not be done until that Monday (03/22/2021). On 06/13/2021 at 11:45 PM, the surveyor conducted a telephone interview with EI #14, the LPN assigned to care for RI #2 on 03/19/2021 on the 10:00 PM to 6:00 AM shift, on 03/20/2021 on the 6:00 AM to 2:00 PM shift; and on 03/21/2021 on the 6:00 AM to 2:00 PM shift. The surveyor asked EI #14, when he worked on 03/19/2021 on the 10:00 PM to 6:00 AM shift, did he recall EI #12 informing him RI #2 had an x-ray report pending. EI #14 said he did not recall receiving that report. When asked where else a nurse would get information like a pending x-ray from, EI #14 said from the resident's chart, on the 24 hour report and the nurse would get it verbally in shift to shift report. On 06/15/2021 at at 10:10 AM, a follow-up interview was conducted with EI #12. When asked if she had been trained or taught how to ensure if an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #12 said you were to document on the 24 hour report sheet and report it to the oncoming shift. On 06/15/2021 at 6:00 PM, the surveyor asked EI #2 was the facility able to locate the 24 hour report sheets for 03/19/2021 to 03/21/2021. The facility was not able to provide evidence the 24 hour reports sheets were completed during that time frame. This deficiency was cited as a result of the investigation of complaint/report number AL 401.

Based on interviews, record review and review of a facility policy titled Baseline Care Plan, the facility failed to ensure: 1) Resident Identifier (RI) #143's resident representative received a copy of RI #143's Baseline Careplan Summary within 48 hours when the resident was admitted to the facility on [DATE]; and 2) a baseline care plan was completed for RI #145 when the resident was admitted to the facility on [DATE]. These deficient practices affected RI #s 143 and 145, two of 22 sampled residents whose plans of care were reviewed. Findings Include: Review of an undated facility policy titled Baseline Care Plan, revealed the following: . Policy Explanation and Compliance Guidelines: . 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary of the resident's medications . 1) RI #143 was admitted to the facility on [DATE], and readmitted on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #143's Admission Physician order [REDACTED].#143 was admitted on the medication Aspirin 325 mg (milligrams) to be taken daily. A review of RI #143's medical records revealed a Baseline Careplan Summary was completed for RI #143 on 08/24/18, but the area for the resident/representative signature was blank. There was no documentation indicating RI #143 or the resident/representative had been given a copy of the Baseline Care Summary. On 05/02/19 at 10:14 a.m., the surveyor conducted a telephone interview with RI #143's resident representative. The resident representative said she was never told RI #143 was receiving Aspirin. When asked was RI #143 admitted on Aspirin, the resident representative said if RI #143 was, she was never told this and the facility should have. The surveyor asked the resident representative when RI #143 was first admitted to the nursing home, did anyone give her any written information about RI #143's plan of care. The resident representative said no. On 05/03/19 at 12:30 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Director of Nursing (DON). The surveyor asked EI #1 was RI #143 admitted on the medication Aspirin. EI #1 said yes. The surveyor asked EI #1 was a baseline care plan completed for RI #143. EI #1 said yes. When asked was RI #143's resident representative given a copy of the base line care plan within 48 hours of RI #143's admission, EI #1 said not that she was aware of. The surveyor asked EI #143 where would there be evidence that the resident representative was given a copy of the baseline care plan. EI #1 said there would be a signature on the baseline care plan summary. The surveyor asked EI #1 did she see the resident representative's signature on RI #143's baseline care plan summary. EI #1 said no. 2) RI #145 was admitted to the facility on [DATE]. A review of RI #145's medical records revealed there had been no baseline care plans completed for RI #145. On 05/02/19 at 11:12 a.m., the surveyor conducted an interview with EI #2, the Licensed Practical Nurse (LPN)/MDS (Minimum Data Set) Coordinator. The surveyor asked EI #2 if RI #145 should have had a baseline care plan completed when he/she was admitted . EI #2 said yes. The surveyor asked EI #2 could she show the surveyor RI #145's baseline care plans. EI #1 said RI #145 did not have any, and she (EI #2) would have to create them. When asked what was the purpose for the resident having a baseline care plan done on admission, EI #2 said the baseline care plan was to inform all staff of any needs of the resident so continuity of care could be provided.

Based on observations, interview, record review and review of a facility policy titled Infection Prevention and Control Program, the facility failed to ensure Resident Identifier (RI) #52 had an isolation sign posted on his/her door to alert staff, family members, and/or visitors of isolation precautions. This deficient practice affected RI #52, one of two residents sampled for isolation precautions, and was observed on three of three days of the survey. Findings Include: Review of an undated facility policy titled Infection Prevention and Control Program, revealed the following: Policy: It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Policy Explanation and Compliance Guidelines: . 11. Resident/Family/Visitor Education: c. Isolation signs are used to alert staff, family members, and visitors of isolation precautions . RI #52 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #52's (MONTH) 2019 Physician order [REDACTED]. On 04/30/19 at 3:30 p.m., the surveyor did not observe a sign on RI #52's door alerting staff, family members, and visitors of any isolation precautions. On 05/01/19 at 8:45 a.m., RI #52's door remained without a sign. On 05/02/19 at 08:07 a.m., RI #52's door remained without a sign. On 05/02/19 at 08:32 a.m., the surveyor conducted an interview with Employee Identifier (EI) #3, the LPN (Licensed Practical Nurse) assigned to care for RI #52 on the 7-3 shift on 5/02/19. The surveyor asked EI #3 what type isolation was RI #52 on. EI #3 said RI #52 [MEDICAL CONDITION] and had recently had his/her toes removed. EI #3 said the type isolation would be contact isolation. When asked if there should be a sign on RI #52's door directing individuals on what to do before entering the room, EI #3 said yes. The surveyor asked EI #3 if she saw a sign on RI #52's door. EI #3 said no.

Based on interviews, a review of CMS' (Centers for Medicare and Medicaid)Long-Term Care Facility Resident Assessment Instrument Manual (RAI), and record reviews, the facility failed to ensure a Quarterly MDS (Minimum Data Set)was coded accurately for transfer assistance required by staff for RI (Resident Identifier) #32. This affected RI #32, one of twenty residents sampled for MDS review. Findings Include: A review of CMS' Long-Term Care Facility Resident Assessment Instrument Manual, Version 3.0, dated (MONTH) (YEAR), revealed: DEFINITION ADL (Activities of Daily Living) SUPPORT PROVIDED Measures the most support provided by staff over the last 7 days, even if that level of support only occurred once. Steps for Assessment 1. Review the documentation in the medical record for the 7-day look-back period. 2. Talk with direct care staff from each shift that has cared for the resident to learn what the resident does for himself during each episode of each ADL activity definition as well as the type and level of staff assistance provided. Remind staff that the focus is on the 7-day lookback period only. 3. When reviewing records, interviewing staff, and observing the resident, be specific in evaluating each component as listed in the ADL activity definition . Coding Instructions For each ADL activity: · Consider all episodes of the activity that occur over a 24-hour period during each day of the 7-day look-back period, as a resident's ADL self-performance and the support required may vary from day to day, shift to shift, or within shifts. There are many possible reasons for these variations to occur, including but not limited to, mood, medical condition, relationship issues (e.g. (example given), willing to perform for a nursing assistant that he or she likes), and medications. The responsibility of the person completing the assessment, therefore, is to capture the total picture of the resident's ADL self-performance over the 7-day period, 24 hours a day (i.e. (in example), not only how the evaluating clinician sees the resident, but how the resident performs on other shifts as well). G0110: Activities of Daily Living (ADL) Assistance Coding Instructions for G0110 Column 2, ADL Support Code for the most support provided over all shifts. Code regardless of how Column 1 ADL Self-Performance is coded A review of RI #32's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #32's Quarterly MDS, with an ARD (Assessment Reference Date) of 1/22/18, revealed the resident required extensive assistance of two people for transferring. A review of RI #32's care plan revealed, .Problem Onset: 08/11/2016 SELF CARE DEFICIT R/T (Related To) GENERALIZED WEAKNESS, DEBILITY, HX (History) [MEDICAL CONDITIONS], COGNITIVE IMPAIRMENT, REQUIRES EXTENSIVE TO TOTAL ASSISTANCE TO COMPLETE ADL'S DAILY . Approaches .TRANSFERS ONE PERSON ASSISTANCE . A review of RI #32's LATE LOSS ADL FLOW SHEET for (MONTH) (YEAR), revealed the lookback period for the 1/22/18 Quarterly MDS was 1/16/18 through 1/22/18. The lookback period of 1/16/18 through 1/22/18 revealed the transfer staff assistance for day and evening shifts was documented as one person assist with no occurrence of the activity on night shift. On 4/11/18 at 2:30 p.m., an interview was conducted with EI (Employee Identifier) #1, a CNA (Certified Nursing Assistant). EI #1 was asked how often she cared for RI #32 and she stated a lot. EI #1 was asked how many staff were required to transfer RI #32 and she stated one person. EI #1 was asked if RI #32 ever became a two person assist with transfer and EI #1 stated, no, RI #32 had always been a one person assist since she had started working at the facility in (MONTH) (YEAR). On 4/11/18 at 3:14 p.m., EI #2, a CNA, was interviewed. EI #2 was asked how often she cared for RI #32 and she stated she was a floater and she also worked other floors. EI #2 was asked how many staff were required to transfer RI #32 and she stated one person. EI #2 was asked if RI #32 ever became a two person assist with transfer. EI #2 stated RI #32 had not been a two person since she had been there. EI #2 started working at the facility in (MONTH) (YEAR). On 4/12/18 at 8:13 a.m., EI #3, a LPN (Licensed Practical Nurse), was interviewed. EI #3 was asked if RI #32 was a one person or two person assist with transfers and she stated one person assist. On 4/12/18 at 8:43 a.m., EI #4, Long Term Care MDS Coordinator, was interviewed. EI #4 was asked how many staff were required to transfer RI #32 and she stated one person. EI #4 was asked what did RI #32's care plan indicate regarding how many staff were to assist the resident during transfer. EI #4 stated one person. EI #4 was asked to review RI #32's Annual MDS dated [DATE], 14-Day MDS dated [DATE], and Quarterly MDS dated [DATE]. EI #4 was asked what did the three MDS' reveal in regards to staff support with transfers. EI #4 stated the Annual MDS indicated one person assist, the 14 Day MDS indicated two person assist, and the Quarterly MDS indicated two person assist. EI #4 was asked when did RI #32 become a two person assist for transfers and she stated she did not know. EI #4 was asked who completed Section G of the MDS and she stated EI #5 completed it for the (MONTH) MDS and she (EI #4)completed it for (MONTH) MDS. EI #4 was asked if the care plan and MDS matched and she stated the last one, no. EI #4 stated (MONTH) was a one person assist based on the ADL Flow sheets. EI #4 was asked why did the (MONTH) MDS indicate a two person assist and she stated it was an error, it was marked in error. EI #4 was asked which was correct, the care plan or MDS for transfer assistance and she stated the care plan was correct. EI #4 was asked who was responsible for ensuring the care plan was correct and she stated she was. EI #4 was asked how was this information gathered to complete the MDS. EI #4 stated she pulled the ADL sheets, saw the resident, and did an assessment. EI #4 was asked if RI #32 was ever a two person assist with transferring. EI #4 stated not on her lookback, she did not complete the previous MDS (October). EI #4 stated they review the CNAs ADL Flow Sheets to see how many staff provided the care to the resident. On 4/12/18 at 9:13 a.m., EI #5, Medicare MDS Coordinator, was interviewed. EI #5 was asked how many staff were required to transfer RI #32 and she stated typically one. EI #5 was asked what did RI #32's care plan indicate regarding how many staff were to assist with transfers and she stated one person. EI #5 was asked what did RI #32's Annual, 14 Day, and Quarterly MDS indicate regarding staff support provided for transferring. EI #5 reviewed the MDS' and stated the Annual indicated extensive assistance with one person assist, 14 Day MDS indicated extensive assistance with two person assist. EI #5 stated she completed the 14 Day MDS. EI #5 further stated the Quarterly MDS indicated extensive with two person assist. EI #5 was asked when did RI #32 become a two person assist with transfers and she stated she was not sure. EI #5 stated she was not sure RI #32 was consistently a two person assist based on the performance. EI #5 was asked if the care plan and MDS matched and she stated not exactly. EI #5 further stated by the code of the (MONTH) MDS and the care plan, they do not match. If there was any instance where two people assist, she had to code it for two person assist. EI #5 stated during her assessment, RI #32 had two person assist on 10/17 and 10/21, the time of her MDS assessment which was seven days. EI #5 was asked how was this information gathered and she stated they use ADL sheets and speak to the aides. EI #5 stated they also make observations and her observations of RI #32 were of one person assist. EI #5 was asked why was RI #32 coded for two person assist in (MONTH) and she stated because there was an instance with two person assist that occurred. A second interview was conducted with EI #5 on 4/12/18 at 2:18 p.m EI #5 was asked if the rule of 3 applied from CMS' RAI manual and she stated it did not apply to column 2. EI #5 explained they follow the code for column 2, ADL Support on the instructions from CMS RAI Manual. EI #5 stated it indicated they must code for the most support provided over all shifts and code regardless of what column 1 (self-performance) was coded. If the resident had a two person assist during the seven day lookback period, then the resident will be coded for two person assist on the MDS. EI #5 was informed that during the interview with EI #4, EI #4 stated RI #32's 1/22/18 MDS was coded in error for transfer. EI #5 stated the ADL Flow Sheets were reviewed in a seven day period. This period was 1/16/18 through 1/22/18 and did not indicate any instances where two person assist with transfers occurred so it was coded incorrectly. EI #5 explained it should have been coded for one person assist since during the seven day assessment, RI #32 did not have two people transfer him/her. EI #5 stated the ADL Flow Sheets were used to complete the MDS, it tells them what care level was provided to the resident by the CNAs.

Based on observations, interviews, and a facility policy titled, Nurse Staffing and Posting Information, the facility failed to ensure that staffing posting included the actual number of licensed staff working on each shift. This was observed on three of four days of the survey and had the potential to affect all residents in the facility. Findings Include: A review of an undated policy titled, Nurse Staffing Posting Information, revealed, Policy: It is the policy of this facility to have sufficient staff to provide nursing services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Policy Explanation and Compliance Guidelines: 1. The nurse staffing information will contain the following information: a. Facility name b. The current date c. Facility's current census d. The total number and actual hours worked by the following staff: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides . On 04/10/2018 at 10:38 AM, an observation was made of the staffing posting and was found completed for the day without the actual number of staff working for each shift. The number of hours were posted but not the actual number of staff. On 04/11/18 at 9:45 AM, an observation was made of the staff posting and was reviewed and found completed for the day without the actual number of staff working for each shift. The number of hours were posted but not the actual number of staff. On 4/12/2018 at 10:54 AM, an observation was made of the staffing posting and was found completed for the day without the actual number of staff working for each shift. The number of hours were posted but not the actual number of staff. On 04/12/2018 at 10:54 AM, an interview was conducted with EI (Employee Identifier) #6, CNA(Certified Nursing Assistant)/Team Leader. EI #6 was asked what was posted on the Census PPD(Preposted Daily Schedule Sheet). EI #6 stated projected hours and hours required daily were on the PPD. EI #6 also said, the actual hours scheduled on the breakdown and it showed one RN(Registered Nurse) working on the floor. EI #6 stated the projected hours showed how many staff were in house and the actual hours showed how many were in the building. EI #6 stated the number of hours were divided by 8 hours for RNs, LPNs(Licensed Practical Nurses) and CNAs. EI #6 said the 8 hours showed one RN was working. EI #6 was asked if the PPD for the facility was easy for people outside of the facility to understand. EI #6 stated the facility staff would be glad to explain it to them but it did not actually show the number, just the hours worked. On 04/12/2018 at 3:57 PM, a second interview was conducted with EI #6. EI #6 was asked if the facility PPD had posted the actual number of staff(not hours) and staff members working on each day 4/10/2018, 4/11/2018, and 4/12/2018 by position or title. EI #6 stated no numbers of staff were posted, just hours. EI #6 was asked if all of the facility hours were accurately being reflected on the PPD form for each titled staff. EI #6 stated the hours were not accurately reflected on the PPD posting. EI #6 was asked if she felt a visitor or family member could understand the PPD form. EI #6 stated no, they could not. EI #6 was asked who created the PPD form. EI #6 stated that the facility Corporate office generated the form. EI #6 was asked who completed the PPD form. EI #6 stated that corporate filled in the information under projected hours and she completed the actual hours. EI #6 was asked how she received the actual hours for each licensed/certified staff. EI #6 stated she used the breakdown schedule sheet and counted the number of people in those positions. On 04/12/2018 at 5:12 PM, an interview was conducted with EI #7, the DON(Director of Nursing). EI #7 was asked if the PPD form had the actual number of staff(not hours) posted with staff members working on 4/10/2018, 4/11/2018, and 4/12/2018 by position or title. EI #7 stated no. EI #7 was asked what did the facility policy say should be included on the PPD form. EI #7 stated the name of the facility, total hours, census, date, the facility total number staff, and actual hours. EI #7 was asked if the PPD for the facility showed all of the areas that were listed in the policy. EI #7 replied, no. EI #7 was asked if she felt a visitor or family member could understand the PPD form. EI #7 stated no not without assistance. EI #7 was asked who completed the PPD form. EI #7 stated that Corporate filled in the projected hours and EI #6 filled out actual hours. EI #7 was asked how the facility determined the actual hours for each licensed/certified staff. EI #7 stated from the facility schedule.

Based on records reviewed, interviews, and a review of a facility policy titled, Care Plans - Goals and Objectives, the facility failed to ensure RI (Resident Identifier) #14's care plan was followed related to the resident's shower schedule. This affected RI #14, one of three residents sampled for ADLs (Activities of Daily Living) assistance. Findings Include: A review of a facility policy and procedure titled, Care Plans - Goals and Objectives with no date present revealed: Highlights Policy Statement Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Policy Interpretation and Implementation 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. 2. Care plan goals and objectives . a. Are resident oriented; . d. Contain timetables to meet the resident's needs . 3. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . A review of RI #14's medical record revealed, a readmission date of [DATE], with [DIAGNOSES REDACTED]. A review of a Quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed RI #14 had a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15, indicating RI #14 was cognitively intact and capable of daily decision making skills. A review of RI #14's care plan revealed: . Problem/Need, Problem Onset 1/11/2017 SELF CARE DEFICIT R/T (Related To) GENERALIZED WEAKNESS, DEBILITY, . SUPERVISION/SET UP ASSISTANCE AT TIMES TO COMPLETE ADL TASKS. Goal & (and) Target Date *WILL BE CLEAN, NEAT, AND APPROPRIATELY DRESSED DAILY . * ASSISTANCE DAILY AS NEEDED FOR PERSONAL HYGIENE AND BATHING . * REVIEWED 4/18/17 Approaches .SHAMPOO, SHOWER/BATHE AS PER SCHEDULE- RESIDENT REQUESTS T (Tuesday), TH (Thursday), SAT (Saturday) 2-10 SHIFT. (The statement after the - dash mark was added 6/8/2017 per interview with EI (Employee Identifier) #1, the DON (Director of Nursing). On 6/8/2017 at 5:23 p.m., an interview was conducted with EI #3, an LPN (Licensed Practical Nurse). EI #3 was asked what care did RI #14 require from a CNA (Certified Nursing Assistant). EI #3 stated RI #14 needed assistance with a bath and whatever other things he/she needed they would do for RI #14. EI #3 said RI #14 received a bath on third shift (10:00 p.m. until 6:00 a.m.). EI #3 stated the facility had a list of when a resident received a shower. EI #3 stated the showers were done on all three shifts and RI #14's was on the 10:00 p.m. to 6:00 a.m. shift. EI #3 was asked why did RI #14 need a shower. EI #3 stated everybody needed a bath, everybody got a shower, some did not want them. EI #3 was asked if she was aware of RI #14 ever refusing a shower. EI #3 said no, he/she could ask for what he/she wanted. EI #3 was asked how often RI #14 received a shower. EI #3 said whenever he/she wanted one. EI #3 was asked what the potential concern or problem was of the resident not receiving a shower. EI #3 stated as far as she knew RI #14 got showers. EI #3 said the resident had to have a bath or they were going to smell. The surveyor reviewed RI #14's ADL care plan with EI #3 and asked EI #3 what was the last entry. EI #3 stated RI #14 was scheduled for a shower on the 2:00 p.m. to 10:00 p.m. shift. EI #3 was asked was the care plan being followed. EI #3 stated May 27th through May 30th, RI #14 had no shower; June 1st through June 7th, RI #14 gave himself/herself a bed bath; and on the days that were left blank, nothing was done. On 6/8/2017 at 5:58 p.m., an interview was conducted with EI #2, a CNA. EI #2 was asked what type of care RI #14 required from CNAs. EI #2 stated they changed RI #14, bathed RI #14 in the bed and gave RI #14 showers, but RI #14 refused. EI #2 stated RI #14 had taken showers. The surveyor reviewed the ADL record with EI #2. The ADL record revealed March through June, RI #14 had bed baths that were self administered, with one shower, and there were multiple days with no documentation of what occurred. EI #2 stated RI #14 received a bed bath on second shift and received showers on third shift. The surveyor reviewed the ADL care plan with EI #2. EI #2 was asked was the care plan being followed related to showers. EI #2 said no, not completely. EI #2 said no, because they bathe him/her by giving a bed bath. EI #2 was asked what the documentation indicated and EI #2 said RI #14 bathed. EI #2 was asked if refusal of showers should be documented. EI #2 said yes. EI #2 was asked if refusal was documented every day March through June. EI #2 said no and no reason was documented. EI #2 stated they were to tell the nurse and document on the ADL sheet when he/she refused a shower.

Based on record reviews, interviews, and a review of a facility policy titled, Orders - Medication, the facility failed to ensure: 1.) Resident Identifier (RI) #14's Medical Doctor (MD) order for Oxygen administration was complete and contained the frequency of administration and 2.) documentation was completed daily related to bathing for RI #14. This affected RI #14, one of eighteen sampled residents whose medical records were reviewed and one of three residents sampled for ADLs (Activities of Daily Living). Findings Include: 1) A review of an undated facility policy titled, Orders - Medication revealed: . Highlights Policy Statement Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Specifications for Drug Orders 6. Orders for medications must include: a. Name and strength of the drug; b. Quantity or specific duration of therapy; c. Dosage and frequency of administration; d. Route of administration if other than oral; and e. Reason or problem for which given. A review of RI #14's medical record revealed, an readmission date of [DATE]. RI #14 was readmitted with [DIAGNOSES REDACTED]. A review of a Quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed RI #14 had a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15, indicating RI #14 was cognitively intact and capable of daily decision making skills. The MDS also revealed RI #14 used Oxygen therapy while a resident at the facility. A review of the physician's orders [REDACTED]. Order date 1/11/17 . OXYGEN AT 2 LITERS [MEDICAL CONDITION] COLLAR WITH 28% (PERCENT) HUMIDIFICATION . An interview was conducted with EI (Employee Identifier) #3, a LPN (Licensed Practical Nurse) at 5:23 p.m. on 6/8/2017. EI #3 was asked what a complete MD medication order had to include. EI #3 replied the right patient, time, dose, medication route, and frequency. EI #3 was asked to review RI #14's MD order for Oxygen dated May 2017. EI #3 was asked if the oxygen MD order was a complete medication order. EI #3 replied no, there was no frequency. An interview was conducted with EI #1, the DON (Director of Nursing), at 6:17 p.m. on 6/8/2017. EI #1 was asked what a complete MD medication order had to include. EI #1 replied the right patient, time, dose, medication route and frequency. EI #1 was asked to review RI #14's MD order for Oxygen. EI #1 was asked if the oxygen order dated May 2017 was a complete MD medication order. EI #1 replied no, there was no frequency. 2) A review of the April 2017 ADL (ACTIVITIES OF DAILY LIVING) RECORD revealed there was no evidence documented that RI #14 received a bath/shower on 4/5, 4/13, 4/14, 4/18 and 4/28. A review of the May 2017 ADL RECORD revealed there was no evidence documented that RI #14 received a bath/shower on 5/10 and 5/15. An interview was conducted with EI #3 at 5:23 p.m. on 6/8/2017. EI #3 was asked to review the ADL RECORD for RI #14. EI #3 was asked if the documentation was complete for March through June 2017. EI #3 replied no, on the days left blank nothing was done for him/her. EI #3 was asked if there was anything documented on the back of the ADL RECORD for the days that had no entries. EI #3 replied no. EI #3 was asked should there be documentation on the back of the ADL RECORD. EI #3 replied yes. EI #3 was asked what should be documented on the back of the ADL record. EI #3 replied the CNA (Certified Nursing Assistant) should show documentation of the resident refusing showers on the back of the ADL record and notification of the nurse. An interview was conducted with EI #1 at 6:17 p.m. on 6/8/2017. EI #1 was asked to review the ADL RECORD for RI #14. EI #1 was asked if the documentation was complete for March through June 2017. EI #1 replied no, there was no documentation of the nurse being notified of RI #14 not receiving a shower and there were blanks on some of the days. EI #1 also replied that there was a documentation issue related to ADLs. EI #1 was asked should there be documentation on the back of the ADL RECORD. EI #1 replied yes.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. RI (Resident Identifier) #1, a resident at risk for UTIs (Urinary Tract Infections), was provided incontinence care in a timely manner on 5/18/16. 2. A Certified Nursing Assistant (CNA) cleaned the front of RI #1's perineal area and provided catheter care during the incontinence observation. 3. A CNA completely removed stool from RI #1's buttocks during the incontinence care. 4. RI #1's indwelling catheter drainage bag was not observed on the floor on one of three survey days. 5. RI #7, a resident at risk for UTIs, was provided incontinence care in a timely manner, and care was provided in a manner to prevent the potential for cross contamination. 6. Staff provided incontinence care for RI #8, a resident at risk for UTIs, in a manner to prevent the potential for cross contamination. 7. RI #8's indwelling catheter drainage bag was not observed on the floor on one of three survey days. These deficiencies affected RI #1, RI #7, and RI #8, three sampled residents at risk for developing a UTI. Findings Include: 1, 2, 3, and 4) A review of POTTER & PERRY . Fundamentals of Nursing .7th Edition .reprint 2009, revealed: .page- 877 and 878 .39-2 .Perineal Care . 3. Apply clean gloves, and assess genitals for signs of inflammation, skin breakdown, or infection. Discard gloves. Perform hand hygiene. 6. Prepare necessary equipment and supplies. 7.Assemble supplies at bedside. 8. Raise bed . 9. Apply clean gloves. 10. If fecal material is present, enclose in a fold of underpad or toilet tissue, and remove with disposable wipes or tissue. Rationale: . Cleansing reduces transmission of microorganisms from anus to urethra or genitalia . Cleanse, rinse, and dry area thoroughly. If needed, place an absorbent pad under client's buttocks. Remove and discard underpad, and replace with clean one. If gloves are soiled, perform hand hygiene and then apply new pair of gloves. 15. Provide Perineal care. B. Male Perineal care . (2) Fold lower corner of bath blanket up between client's legs and unto abdomen. Wash and dry client's upper thighs. (3) Gently raise penis, and place a bath towel underneath. Gently grasp shaft of penis. (4) Wash tip of penis at urethral meatus first. (6) Wash shaft of penis . (7) Gently cleanse scrotum . (8) Fold bath blanket back over client's perineum, and assist client in turning to side-lying position. 16. If client has had urinary or bowel incontinence, apply thin layer of skin barrier containing [MEDICATION NAME] or zinc oxide over anal and perineal skin. The review of a facility document titled, Incontinence Care, revealed: . Steps in the Procedure . 7. Remove or fold brief and any other soiled linen and article of clothing 8. Remove soiled gloves, wash hands and re-glove . 10. For a male resident: a. Clean the shaft of the penis using a cupped hand. Utilize a clean wipe for each swipe. Remove gloves, wash hands and re-glove. b. With gloved hands, pull back the foreskin and hold in place. Use other hand to clean the head of the penis. Use one wipe for each swipe. c. Air dry before replacing foreskin. d. Clean scrotum. Use one wipe for each downward swipe. Clean one side of the scrotum then the second side of the scrotum then down the center area of the scrotum 11. Discard soiled gloves, wash hands, and re-glove 12. Clean buttock area using a wipe for each swipe 13. Clean each buttock and anal area (between buttocks) 14. Discard gloves, wash hands, re-glove and apply a clean brief 15. Discard soiled linen in plastic bag 16. Remove gloves, wash hands, clean bedside table. Ensure resident is comfortable, railing is in place if required, retract privacy curtain. Remove soiled items in plastic bags and exit room. A review of RI #1's medical record revealed, the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 5/19/16, revealed the resident was in a persistent vegetative state with no discernible consciousness. RI #1 was totally dependent on staff for all ADLs (Activities of Daily Living). RI #1 was always incontinent of bowel and had an indwelling catheter. A review of RI #1's care plan, with a problem onset date of 4/18/16, revealed: INFECTION, RISK FOR R/T (related to)* INDWELLING FOLEY CATHETER . Approaches . PERI (perineal) AND CATHETER CARE Q (every) SHIFT AND PRN (as needed) USING PROPER TECHNIQUE WIPING FRONT TO BACK *ENSURE GU (genital urinary) BAG IS DRAINING PROPERLY, CHECK BAG PLACEMENT ON GERI/WHEEL CHAIR AND WHEN IN BED FOR PROPER PLACEMENT . On 05/18/16 at 8:30 AM, during the tour of the facility, RI #1's indwelling catheter drainage bag was observed on the floor. On 5/18/2016 at 9:15 AM, a continuous observations for turning, repositioning, checking and changing was started for RI #1. 9:15 AM, Resident on left (L) side with (HOB) head of bed elevated, eyes closed. 9:30 AM, Laying on (L) side with HOB elevated. 9:45 AM, Lying on (L) side with HOB elevated. 10:00 AM, Lying on (L) side with HOB elevated. 10:15 AM, Lying on (L) side with HOB elevated. 10:20 AM, an LPN (Licensed Practical Nurse), EI (Employee Identifier) #5 entered the room to check on RI #1. No care was provided. 10:30 AM, Lying on (L) side with HOB elevated. 10:40 AM, EI #5 entered the room. No care was provided. 10:45 AM, RI #1 was lying on (L) side with HOB elevated. 11:00 AM, Lying on (L) side with HOB elevated. 11:15 AM, Lying on (L) side with HOB elevated. 11:30 AM, Lying on L side with HOB elevated. 11:45 AM, EI #5 entered and applied gloves, repositioned the indwelling catheter drainage bag and disconnected the TF (Tube Feeding). The LPN said the resident received perineal care this AM and would receive care again after lunch. She did not reposition the resident. Resident remained on (L) side with HOB elevated. 12:00 PM, Resident lying on (L) side with HOB elevated. 12:15 PM, Resident lying on (L) side with HOB elevated. 12:25 PM, an LPN entered with a new TF set up, washed hands, applied gloves and checked her TF placement. The LPN flushed with 30 ml (milliliters) of water, reconnected the TF, and started the TF at 65 ml per hour. On 5/18/16 at 12:30 PM, two CNAs, EI #10 and EI #11, entered RI #1's room and turned the resident on the right (R) side, and was in the process of placing a wedge on the left side to position the resident. The surveyor asked the CNAs to check the resident to see if he/she had a BM (bowel movement). A circle of stool was observed on RI #1's adult brief. The resident also had a skin break on the (L) buttocks. On 5/18/16 at 12:35 PM, the following was observed during incontinence care for RI #1. EI #10 and EI #11 washed their hands and applied gloves. The back right of RI #1's adult brief was removed. EI #10 wiped from back to front three times between the buttocks to remove the stool with 3 different wipes. Stool was observed on the wipes each time. EI #10 and EI #11 applied a clean adult brief. The gloves were not changed and EI #10 and EI #11 did not wash their hands after cleaning stool from the resident's bottom. EI #10 and EI #11 pulled the resident up in the bed and turned him/her on the right side. The surveyor requested EI #10 wipe the resident from front to back. EI #10 opened the brief and wiped from back to front twice with separate wipes. Stool was observed on each wipe. The surveyor asked EI #10 what was observed on the wipes. EI #10 stated, A smear of stool. EI #10 wiped from back to front five times with separate wipes. Stool was observed on each wipe. EI #10 and EI #11 did not change gloves or wash their hands. EI #11 said, He has a skin problem on his penis. EI #11 applied a skin barrier to the head of RI #1's penis. No catheter care was provided for RI #1. On 5/18/16 at 12:45 PM, EI #5 entered RI #1's room and provided wound care for RI #1. The surveyor asked EI #5 to wipe RI #1's bottom. EI #5 wiped RI #1's bottom from front to back twice. Stool was observed on the wipes when EI #5 wiped between RI #1's buttocks fold. EI #5 properly cleaned the stool off of RI #1's buttocks. At 5/18/16 at 12:55 PM, RI #1's adult brief was closed. The front of the resident's perineal area was not cleaned and RI #1 was not provided catheter care during the incontinence care observation. RI #1 was repositioned on the right side. An interview was conducted with EI #10 on 5/18/16 at 1:30 PM. The surveyor asked EI #10 how she was taught to provide incontinence care for a male resident. EI #10 stated, I was taught to wipe back to front. EI #10 stated she she attended a 2 to 3 week CNA training at a local home health agency. The surveyor asked EI #10 how was she taught to clean the resident's penis. EI #10 stated, I was taught to clean the head of the penis with a wipe and discard the wipe. I then clean the penis around and discard the wipe. I then wipe the crease and throw the wipe away. I wipe the crease first and across the upper area first, then I wipe the penis. The surveyor asked EI #10 when did she check and change RI #1 that morning on 5/18/16. EI #10 stated, When I came in around 6:00 AM, I checked him at 6:00 AM, that is the first round. I checked him/her about 9:00 AM and emptied his/her urinal. I came back at 11:00 AM and turned him/her back to the left side. I should have turned him/her on the right side. I took EI #11 with me. The nurse saw me do it. I try my best to keep my residents clean. The surveyor asked EI #10 what direction did she wipe to clean the stool from RI #1's bottom. EI #10 stated, I did it the correct way. I moved fast. I wiped down. The surveyor asked EI #10 what was on the wipe when she was asked to wipe RI #1 from front to back, after she had completed the incontinence care for the resident. EI #10 stated, A smear of stool. EI #10 was asked if she had cleaned the front of RI #1's peri area, or the penis. EI #10 stated, I thought I did, I don't remember. No I didn't clean front. The surveyor asked EI #10 what was the concern when stool was not completely removed from a resident and the resident was not cleaned and the front of their perineal area was not wiped from front to back. EI #10 stated, It can cause a bacteria and a UTI (Urinary Tract Infection). On 5/19/2016 at 5:05 PM, an interview was conducted with EI #8, a Licensed Practical Nurse, and the facility's Infection Control Nurse. EI #8 was asked how staff members were trained to provide incontinence care for a male resident. EI #8 responded the facility did routine in-services. EI #9 the facility's Assistant Director of Nursing was present during the interview and added, the in-services included return demonstrations every 6 months. She stated the facility would increase the in-services to quarterly, upon new hire, and if new issues aroused. EI #9 further explained, if in the class room they used a mannequin for demonstration. EI #9 stated, For a male resident knock .we are going to wipe once down around the penis in a circular motion with our wipe with each complete turn, from the shaft to the top. Still holding the penis in your hand, wipe the scrotum from each side. If the foreskin (is present) pull back and clean from top tip in a circular motion once with each wipe. Replace foreskin if applicable. Wipe once across pelvic area and down each thigh. Apply barrier cream and brief if applicable. Perform hand hygiene and cover resident up, (and perform) hand hygiene. When cleaning the resident's bottom turn to the side, wipe as many times as needed, swipe as many times as needed, from front to back. Once clear, no stool, wipe across the top of bottom and down each thigh, apply barrier cream and brief if needed. The surveyor discussed the incontinence care that was provided by EI #10 for two residents and then asked what was the concern. EI #8 stated, High risk of infection and skin breakdown. The surveyor asked EI #8 when should staff wash hands during incontinence care, especially when stool is involved. EI #8 stated, Before, after and as needed. 5) A review of the facility's undated policy titled, Incontinence Care, revealed: .Steps in the Procedure . 5. Wash hands and apply gloves . 9. For a female resident: a. Utilizing a clean wipe, clean the groin area of the resident. Use a downward motion; swipe only once . b. Use one gloved hand to stabilize and separate the labia. Utilize clean wipe to clean each side of labia and then the center of the vagina. c. Use a clean wipe for each swipe . 12. Clean buttock area using a wipe for each swipe 13. Clean each buttock and anal area (between buttocks) 14. Discard gloves, wash hands, re-glove and apply a clean brief 15. Discard soiled linen in plastic bag 16. Remove gloves, wash hands . RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #7's Quarterly MDS, with an Assessment Reference Date of 04/04/2016, indicated RI #7 had severely impaired cognition. the resident was also coded as totally dependent on staff for personal hygiene. RI #7 was coded for having a UTI in the last 30 days. RI #7's lab report dated 04/03/2016 revealed: Urine Culture Final Report .Pseudomonas aeruginosa . A lab report dated 02/27/2016 revealed: Urine Culture Final Report .[DIAGNOSES REDACTED] pneumonia . A lab report dated 11/08/2015 revealed: Urine Culture Final Report .Providencia stuartii . A review of RI #7's Self Care Deficit care plan, dated 04/04/2016, listed an intervention to assist to toilet every two hours and pericare after each incontinent episode. RI #7's Risk for Infection related to history of UTI's care plan dated 04/04/2016 listed the following intervention: .correct perineal cleansing . On 05/18/2016 at 8:12 AM, the surveyor conducted a continuous observation of RI #7. After four hours and thirty seven minutes of observation, staff did not check RI #7 for incontinence. At 12:49 PM, EI #15, a CNA, took RI #7 to his/her room to start incontinent care. The surveyor observed EI#15 providing incontinence care for RI #7. During the procedure, EI#15 with soiled gloves on, touched drawers, bedside table, and the curtain. EI #15 discarded the gloves and left the room without washing her hands to gather more supplies. Upon returning, EI #15 failed to wash her hands before putting gloves on. During provision of peri care for RI#7, EI#15 wiped twice down the front without changing the cloth or corners of the cloth. EI #15 did not separate the labia of RI #7 during the incontinence care. After cleaning the buttocks of stool properly, EI#15 positioned the resident on his/her back and continued to clean front peri area by wiping from bottom to top twice with two separate wipes. Without changing her gloves, EI#15 applied a clean brief and the resident's clothing. With the same gloves on, EI#15 removed the trash bag with soiled items and left the room without washing her hands or changing her gloves. EI #15, a CNA, was interviewed on 5/18/2016 at 1:50 PM. The surveyor asked EI #15 when should she wash her hands and change gloves. EI #15 said, Before you get ready to do it and after you get through with the procedure. The surveyor asked EI #15 when she changed her gloves. EI #15 explained, I used the sanitizer outside the room. After the procedure I washed my hands. I had gloves on. I didn't change during procedure. The surveyor asked EI #15 what direction should she wipe during incontinence care. EI #15 replied, front to back. The surveyor asked EI #15 what direction did she wipe. EI #15 said, I don't know, I probably messed up. The surveyor asked EI #15 what items did she touch while wearing the soiled gloves. EI #15 replied, drawers and curtain. The surveyor asked if she should touch the items with soiled gloves. EI #15 replied, no, because of cross contamination. The surveyor asked EI #15 why was it important to follow the proper procedure for incontinence care. EI #15 said, Because a person could get an infection. EI #19, Care Plan Coordinator, was interviewed on 05/19/2016 at 11:42 AM. When asked about the importance of following care plans, EI #19 explained it was important because RI #7 had a history of [REDACTED]. EI#19 was asked if the care plan was implemented based on the improper incontinence care provided to RI#7. EI #19 stated, No and it would put RI #7 at risk for UTI. 6 and 7) A review of RI #8's current medical record revealed, the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's Quarterly MDS, with an Assessment Reference Date (ARD) of 4/12/2016, revealed RI #8 was coded as having a BIMS (Brief Interview of Mental Status) score of 6 out of a possible 15, which indicated RI #8 had severe cognitive impairment. RI #8 required extensive to total assistance for all ADLs. RI #8 was coded as always incontinent of bowel and had an indwelling catheter. On 05/17/16 at 10:05 AM, during the tour of the facility, RI #8's indwelling catheter drainage bag was observed on the floor. On 05/17/16 at 3:40 PM, RI #8's indwelling catheter drainage bag was observed on the floor. On 5/18/16 at 11:15 AM, EI #10, a CNA, entered RI #8's room with incontinent care supplies and put the incontinent supplies on the bedside table. EI #10 washed her hands. EI #10 removed RI #8's foot support, then removed the front of the adult brief. EI #10 wiped down the left side and then the right side with separate wipes. EI #10 wiped the resident's shaft of the penis on the right, then the left side and turned to wipe the head of the penis five times without changing the position of the wipe. EI #10 did not clean the residents scrotum or under the penis. RI #8 was turned to the right side. EI #10 wiped the bottom from back to front on the right side and then the left side with separate wipes. EI #10 did not change her gloves or wash her hands. EI #10 turned RI #8 and applied a clean brief. EI #10 positioned RI #8 on the back and raised the head of the bed. EI #10 adjusted RI #8's oxygen tubing with the same gloves she used to provide incontinence care. EI #10 removed her gloves and elevated the head of the bed. EI #10 washed her hands. EI #10 did not provide catheter care for RI #8. An interview was conducted with EI #10 on 5/18/16 at 1:30 PM. The surveyor asked EI #10 when did she clean the scrotum of RI #8. EI #10 stated, I cleaned those when I turned him/her. The surveyor asked EI #10 when did she change her gloves and wash her hands during RI #8's incontinence care. EI #10 stated, When I first came in, I washed hands and put gloves on. Once I got through with care I washed my hands. I washed my hands again, picked up the used items, put (things) back in place, took (things) to the soiled utility, and used the alcohol gel and washed (hands) again. The surveyor asked what was the concern when the scrotum was not cleaned and the resident was not cleaned from front to back during incontinent care. EI #10 stated, It can lead to a UTI (Urinary Tract Infection). On 5/19/16 at 5:55 PM, an interview was conducted with EI #8. The surveyor shared the concern, regarding the indwelling catheter drainage bags and tubing for 2 different residents, were observed on the floor. The surveyor asked what was the concern regarding the observations. EI #8 stated, Infection control.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. A licensed nurse observed during medication pass: a) Did not use an un-sanitized medication tray between residents b) Did not place an un-sanitized glucometer in the medication cart. c) Did not handle a medication capsule with bare hands. d) Did not place used feeding syringes into the plastic storage bags without cleaning and drying the syringes. e) Did not close the privacy curtain with gloved hands prior to administering a G-(Gastrostomy) tube feeding. f) Washed or sanitized her hands between residents during medication pass. 2. The facility failed to ensure the LPN did not handle a foley drainage bag and then change out the [DEVICE] feeding for RI (Resident Identifier) #1. These deficient practices affected RI #'s 1, 15, 16, 17, and 18, five of twenty sampled residents. Findings include: 1. A review of Chapter 28 titled Infection Prevention and Control page 411 of Fundamentals of Nursing Eighth Edition with a copyright date of 2013 revealed: . The CDC (Centers for Disease Control and Prevention) recommends the following: . 3. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in the following clinical situations: a) Before, after, and between direct patient contact . The review of a facility document titled, Infection Control Guidelines for All Nursing Procedures, with no date, revealed: Purpose To provide guidelines for general infection control while caring for residents. General Guidelines 1. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. 3. Employees must wash their hands for ten (10) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents; b. When hands are visibly dirty or soiled with blood or other body fluids; c. After contact with blood, body fluids, secretion, mucous membranes, or non-intact skin; d. After removing gloves; . A review of RI #15's medical record revealed, the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During medication administration observation on 5/17/16 at 4:35 PM, Employee Identifier (EI) #6, a Licensed Practical Nurse, (LPN), was observed to obtain a FSBS (finger stick blood sugar) for RI #15. EI #6 set up the supplies for the FSBS on a tray and obtained the blood sugar. She obtained the insulin in a syringe and placed it on the tray. EI #6 administered the insulin. EI #6 washed her hands but did not sanitize the glucometer, nor did she sanitize the tray the items were placed on. EI #6 put the used items on the medication cart and proceeded to administer medications to RI #16. A review of RI #16's medical record revealed, the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During medication administration observation on 5/17/16 at 4:45 PM, EI #6 was observed to prepare medications for RI #16. EI #6 opened a capsule with her bare hands prior to administering the medication to RI #16. EI #6 did not wash her hands, use alcohol gel, sanitize the glucometer, nor the tray on top of the medication cart. EI #6 pushed the medication cart to the nursing station and put the un-sanitized glucometer into a case and then into a drawer of the medication cart. EI #6 poured water from a pitcher on top of the medication cart into her personal container, added a mixture, shook it up and drank from her container. EI #6 took the water pitcher into the nourishment room near the nursing station, washed her hands, rinsed and refilled the water pitcher. She then put the pitcher on top of the medication cart. On 5/18/16 at 6:20 PM, an interview was conducted with EI #6. The surveyor asked EI #6 when did she sanitize the tray that she put the FSBS supplies on during the observations on 5/17/16. EI #6 stated, I sanitized the tray at the beginning of the shift. I then use paper towels on the tray during FSBS as a barrier. The surveyor informed EI #6 that paper towels were not observed on the tray during her medication pass observations. The surveyor asked EI #6 when did she wash her hands during the medication pass observations. EI #6 stated, I used (alcohol) gel, gave the injection, no gloves, and washed hands. I used hand sanitizer in the hallway. I try to wash my hands every third person. It is usually for those patients who don't use the rest room. The surveyor informed EI #6 that she was not observed to sanitize the glucometer during the FSBS for RI #15. EI #6 stated, That was my last FSBS. I usually sanitize it when I put it in the drawer. I re-sanitize it prior to using it again. The surveyor asked EI #6 what was the concern when the glucometer was not sanitized. EI #6 stated, It contaminates the drawer. The surveyor shared the observation when EI #6 opened the capsule with her bare hands and asked what was the concern. EI #6 stated, Infection control, you make people nervous. I remember that, I thought after the fact. The surveyor shared the observation above, when EI #6 did not wash her hands, used the water pitcher from the medication cart, and then drank out of her personal container at the nursing station. The surveyor asked what was the concern. EI #6 stated, I was thirsty, my mouth was very dry. I did not put it back on the cart without getting fresh ice and water, after rinsing the pitcher. The surveyor asked EI #6 what was the concern with the observations. EI #6 stated, Cross contamination, infection control, patient germs, my germs . A review of RI #17's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #17's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 4/25/16, revealed RI #17 was totally dependent on staff for all ADLs (Activities of Daily Living) and had a Gastrostomy tube. During medication administration observation on 5/18/16 at 10:45 AM, EI #5 was observed to administer a liquid medication to RI #17 via [DEVICE]. After the medication was administered, there was a residual of the medication observed in the syringe. EI #5 did not rinse the feeding syringe after the medication administration. She shook the syringe and put it back into the plastic bag. A review of RI #1's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Admission MDS, dated [DATE], revealed the resident was in a persistent vegetative state. RI #1 was totally dependent on staff for all ADLs. On 5/18/16 at 12:25 PM, an observation of RI #1's [DEVICE] set up was done by EI #5. EI #5 flushed the [DEVICE], connected the feeding, and started the pump. EI #5 did not rinse and dry the feeding syringe. She put the wet syringe in the plastic bag. An interview was conducted with EI #5 on 5/1816 at 2:05 PM. The surveyor asked EI #5 if she washed and dried the feeding syringes after using them for RI #1 and RI #17. EI #5 stated, No I did not. I shook the syringe and got the excess off and put it back into the bag. The surveyor asked what was the concern with not rinsing and drying the feeding syringe after use. EI #5 stated, I'm just not sure. A review of RI #18's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #18's Quarterly MDS dated [DATE], revealed RI #18 was totally dependent on staff for all ADLs, had a Gastrostomy tube, and was incontinent of bowel and bladder. RI #18 had severe, cognitive impairment. During a medication administration observation on 5/18/16 at 10:50 AM, EI #7, an LPN, was observed to administer a medication for RI #17 via G (Gastrostomy) tube. EI #7 washed her hands and applied gloves. EI #7 closed the privacy curtain with gloved hands, and proceeded to administer medication via [DEVICE] to RI #18. An interview was conducted with EI #7 on 5/19/16 at 10:45 PM. The surveyor asked EI #7 what was the concern when the curtain was closed with gloved hands and then a [DEVICE] medication was administered. EI #7 stated, A potential for cross contamination. On 5/19/2016 at 5:05 PM, an interview was conducted with EI #8, a Licensed Practical Nurse/Infection Control Nurse for the facility. EI #8 was asked how should a nurse open a capsule prior to administration of a medication to a resident. EI #8 stated, Perform hand hygiene, put on gloves after identifying the 5 rights. EI #8 was asked what the concern was when a resident's curtain was closed with gloved hands and then a [DEVICE] medication was administered without changed gloves or washing hands. EI #8 responded, The concern is infection control. EI #8 was asked what should be done with a feeding syringe after administration of medications via [DEVICE]. EI #8 stated, Rinse and dry it out. No residue should be in there. The surveyor shared concern of the tube feeding syringes that were not rinsed and dried after use and asked what was the concern. EI #8 stated, The concern is infection control. EI #8 was asked when a nurse should sanitize the glucometer after use. EI 8# stated, Immediately after use. EI #8 was asked when should a nurse sanitize the medication trays during medication administration. EI #8 stated, After each use and before. EI #8 was asked when should a nurse wash hands during medication pass. EI #8 responded, Before and after. The surveyor shared the concerns of the above medication pass observations with EI #8 and asked what was the concern. EI #8 stated, Contamination and infection control. On 5/18/16 at 11:45 AM, EI #5 was observed to apply gloves and then repositioned RI #1's foley catheter drainage bag. EI #5 then proceeded to disconnect RI #1's [DEVICE] feeding with the same gloves used to reposition the foley catheter drainage bag. An interview was conducted with EI #5 on 5/19/16 at 3:50 PM. The surveyor shared the above observation with EI #5, and asked what was the concern. EI #5 stated, I remember doing that, but I had on my gloves. What should I have done? On 5/19/2016 at 5:55 PM, an interview was conducted with EI #8. The above observation was shared with EI #8 and asked what was the concern EI #8 stated, Contamination and infection control.

Based on observation, record reviews, and interviews, the facility failed to ensure staff did not stand over Resident Identifier (RI) #7 while feeding during the 5/17/2016 supper meal. This affected one of 13 sampled residents for whom meals were observed. Findings include: A review of the medical record revealed RI #7 was readmitted to the facility 7/08/2015 with [DIAGNOSES REDACTED]. A review of RI #7's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 04/04/2016, indicated RI #7 had severely impaired cognition and required extensive assistance with one person physical assist with eating. On 5/17/2016 at 6:15 PM, the surveyor observed EI (Employee Identifier) #13, Unit Manager, standing over RI #7 while feeding her/his dinner in the sun/ day room, on the floor RI #13 resided. The surveyor interviewed EI #13, a Unit Manager, on 5/17/2016 at 6:30 PM. EI #13 was asked how should residents be assisted with feeding. EI #13 explained the resident should be in an upright position, and person feeding should be seated for eye contact with resident. The surveyor asked why would this be important. EI #13 replied, The resident could feel intimidated by someone unknown to them. The surveyor asked EI #13 why did she stand to feed RI #7. EI #13 stated, A chair would have had to be gotten from the dayroom. An interview was conducted with EI #1, the DON (Director of Nursing), on 5/19/16 at 11:20 AM. The surveyor asked how residents should be fed. EI #1 replied, Residents should be in an upright and comfortable position. I would sit to feed a resident because it would make them feel comfortable. If I had to stand I would raise the bed to eye level. My concern would always be for their comfort. The surveyor asked EI #1 what staff should do if a chair wasn't available to feed a resident. EI #1 answered, They should go and get a chair or they can raise the bed to eye level with the resident.

Based on observation, record reviews, and interviews, the facility failed to ensure housekeeping staff cleaned the handwashing sink in the 3rd floor nourishment room which resulted in a large amount of black build up all around the inside of the sink. This affected one of three nourishment room sinks located on one of three resident units. Findings include: A facility housekeeping document titled, (Name of facility) Employee Detail, revealed, . Shift Time: 700AM-330PM . Job Type: Housekeeper . Blank spaces on the form were designated for the staff member name and date. The area box included the floor assignment. Areas listed to be cleaned included residents' rooms, the nurse station, the sun room, Kitchen (the area where the handwashing sink is located), MDS (Minimum Data Set coordinator office), and shower. A review of a facility document titled Room and Restroom Daily Cleaning Duties, revealed, . 3, Vents, sinks, partitions, doors and door handles, shower walls and floors. 4. Spray with cleaner and wipe down. Remove stubborn stains with scrubbing pad or sponge. Rinse thoroughly and wipe dry. An observation was made on 5/17/16 at 4:30 PM of the handwashing sink located in the kitchen/nourishment room on the 3rd floor. The sink was noted with a black slime build up all around the inside of the sink. EI (Employee Identifier) #13, the Unit Manager, was observed to wipe the sink with a paper towel. There was a black substance residue on the paper towel. During this observation, staff were noted to utilize this sink 3 times. An interview was conducted with EI #14, the District Manager for Housekeeping, on 5/17/16 at 5:15 PM. EI #14 stated the sink should be cleaned on a daily basis and it was not being done. EI #14 was asked why should it be done and he answered to keep odor, bacteria, and mildew down. An interview was conducted with EI #12, the Housekeeping Supervisor, on 5/19/16 at 11:33 AM. EI #12 was asked who was responsible for cleaning the sinks in the kitchen area on each floor. She answered housekeeping. EI #12 was asked how often were they supposed to be cleaned. She answered every day.

This deficiency was written as a result of the investigation of complaint # AL 025. Based on interviews and record reviews, the facility failed to ensure that a licensed staff member notified Resident Identifier Number (RI #) 1's physician when: 1. The resident experienced a decrease in her oral (PO) intake as evidence by her refusing meals or eating 50 percent (%) or less during the period of [DATE] - [DATE]; and, 2. By not promptly notifying RI #1's physician when her blood glucose level was noted to be 66 on [DATE], prior to the administration of her oral diabetic medication. This resulted in RI #1's blood glucose level dropping to 24. RI #1 was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. This affected RI # 1, one of two residents sampled for diabetic monitoring. This deficient practice placed RI # 1's health in immediate jeopardy, as it was likely to have caused serious injury, harm or death. On [DATE] at 7:41 PM, the facility's Executive Director and the Director of Nursing (DON) were made aware that the survey team had identified a serious concern in the area of notification of change, cited at F157, Immediate Jeopardy (IJ) level, surrounding the incident with Resident Identifier (RI) #1, which occurred on [DATE]. The immediate jeopardy was relieved on [DATE] at 4:32 PM, when the facility implemented immediate corrective actions to remove the immediacy and prevent any future recurrence. Findings Include: RI # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The five day scheduled Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], identified RI #1 as having memory problems. According to her MDS she was coded as being totally dependent on staff for her Activities of Daily Living. She was coded as needing oversight, encouragement, or cueing during meals as well as requiring set-up assistance. RI #1's "Interim Plan Of Care" dated [DATE], identified the resident as obese, with all ADLs performed by staff. This interim plan of care documented that RI #1 was alert and on a 1600 calorie ADA (American Dietetic Association) diet with regular fluids. The [DATE], "admission orders [MEDICATION NAME] 2.5 mg (milligrams) po (by mouth) QD (every day)..." According to these admission orders [REDACTED]. RI #1's "Resident Care Flow Record" for [DATE], documented that the resident experienced a decline in eating from [DATE] - [DATE]. On [DATE], RI #1 consumed 50 % of the lunch meal and 20% of the dinner meal. On [DATE], RI #1 ate 25% of the breakfast meal; however, the lunch and dinner meal had no oral intake recorded for the resident. For [DATE], RI #1's resident care flow record included no recorded oral intake for breakfast, lunch and dinner. On [DATE], RI #1 refused breakfast and lunch, with no recorded intake for the dinner meal. RI #1 ate 50% of the breakfast meal on [DATE]. The survey team reviewed the facility's nursing assignment schedule from [DATE] - [DATE], to identify nursing staff by name that provided care to RI #1. Certified Nursing Assistants (CNAs) who provided care to RI #1, during the timeframe of [DATE] - [DATE], were interviewed regarding RI #1's eating habits / meal consumption. On [DATE] at 2:05 PM, Employee Identifier (EI) #2, the CNA assigned to RI #1 from [DATE] - [DATE], recalled that RI #1 ate about half (50%) of her food when the resident first came to the second floor, but, RI #1 stopped eating and refused all meals, after a while. EI #2 recalled reporting that RI #1 was not eating on at least four or five different occasions. On [DATE] at 11:20 AM, EI #5, the CNA assigned to RI #1 on [DATE], stated that RI #1 did not eat much. EI #5 said that RI #1's appetite got worse over time; and, the resident just stopped eating all together. EI #5 recalled that RI #1 would refuse refuse the alternates and health shakes offered. EI #5 reported to the charge nurse that RI #1 was not eating. On [DATE] at 2:10 PM, EI #11, the CNA who provided care to RI #1 on [DATE] and [DATE], recalled that RI #1 ate pretty good when the resident first arrived on the second floor, but started eating less, until the resident stopped eating. EI #11 said that RI #1 refused the alternates and the health shakes offered. EI #11 was asked about the documentation on the "Resident Care Flow Record" for [DATE], which documents that RI #1 ate 50% of the breakfast meal. EI #11 responded that the value of 50% was incorrect, and would be documented as "R" for refused. EI #11 explained that RI #1 slept through breakfast on the morning of [DATE], and had not eaten anything when the meal tray was removed from RI #1's room. EI #11 recalled that she attempted to feed RI #1; but, the resident only ate one spoonful of grits and drank a little of water. EI #11 reported that RI #1 was not eating to the charge nurse. On [DATE] at 5:20 PM, EI #6, the CNA assigned to RI #1 on [DATE] and ,[DATE].11, said that RI #1 would not eat her snack, and recalled being told by the other CNAs that RI #1 was not eating meals. EI #6 reported to the evening charge nurse (EI #7) that RI #1 was not eating. On [DATE] at 2:30 PM, an interview was conducted with EI #4, (A Licensed Practical Nurse who provided care to RI #1 on [DATE] according to the facility staffing schedule). EI #4 was asked if staff would make a report to her if a resident was not eating. EI #4 responded that the staff would report that to her. EI #4 recalled that staff told her that RI #1 was refusing to eat and that she had even tried to feed the resident herself once and the resident refused to eat. EI # 4 reviewed the resident's "Resident Care Flow Sheet" and stated that based on her knowledge and the information on the sheet, it looked like RI #1 had a pattern of not eating and that was something that definitely should have been reported to RI #1's doctor and the registered dietician (RD) and possibly to the nurse practitioner. According to EI #4, this should have been reported so that the doctor could possibly order an appetite stimulant for the resident or may even consider [DEVICE] placement. EI #4 was asked if she reported that RI #1 was not eating to anyone. According to EI #4 she did not report that RI #1 was not eating to the resident's doctor or to the dietician. In an interview on [DATE] at 7:40 AM, EI #7, the night shift Licensed Practical Nurse (LPN) who provided care to RI #1 on evening of [DATE] until the morning of [DATE], affirmed that the prior shift's nurse, as well as, one of the CNAs had reported that RI #1 was not eating. EI #7 was asked to describe the events on the morning of [DATE], in regards to RI #1. EI #7 recalled that on [DATE], she went into RI #1's room, woke the resident up, and obtained a fingerstick blood sugar level on RI #1. RI #1's blood sugar level measured 66; EI #7 offered RI #1 a snack, which the resident refused. She finished making her rounds and started doing her documentation for the shift. EI #7 recalled that she did not notify the physician because the resident's blood sugar was not below 60, and did not recheck the resident's blood sugar in one hour. EI #7 stated that she reported the blood sugar of 66, to the oncoming nurse, EI #3. EI #7 was asked based on the information on the standing orders what should she have done on [DATE] when she got the blood glucose value of 66. EI #7 responded that the resident's doctor should have been contacted if RI #1's blood glucose was less than 70. According to RI #1's "Diabetic Monitoring Flow Sheet", EI #7 documented that on [DATE] at 6:00 AM, RI #1 had a blood sugar level of 66, and the resident refused a snack. The facility's undated standing order's which are signed by physician, EI #10, document: "...7. ...If BG (Blood Glucose) > (greater than) 400 or < (less than) 70 then call (Name of EI #10)...." RI #1's "Resident Progress Notes", dated [DATE] at 10:15 AM, documented: "Resident refused breakfast. Sponsor notified, states "believe it's time for her to go back to hospital." This progress note is signed by EI #3, a Registered Nurse (RN). RI #1's resident progress note signed by EI #3 and dated [DATE] at 1:28 PM, documented: "1100 (11:00 AM) FSBG (fingerstick blood glucose) 49; glucose inj (injection) given per SO (Standing Orders) r/t (related to) inability to swallow; recheck 56, gave juice c (with) sugar, recheck 84; Resident awake c (with) confusion @ (at) this time, Family @ bedside, assisting c feeding. ...Will continue to monitor for s/s (signs / symptoms) of hypo / [MEDICAL CONDITION]. ..." On [DATE] at 1:57 PM, an interview was conducted with RI #1's sponsor. He stated that his wife (RI #1) was admitted to the facility on [DATE], and assigned to a room on the fourth floor, when first admitted in the facility. According to RI #1's sponsor, his wife (RI #1) moved down to the second floor a couple of days later; then, he noticed a decline in her condition. He stated that RI #1 stopped eating as much as she used to until eventually she stopped eating all together. RI #1's sponsor recalled visiting his wife during the scheduled meal times, and attempting to get RI #1 to eat. He states that RI #1 was refusing to eat and that for about three days she did not eat any of her meals. According to RI #1's sponsor, on [DATE], sometime after 8:00 AM, a male nurse called and reported that RI #1 was refusing to eat breakfast. RI # 1's sponsor recalled telling the nurse that he (the sponsor) thought it was about time that for RI #1 to be sent out to the hospital. After receiving the call, RI #1's sponsor stated that he went to the facility to check on RI #1. Upon arrival at the facility, RI #1's sponsor found his wife (RI #1) nonresponsive; he went to the desk and got the nurse. RI #1's sponsor recalled that the male nurse performed a fingerstick blood sugar on RI #1, which measured 24. The sponsor said that the nurse gave RI # 1 some kind of shot because of the nurse was afraid that RI #1 might choke, if given something to swallow. The nurse waited a few minutes and did another fingerstick blood sugar, which measured around 48 or 49. Then, the nurse asked the sponsor to try to get RI #1 to drink some juice. The sponsor reported that RI #1 did drink some juice, and another fingerstick blood sugar was done. According to RI #1's sponsor, RI #1's blood sugar level had come up some more. RI #1's sponsor said that he asked the nurse to send RI #1 out to the hospital, and if they (the facility staff) were not willing to send RI #1 out that he would call the cops and see if they (the police / cops) could help get his wife (RI #1) sent out. According to RI #1's "Diabetic Monitoring Flow Sheet", EI #3 documented that on [DATE] at 11:00 AM, RI #1 had a blood sugar level of 24, and [MEDICATION NAME] IM (Intramuscular) was given. An untimed "Resident Progress Notes" for RI #1, documented: "[DATE] Resident out to Providence Hospital per Sponsor request r/t refusing food. This progress note is signed by EI #3. A "Physician's Telephone Orders" for RI #1, dated [DATE] at 1500 (3:00 PM), documented: "Transfer to Providence Hospital..." RI #1's hospital records titled, "Emergency Department Nursing Assessment", document that RI #1 arrived in the emergency department by EMS (Emergency Medical Services) at 4:45 PM, with a blood sugar level of 54. This emergency department record documented a chief complaint of low blood glucose (sugar) related to not eating. A physician's "Consultation" report dated, [DATE], documents the reason for consultation as, "Assist with respiratory and ICU (intensive care unit) management." This consultation report included the diagnosis (impression) of: "1. [DIAGNOSES REDACTED] -- on oral hypoglycemic agents in the setting of chronic [MEDICAL CONDITION]. 2. Acute on chronic kidney failure. 3. Acute on chronic [MEDICAL CONDITION]. 4. [MEDICAL CONDITION]. ..." Additionally, this consultation report the treatment plan as: "1. Noninvasive ventilation for now. 2. Stop the oral hypoglycemic medications. 3. Change the antibiotics to cover for healthcare associated pneumonia and aspiration pneumonia. ..." RI #1's hospital "Physician's Orders" dated [DATE] at 1621 (4:21 PM) indicates that RI #1 died (expired). This physician's order documented, OK (okay) to pronounce and release body to morgue @ 1621..." On [DATE] at 10:00 AM, an interview was conducted with EI #3, the Registered Nurse (RN) who provided care to RI #1 on [DATE]. EI #3 was asked at what blood sugar value should the resident's physician be notified. EI 33 responded that usually information regarding when to notify the physician would be listed on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. EI #3 explained that if it is not there; then, staff have to refer to the standing orders. According to EI #3, the standing orders instruct the nurse to contact the physician if the blood sugar values are less than 70. EI #3 stated that the the prior shift's nurse (EI #7) should have contacted RI #1's physician, in accordance with the standing orders. EI 33 was asked what he would have done differently if the nurse on the previous shift would have contacted RI #1's physician regarding the resident's low blood sugar value. EI #3 responded that if the physician had been contacted about RI #1's low blood sugar, an order to hold RI #1's oral diabetic medication may have been given. Then, EI #3 further explained that RI #1 would not have been given the morning dose of oral diabetic medication ([MEDICATION NAME]). EI #3 was asked what were some possible outcomes that could have occurred if RI #1's oral diabetic medications had been held (not given). EI #3 responded that RI #1's blood sugars may not have decreased to such an extent (decreased from 66 at 6 AM to 24 at 11 AM). EI #3 was asked if he thought that it would have been important for the nurse to have notified the physician. EI #3 responded that it was very important because getting the physician involved may have changed the outcome of the situation. EI #3 was asked if he felt the failure to notify RI #1's physician may have compromised RI #1's health. EI #3 responded that it could have. On [DATE] at 3:26 PM, an interview was conducted with EI #8, (a RN Unit Manager). EI #8 was asked to review RI #1's chart. EI #8 said that it was important for the physician to be notified if a diabetic resident was not eating especially if the resident was receiving oral agents or insulin. EI #8 explained that if the medication was continued and the resident was not eating; then, the resident could bottom out, go into a coma, have a stroke, go into [MEDICAL CONDITION], and also could die. EI #8 said that RI #1's physician was not contacted and notified of the resident's situation. EI #8 stated that it would have been important for the physician to have been contacted because the resident could have become medically compromised. On [DATE] at 4:27 PM, an interview was conducted with EI #9 (a RN / Director of Nursing). EI #9 was asked if a resident's oral diabetic medication should have been given if the resident was known not to be eating, and had a low blood sugar value. EI #9 answered that with a resident not eating and having a blood sugar value of 66, she (EI #9) would have tried to feed the resident again. EI #9 said that she would have waited on the resident's morning diabetic oral medication. EI #9 explained that if unsuccessful in feeding the resident, she (EI #9) would have gone ahead and called the physician. The surveyor asked EI #9 if the nurse on the morning of [DATE], should have contacted the physician when she determined that RI #1's blood sugar value was 66. EI #9 answered that the nurse on the morning of [DATE], who saw that RI #1's blood sugar value was 66, should have called the resident's physician as per instructions outlined on the standing orders. According to EI #9, RI #1's physician should have been called earlier, and provided an update on the resident's status. EI #9 was asked based on the information in RI #1's chart and on the diabetic monitoring flow sheet what did both the nurses involved in the incident on [DATE], fail to do. EI #9 answered based on the documentation in RI #1's chart and the information on the "Diabetic Monitoring Flow Sheet," both the nurses providing care to RI #1 on the morning of [DATE], failed to notify the resident's physician in a timely manner, resulting in a change in the resident's medical condition. On [DATE] at 3:10 PM, a telephone interview was conducted with EI #12 (an associate of RI #1's physician). EI #12 stated that theoretically if a resident was not eating and had a blood glucose level of 66, that the doctor probably should have been notified prior to the administration of oral diabetic medications and that possibly the doctor would have given an order to hold the medication. EI #12 stated that without being able to review the record, she could not say for sure, what the nurse should have done. Review of the facility policy titled, "Notifications POL ,[DATE] " dated, [DATE], revealed " ... Staff informs the resident, consults with their attending physician, and notifies the resident ' s surrogates when: ... A significant change occurs in the resident ' s physical, mental or psychosocial status; Treatment needs to be altered significantly; or..." ______________________________________ On [DATE] at 4:02 PM, the facility's Executive Director provided the survey team with the following acceptable Allegation of Credible Compliance. Revised and submitted [DATE] Credible Allegation of Compliance as of [DATE] F157, Notification of Change 1. RI #1 was discharged from the facility on [DATE]. The licensed nurses associated with the direct care for RI #1 received inservice training with the director of nurses [DATE] regarding notification of change and hypoglycemic monitoring. (See Attachments) The director of nurses and nursing managers audited all residents with physician orders for accu checks on [DATE] to ensure that Diabetic Flow Records are accurate per physician orders. (See Attached) 2. Residents eating less than 50% of food over 48 hours or with blood sugars below 60 have the potential of being affected. The director of nurses and nursing managers audited all residents with physician orders for accu checks on [DATE] to ensure that Diabetic Flow Records are accurate per physician orders. (See Attached) 3. ___, DNS will provide the education and training for the nursing staff. Ms Coolie is an RN with over [AGE] years of long term care experience that includes charge nurse/floor nursing, MDS coordinator and over 5 years of experience as a Director of Nursing. The director of nurses initiated inservices with the Licensed Nurses [DATE] regarding policy and procedures for notification of change in reference to blood glucose levels less than 60. Policy, PRO was reviewed and revised to read that the physician would be contacted if the blood glucose level was below 60 ml. This change in policy was approved by Dr. George Sutton, medical director. Copies of inservices, handouts and sign in sheets are being maintained in the director of nurses office for future review. (See Attachments) Credible Allegation of Compliance page 2 Inservices were initiated [DATE] with licensed nurses regarding notifying the physician when there are significant changes in eating habits which are not resolved in 48 hours. Copies of handouts/materials and sign in records being maintained in the director of nurses office for future review. (See Attachments) Staff scheduled to work today and forward will not be allowed to report to their assigned areas until they have received inservices related to F157. Signs are posted at the time clock and near the elevator to notify staff of mandatory inservices prior to working with residents. 4. The director of nurses or designee/s will review the diabetic monitoring flow logs and the 24-hour report in the morning clinical meeting, Monday - Friday, for 8 weeks and then every other week for 4 weeks, to ensure blood glucose checks below 60 are managed according to policy and procedure. Concerns with results of these audits will result in immediate re-education. (See Attached) The director of nurses or designee will audit residents who have a significant change in eating habits which is not resolved in 48 hours, Monday - Friday, for 8 weeks, and then every other week for 4 weeks to ensure the physician is notified. Concerns noted through the audit process will result in immediate re-education. The executive director will review audits weekly. Results of these audits will be forwarded to the performance improvement committee. Respectfully submitted, Executive Director _____________________________________ On [DATE] at 4:32 PM, after verifying in-service records and interviewing nursing staff, the survey team concluded the facility implemented corrective measures as described in their Allegation of Credible Compliance provided to the survey team on [DATE] at 4:02 PM, to prevent any future reoccurrence. The Immediate Jeopardy was relieved on [DATE] at 4:32 PM, and the scope and severity was lowered to a "D" level, to allow the facility time to monitor and revise their corrective actions as needed to establish substantial compliance with F 157.

This deficiency was written as a result of the investigation of complaint # AL 025. Based on record review and interviews, the facility's licensed nursing staff administered an oral hypoglycemic medication ([MEDICATION NAME]) to Resident Identifier (RI) #1, a diabetic known to refuse meals / snacks or eat less than 50 percent (%) of a meal for five consecutive days ([DATE], [DATE], [DATE], [DATE] and [DATE]). From [DATE] - [DATE], the licensed nursing staff administered the oral hypoglycemic medication to RI #1, daily at 8:00 AM, without communicating the resident's decline in oral intake to the resident's physician to allow the physician an opportunity to modify RI #1's diabetic treatment / management plan of care as needed to decrease the risk of an hypoglycemic reaction. On [DATE] at 6:00 AM, a Licensed Practical Nurse (LPN), Employee Identifier (EI) #7, obtained RI #1's fingerstick blood sugar (FSBS), which measured 66. EI #7, offered the resident a snack; but, the resident refused to eat. EI #7 documented the resident's blood sugar level of 66, and the resident's refusal of a snack on the 24 hour reporting form. Contrary to the physician's standing orders, EI #7 did not notify the physician of RI #1's low blood sugar of 66 and the resident's refusal to eat a snack. EI #7 notified the oncoming licensed nurse (EI #3) at the change of shift that RI #1 had a blood sugar of 66 and had refused to eat a snack. According to EI #3 (an LPN), RI #1 refused breakfast on [DATE]; however, EI #3 was able to get the resident to take her 8:00 AM medications, which included the [MEDICATION NAME] (an oral hypoglycemic medication). At 10:15 AM, EI #3, notified RI #1's sponsor that the resident had refused breakfast; and, the sponsor requested that the resident be sent out to the hospital. At 11:00 AM, EI #3 (an LPN) obtained a fingerstick blood sugar level of 24 on RI #1. EI #3, rechecked RI #1's blood sugar, which measured 49, then administered an Intramuscular (IM) injection of [MEDICATION NAME] because of the resident's inability to swallow. At 1:38 PM, EI #3 documented that RI #1 was awake with confusion, family at bedside assisting with feeding, and would continue to monitor for signs and symptoms of [DIAGNOSES REDACTED]. At 3:00 PM, EI #3 obtained a physician's orders [REDACTED].#1 was sent out to a local hospital per sponsor's request related to refusing food. RI #1's hospital records document that the resident arrived in the emergency department by EMS (Emergency Medical Services) at 4:45 PM, with a blood sugar level of 54. RI #1 was admitted to the hospital for treatment of [REDACTED]. RI #1's hospital treatment plan included stopping the oral hypoglycemic medication ([MEDICATION NAME]), placing the resident on a non-invasive ventilator and administering antibiotics for healthcare associated pneumonia and aspiration pneumonia. RI #1 expired at the hospital on [DATE]. This affected RI #1, one of two residents sampled for diabetic monitoring. This deficient practice placed RI #1's health in immediate jeopardy, as it was likely to have caused serious injury, harm or death. On [DATE] at 7:41 PM, the facility's Executive Director and the Director of Nursing (DON) were made aware that the survey team had identified a serious concern in the area of Quality of Care and Services, cited at F309, Immediate Jeopardy (IJ) level, surrounding the incident with Resident Identifier (RI) #1, which occurred on [DATE]. The immediate jeopardy was relieved on [DATE] at 4:32 PM, when the facility implemented immediate corrective actions to remove the immediacy and prevent any future recurrence. Findings Include: RI # 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Five Day Minimum Data Set (MDS, with an Assessment Reference Date (ARD) of [DATE], identified RI #1 as having memory problems. According to this assessment, RI #1 was coded as being totally dependent on staff for her Activities of Daily Living (ADLs). RI #1 was identified as needing oversight, encouragement, or cueing during meals, as well as, requiring set-up assistance. RI #1's "Interim Plan Of Care" dated [DATE], identified the resident as obese, with all ADLs performed by staff. This interim plan of care documented that RI #1 was alert and on a 1600 calorie ADA (American Dietetic Association) diet with regular fluids. The [DATE], "admission orders [MEDICATION NAME] 2.5 mg (milligrams) po (by mouth) QD (every day)..." According to these admission orders [REDACTED]. RI #1's "Resident Care Flow Record" for [DATE], documented that the resident experienced a decline in eating from [DATE] - [DATE]. On [DATE], RI #1 consumed 50 % of the lunch meal and 20% of the dinner meal. On [DATE], RI #1 ate 25% of the breakfast meal; however, the lunch and dinner meal had no oral intake recorded for the resident. For [DATE], RI #1's resident care flow record included no recorded oral intake for breakfast, lunch and dinner. On [DATE], RI #1 refused breakfast and lunch, with no recorded intake for the dinner meal. RI #1 ate 50% of the breakfast meal on [DATE]. The survey team reviewed the facility's nursing assignment schedule from [DATE] - [DATE], to identify nursing staff by name that provided care to RI #1. Certified Nursing Assistants (CNAs) who provided care to RI #1, during the timeframe of [DATE] - [DATE], were interviewed regarding RI #1's eating habits / meal consumption. On [DATE] at 2:05 PM, Employee Identifier (EI) #2, the CNA assigned to RI #1 from [DATE] - [DATE], recalled that RI #1 ate about half (50%) of her food when the resident first came to the second floor, but, RI #1 stopped eating and refused all meals, after a while. EI #2 recalled reporting that RI #1 was not eating on at least four or five different occasions. On [DATE] at 11:20 AM, EI #5, the CNA assigned to RI #1 on [DATE], stated that RI #1 did not eat much. EI #5 said that RI #1's appetite got worse over time; and, the resident just stopped eating all together. EI #5 recalled that RI #1 would refuse refuse the alternates and health shakes offered. EI #5 reported to the charge nurse that RI #1 was not eating. On [DATE] at 2:10 PM, EI #11, the CNA who provided care to RI #1 on [DATE] and [DATE], recalled that RI #1 ate pretty good when the resident first arrived on the second floor, but started eating less, until the resident stopped eating. EI #11 said that RI #1 refused the alternates and the health shakes offered. EI #11 was asked about the documentation on the "Resident Care Flow Record" for [DATE], which documents that RI #1 ate 50% of the breakfast meal. EI #11 responded that the value of 50% was incorrect, and would be documented as "R" for refused. EI #11 explained that RI #1 slept through breakfast on the morning of [DATE], and had not eaten anything when the meal tray was removed from RI #1's room. EI #11 recalled that she attempted to feed RI #1; but, the resident only ate one spoonful of grits and drank a little of water. EI #11 reported that RI #1 was not eating to the charge nurse. On [DATE] at 5:20 PM, EI #6, the CNA assigned to RI #1 on [DATE] and ,[DATE].11, said that RI #1 would not eat her snack, and recalled being told by the other CNAs that RI #1 was not eating meals. EI #6 reported to the evening charge nurse (EI #7) that RI #1 was not eating. A review of RI #1's "Medication Record" for [DATE], revealed that the licensed nurses administered RI #1's 8:00 AM diabetic medication, "[MEDICATION NAME] 2.5 mg po QD," from [DATE] thru [DATE]. In an interview on [DATE] at 7:40 AM, EI #7, the night shift Licensed Practical Nurse (LPN) who provided care to RI #1 on evening of [DATE] until the morning of [DATE], affirmed that the prior shift's nurse, as well as, one of the CNAs had reported that RI #1 was not eating. EI #7 was asked to describe the events on the morning of [DATE], in regards to RI #1. EI #7 recalled that on [DATE], she went into RI #1's room, woke the resident up, and obtained a fingerstick blood sugar level on RI #1. RI #1's blood sugar level measured 66; EI #7 offered RI #1 a snack, which the resident refused. She finished making her rounds and started doing her documentation for the shift. EI #7 recalled that she did not notify the physician because the resident's blood sugar was not below 60, and did not recheck the resident's blood sugar in one hour. EI #7 stated that she reported the blood sugar of 66, to the oncoming nurse, EI #3. EI #7 was asked based on the information on the standing orders what should she have done on [DATE] when she got the blood glucose value of 66. EI #7 responded that the resident's doctor should have been contacted if RI #1's blood glucose was less than 70. According to RI #1's "Diabetic Monitoring Flow Sheet", EI #7 documented that on [DATE] at 6:00 AM, RI #1 had a blood sugar level of 66, and the resident refused a snack. The facility's undated standing order's which are signed by physician, EI #10, document: "...7. ...If BG (Blood Glucose) > (greater than) 400 or < (less than) 70 then call (Name of EI #10)...." RI #1's "Resident Progress Notes", dated [DATE] at 10:15 AM, documented: "Resident refused breakfast. Sponsor notified, states "believe it's time for her to go back to hospital." This progress note is signed by EI #3, a Registered Nurse (RN). RI #1's resident progress note signed by EI #3 and dated [DATE] at 1:28 PM, documented: "1100 (11:00 AM) FSBG (fingerstick blood glucose) 49; glucose inj (injection) given per SO (Standing Orders) r/t (related to) inability to swallow; recheck 56, gave juice c (with) sugar, recheck 84; Resident awake c (with) confusion @ (at) this time, Family @ bedside, assisting c feeding. ...Will continue to monitor for s/s (signs / symptoms) of hypo / [MEDICAL CONDITION]. ..." On [DATE] at 1:57 PM, an interview was conducted with RI #1's sponsor. According to RI #1's sponsor, on [DATE], sometime after 8:00 AM, a male nurse called and reported that RI #1 was refusing to eat breakfast. RI # 1's sponsor recalled telling the nurse that he (the sponsor) thought it was about time that for RI #1 to be sent out to the hospital. After receiving the call, RI #1's sponsor stated that he went to the facility to check on RI #1. Upon arrival at the facility, RI #1's sponsor found his wife (RI #1) nonresponsive; he went to the desk and got the nurse. RI #1's sponsor recalled that the male nurse performed a fingerstick blood sugar on RI #1, which measured 24. The sponsor said that the nurse gave RI # 1 some kind of shot because of the nurse was afraid that RI #1 might choke, if given something to swallow. The nurse waited a few minutes and did another fingerstick blood sugar, which measured around 48 or 49. Then, the nurse asked the sponsor to try to get RI #1 to drink some juice. The sponsor reported that RI #1 did drink some juice, and another fingerstick blood sugar was done. According to RI #1's sponsor, RI #1's blood sugar level had come up some more. RI #1's sponsor said that he asked the nurse to send RI #1 out to the hospital, and if they (the facility staff) were not willing to send RI #1 out that he would call the cops and see if they (the police / cops) could help get his wife (RI #1) sent out. According to RI #1's "Diabetic Monitoring Flow Sheet", EI #3 documented that on [DATE] at 11:00 AM, RI #1 had a blood sugar level of 24, and [MEDICATION NAME] IM (Intramuscular) was given. An untimed "Resident Progress Notes" for RI #1, documented: "[DATE] Resident out to Providence Hospital per Sponsor request r/t refusing food. This progress note is signed by EI #3. A "Physician's Telephone Orders" for RI #1, dated [DATE] at 1500 (3:00 PM), documented: "Transfer to Providence Hospital..." RI #1's hospital records titled, "Emergency Department Nursing Assessment", document that RI #1 arrived in the emergency department by EMS (Emergency Medical Services) at 4:45 PM, with a blood sugar level of 54. This emergency department record documented a chief complaint of low blood glucose (sugar) related to not eating. RI #1's emergency department record documented that RI #1 received 50% [MEDICATION NAME] and Water (D50W) one [MEDICATION NAME] at 5:00 PM and at 6:50 PM. RI #1's blood glucose level is recorded as 43 at 6:00 PM and 64 at 6:45 PM. A physician's "Consultation" report dated, [DATE], documents the reason for consultation as, "Assist with respiratory and ICU (intensive care unit) management." This consultation report included the diagnosis (impression) of: "1. [DIAGNOSES REDACTED] -- on oral hypoglycemic agents in the setting of chronic [MEDICAL CONDITION]. 2. Acute on chronic kidney failure. 3. Acute on chronic [MEDICAL CONDITION]. 4. [MEDICAL CONDITION]. ..." Additionally, this consultation report the treatment plan as: "1. Noninvasive ventilation for now. 2. Stop the oral hypoglycemic medications. 3. Change the antibiotics to cover for healthcare associated pneumonia and aspiration pneumonia. ..." A hospital Progress Note for RI #1, dated [DATE] at (approximately) 1:30 PM, documented, "...Some confusion / agitation ...[DIAGNOSES REDACTED] resolved - using SSI (Sliding Scale Insulin) [MEDICATION NAME] washing out..." RI #1's hospital "physician's orders [REDACTED].#1 died (expired). This physician's orders [REDACTED].@ 1621..." On [DATE] at 10:00 AM, an interview was conducted with EI #3, the Registered Nurse (RN) who provided care to RI #1 on [DATE]. EI #3 was asked at what blood sugar value should the resident's physician be notified. EI 33 responded that usually information regarding when to notify the physician would be listed on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. EI #3 explained that if it is not there; then, staff have to refer to the standing orders. According to EI #3, the standing orders instruct the nurse to contact the physician if the blood sugar values are less than 70. EI #3 stated that the the prior shift's nurse (EI #7) should have contacted RI #1's physician, in accordance with the standing orders. EI 33 was asked what he would have done differently if the nurse on the previous shift would have contacted RI #1's physician regarding the resident's low blood sugar value. EI #3 responded that if the physician had been contacted about RI #1's low blood sugar, an order to hold RI #1's oral diabetic medication may have been given. Then, EI #3 further explained that RI #1 would not have been given the morning dose of oral diabetic medication ([MEDICATION NAME]). EI #3 was asked what were some possible outcomes that could have occurred if RI #1's oral diabetic medications had been held (not given). EI #3 responded that RI #1's blood sugars may not have decreased to such an extent (decreased from 66 at 6 AM to 24 at 11 AM). EI #3 was asked if he thought that it would have been important for the nurse to have notified the physician. EI #3 responded that it was very important because getting the physician involved may have changed the outcome of the situation. EI #3 was asked if he felt the failure to notify RI #1's physician may have compromised RI #1's health. EI #3 responded that it could have. On [DATE] at 3:26 PM, an interview was conducted with EI #8, (a RN Unit Manager). EI #8 was asked to review RI #1's chart. EI #8 said that it was important for the physician to be notified if a diabetic resident was not eating especially if the resident was receiving oral agents or insulin. EI #8 explained that if the medication was continued and the resident was not eating; then, the resident could bottom out, go into a coma, have a stroke, go into [MEDICAL CONDITION], and also could die. EI #8 said that RI #1's physician was not contacted and notified of the resident's situation. EI #8 stated that it would have been important for the physician to have been contacted because the resident could have become medically compromised. On [DATE] at 4:27 PM, an interview was conducted with EI #9 (a RN / Director of Nursing). EI #9 was asked if a resident's oral diabetic medication should have been given if the resident was known not to be eating, and had a low blood sugar value. EI #9 answered that with a resident not eating and having a blood sugar value of 66, she (EI #9) would have tried to feed the resident again. EI #9 said that she would have waited on the resident's morning diabetic oral medication. EI #9 explained that if unsuccessful in feeding the resident, she (EI #9) would have gone ahead and called the physician. The surveyor asked EI #9 if the nurse on the morning of [DATE], should have contacted the physician when she determined that RI #1's blood sugar value was 66. EI #9 answered that the nurse on the morning of [DATE], who saw that RI #1's blood sugar value was 66, should have called the resident's physician as per instructions outlined on the standing orders. According to EI #9, RI #1's physician should have been called earlier, and provided an update on the resident's status. EI #9 was asked based on the information in RI #1's chart and on the diabetic monitoring flow sheet what did both the nurses involved in the incident on [DATE], fail to do. EI #9 answered based on the documentation in RI #1's chart and the information on the "Diabetic Monitoring Flow Sheet," both the nurses providing care to RI #1 on the morning of [DATE], failed to notify the resident's physician in a timely manner, resulting in a change in the resident's medical condition. On [DATE] at 3:10 PM, a telephone interview was conducted with EI #12 (an associate of RI #1's physician). EI #12 stated that theoretically if a resident was not eating and had a blood glucose level of 66, that the doctor probably should have been notified prior to the administration of oral diabetic medications and that possibly the doctor would have given an order to hold the medication. EI #12 stated that without being able to review the record, she could not say for sure, what the nurse should have done. ____________________ On [DATE] at 4:02 PM, the facility's Executive Director provided the survey team with the following acceptable Allegation of Credible Compliance: Revised and submitted [DATE] Credible Allegation of Compliance as of [DATE] F309, Each Resident must receive Necessary Care and Services 1. RI #1 was discharged from the facility on [DATE]. 2. Residents with blood glucose levels below 60 or significant changes in eating habits with less than 50% meal consumption which is not resolved within 48 hours are at risk. The director of nurses and nursing managers audited all residents with physician orders [REDACTED]. (See Attached) 3. The director of nurses began inservices with licensed nurses [DATE] regarding notification of change with emphasis on blood glucose monitoring related to [DIAGNOSES REDACTED]. (See Attachments) These inservices are ongoing at the present. The director of nurses and nursing managers audited all residents with physician orders [REDACTED]. (See Attached) Credible Allegation of Compliance page 3 Policy, PRO was reviewed and revised to read that the physician would be contacted if the blood glucose level was below 60 ml. This change in policy was approved by ___, medical director. The director of nurses has began inservices with licensed nurses as of [DATE] regarding reporting residents who have significant changes in eating habits which are unresolved in 48 hours to ensure physician notification. Nursing assistant staff will be inserviced by the director of nurses or designee on charting and reporting of percentages to denote residents with meal consumption less than 50%. (See Attachments) Copies of all inservices with handouts will be maintained in the director of nurses office for future review. Staff scheduled to work today and forward will not be allowed to report to their assigned areas until they have received inservices related to F309. Signs are posted at the time clock and near the elevator to notify staff of mandatory inservices prior to working with residents. 4. The director of nurses or designee/s will review the diabetic monitoring flow logs in the morning clinical meeting, Monday - Friday, for 8 weeks and then every other week for 4 weeks, to ensure blood glucose checks below 60 are managed according to policy and procedure. Concerns with results of these audits will result in immediate re-education. The director of nurses and/or designee/s began audits on [DATE] using the blood glucose monitoring log. (See Attached) A licensed nurse will be assigned by the director of nurses to audit 10% of Resident Care Flow records daily, Monday - Friday, to monitor food intake and percentage of meals consumed to denote any resident eating less than 50 % which is not resolved in 48 hours. These audits will be reviewed in the morning clinical meeting to ensure changes in eating habits are being addressed with appropriate interventions. The executive director will review audits weekly. Results of audits will be forwarded to the performance improvement committee. Respectfully submitted, Executive Director _____________________ On [DATE] at 4:32 PM, after verifying in-service records and interviewing nursing staff, the survey team concluded the facility implemented corrective measures as described in their Allegation of Credible Compliance provided to the survey team on [DATE] at 4:02 PM, to prevent any future reoccurrence. The Immediate Jeopardy was relieved on [DATE] at 4:32 PM, and the scope and severity was lowered to a "D" level, to allow the facility time to monitor and revise their corrective actions as needed to establish substantial compliance with F 309.

Based on interview and record review, Employee Identifier (EI) number (#) 10, the Director of Therapy, failed to initiate measures to prevent any reoccurrence of abuse between Resident Identifiers (RI) #2 and 3, two residents sharing a semi-private room, after RI #3 reported being kicked by his roommate, RI #2, an alert and oriented resident. On the evening of 08/11/10, EI #10 entered the semi-private room shared by RI #2 and 3, and saw RI #3 lying "askew" (twisted to one side) on his bed. When EI #10 asked RI #3 the reason he was positioned "askew" in bed, RI #3 pointed at RI #2's bed and replied, "He hit me." While pointing at RI #2's bed, RI #3 further verbalized, "That SOB (Son of a [***] ) kicked me in my face. I don't like the GD (Got Damn) SOB." RI #3 stopped talking when RI #2 came out of the bathroom and got into bed. Prior to EI #10 leaving the room, RI #3 asked that the curtain between the beds be drawn. Next, EI #10 said good-bye to both residents and exited the room, leaving the two men alone, unsupervised. Then, EI #10 said that she went to the nursing station and reported the accusation to the unit manager. RI #2 admitted to kicking RI #3. RI #2 reported to facility staff that he had been jumped on by RI #3. After becoming aware of a physical altercation between RI #2 and 3, EI #10 left RI #2 and 3 alone in their room, unsupervised to go report the allegation of physical abuse to the unit manager. This deficient practice of leaving RI #2 and RI #3 alone, unsupervised in their room increased the risk of further abuse between the two residents, and posed an immediate threat to their health and safety on 08/11/10. This deficient practice affected RI#2 and RI #3, two of seven sampled residents. Additionally, EI #10's failure to initiate measures to prevent further resident-on-resident abuse once she (EI #10) became aware of an allegation of abuse had the potential to affect all 141 residents residing in the nursing home facility at the time of the survey. On 08/30/2010 at 5:55 PM, the facility's Executive Director, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were made aware that the survey team had identified deficient practice at an Immediate Jeopardy (IJ) level in the area of abuse (F 223). The IJ began on 08/11/10, and was relieved on 08/31/10, when the facility implemented immediate corrective actions to remove the immediacy. Findings Include: During an abbreviated survey, the survey team reviewed the facility's investigation reports of all abuse allegations reported to the State Agency within the past year. During this review, the survey team discovered a "Final Investigation Report" of resident-on-resident abuse involving RI #2 and RI #3, which occurred on 08/11/10. This "Final Investigation Report" dated 08/18/10, was signed by EI #15, the facility's Director of Nursing (DON). According to this investigation report, RI #3 entered the facility on 07/16/10, with [DIAGNOSES REDACTED]. This report further describes RI #3 as having episodes of disorganized speech. RI #3 is identified as having moderately impaired cognitive skills for daily decision making, with short and long term memory problems. This report describes RI #2 as being independent in cognitive skills for daily decision making, with no short/long term memory problems. RI #2 is identified as being admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. This final investigation report contained the following summary of events: "...On August 11, 2010 at approximately 6:00 PM, it was reported to nursing staff that there was an altercation between residents, (Name of RI #2 and Name of RI #3). The residents were separated immediately and investigation began. Nurse assessed both residents. (Name of RI #3) had a small red mark and red area to left side of face. (Name of RI #2) had red areas noted to left forearm and left side of forehead. ..." Further review of the facility's final investigation report dated 08/18/10, revealed documents entitled, "Kindred Healthcare Center Witness Statement for Any Events." The Therapy Department Director ' s (EI #10's) signed witness statement dated 08/12/10 at 10:00 AM, documents: "On 8-11-10 I entered (numerical room location of RI #2 and 3). (Name of RI #2) was in the bathroom (door partially open) and (Name of RI#3) was lying askew on his bed. I asked (Name of RI #3) why he was in his bed in that manner. He replied, "He hit me. ...no one else was in the room I asked for clarification. (Name of RI #3) responded verbally while pointing to (Name of RI #2 's) bed "that SOB kicked me in my face. I do not like that GD SOB." (Name of RI #2) came out of the bathroom and got in his bed. (Name of RI #3) did not say any more about (Name of RI #2). The two men ate their meals. (Name of RI #3) was on the side of his bed while (Name of RI#2) was lying on his bed. (Name of RI#3) requested the curtain be drawn prior to me leaving the room. I said good-bye to both gentlemen and exited the room. I informed the unit manager of the accusation. ..." A Kindred Healthcare Center Witness Statement completed by EI # 9, the RN Unit Manager, on 08/11/10 at 1800 hours (6:00 PM), documents the following: "(Name of EI #10), the Rehab Manager came to the nursing station reporting that (Name of RI #3) told her that his roommate kicked him in the face I went down to (numerical location of RI #2 and 3) separated the 2 men and took (name of RI #2) out of the room to interview him. Investigation began... . Resident was resting in his bed, aggitated (agitated) and excited about the event. Stating that he did not do it - ain't done nothing to him. He's mean. " An interview was conducted with RI #2 on 08/28/2010 at 10:00 AM. Because RI #2 is non-verbal (aphasic), the survey conducted the interview by writing out the questions and allowing RI #2 to write written responses to each question. RI #2 was asked to please tell the surveyor what happened. RI #2 wrote, "I knew it would come to that cause he would always jump up to them curse them out an (and) call names he hit an (and) kick me in head and chest jumped me pretty good I was scared for my life could not yell for help had to try and get him off me so I kick him and he fell back that is when that lady from therapy came in." The surveyor questioned RI #2 about if there had been previous instances in which he feared being hurt by RI #3, felt unsafe and if he (RI #2) told staff. RI #2 wrote, "Told them he (RI #3) was worse on ever put in room with me Told me we (staff) know Asked to be moved They said no Talked with (first name of former Social Worker, EI #14)" When asked if he communicated feeling unsafe, RI #2 wrote, "yes." The surveyor asked RI #2 when he communicated not feeling safe; and, RI #2 wrote, "don't remember date." RI #2 was asked what happened to stop the fight; he wrote, "kick him (RI #3) back Therapy lady (EI #10) walk in." When asked what started the fight, RI #2 wrote, "He (RI #3) is crazy Nurse made him (RI #3) mad earlier He (RI #3) was still mad." When asked if he (RI #2) saw a staff member come into the room, RI #2 wrote, "Yes Lady next door an (and) lady who come see him (RI #3) for therapy." The surveyor asked if he tried to get the staff member's (therapy lady ' s) attention to tell what happened. RI #2 wrote, "No he (RI #3) told her (therapy lady) I (RI #2) hit him (RI #3) I (RI #2) tried to get her (therapy lady) attention so she would not leave me (RI #2) with him (RI #3) Waved at her (therapy lady) She (therapy lady) ignored me (RI #2). "RI #2 affirmed in writing that the staff member (EI #10) left him (RI #2) in the room with RI #3. When asked how this made him feel, RI #2 wrote, "My life was in danger; felt trapped." RI #2 was asked how long it was before someone else comes back into the room. He responded in writing, "Don't remember but staff in charge called me out Felt like forever." RI#2 was asked if RI #3 said or did anything to him (RI #2) while they (RI #2 and RI #3) were alone in the room together. RI #2 wrote the following written response: "Yes you (RI #2) nigger I (RI #3) am going to kill you (RI #2) nigger I (RI #3) am going to kill you (RI #2). RI #2 affirmed in writing that he would have felt safer if EI #10 had taken him (RI #2) out of the room with her (EI #10) when she (EI #10) became aware of him (RI #2) hitting RI #3. When asked if he had injuries, RI #2 wrote, "head -chest-leg-arm." RI #2's "Pain Assessment", with a pain onset date of 08/11/10, documents that the resident experienced an aching type of pain in his left temple and left forearm, and exhibited facial grimacing / facial distortion. The severity of RI #2's pain was rated as a four (hurts little more), on a scale of zero to ten, with zero representing no hurt and ten representing worst hurt. This pain assessment further documents that RI #2 received a pain management intervention of his scheduled pain medication, [MEDICATION NAME] 10 mg (a narcotic). An "American Mobile Imaging" report, with a service date of 08/11/2010, document that RI #2 had an x-ray of his left forearm and of his skull for wrist / forearm pain, and facial (head, neck, mouth) swelling. Both x-rays resulted in normal findings. A phone interview was conducted with RI #3 and his mother on 08/28/2010 at 12:00 PM. During the interview, RI #3's mother was asked how she first became aware of the incident between RI #3 and his roommate (RI #2). She communicated that the nurse called to notify her that her son (RI #3) was being sent out to a local hospital ' s inpatient psychiatric unit because his roommate (RI #2) said that RI #3 kicked him (RI #2). Also, RI #3's mother said the nurse reported that RI #3 had no injuries and had accused RI #2 of kicking him (RI #3). According to RI #3's mother, RI #3 told her that his roommate (RI #2) lied; and, it was his roommate (RI #2) who had kicked him (RI #3) in the face. RI #3's mother was asked if her son reported that he had been kicked to the facility staff. She responded that according to her son (RI #3), he reportedly told the lady from therapy (EI #10) that his roommate (RI #2) kicked him in the face. RI #3 said that the lady from therapy (EI #10) did not do anything. RI #3's mother recalled that this upsetting because she felt that there was the potential for RI #2 to have done more harm to her son (RI #3). RI# 3's mother was asked if she knew whether or not staff separated RI #3 and his roommate (RI #2) after RI #3 reported being kicked in the face. She responded that she knew they (staff) sent her son (RI #3) out; but, she did not know how long between when it happened and when he was sent out. She stated RI #3 told her that he reported it to the lady from therapy (EI #10); and, she (EI #10) just walked out and did not do anything. RI #3's mother stated this surprised her because she thought that the staff member would have done something to make sure RI #2 and 3 did not get back into it. During this interview on 08/28/2010 at 12:00 PM, RI #3 was asked if he remembered what happened between him and his roommate, RI #2. RI #3 affirmed that he did and responded that RI #2 kicked him in the face by his eye. He corroborated what his mother said about the incident. RI #3 said that he told the therapy lady (EI #10) that RI #2 had kicked him in the head and that his head hurt. According to RI #3, EI #10 left the room after he informed her that RI #2 had kicked him. RI #3 further explained that later a nurse came into the room, gave him a shot and sent him to the hospital. RI #3 denied doing anything. He communicated that he was very angry and hurt that his roommate (RI #2) lied and that no one would listen to him (RI #3). RI #3 was asked if he wanted to be taken out of the room by the staff member (EI #10). He responded that he did because RI #2 had kicked him once and could do it again. An "Alleged Abuse, Neglect and Exploitation Investigation Worksheet" dated 08/18/2010, identifies physical abuse as the type of allegation, list RI #3 as the "alleged victim" and RI #2 as the "alleged perpetrator." This abuse worksheet indicates that the incident allegedly occurred in the resident ' s room and documents: "Resident stated 'That nigger hit me with his foot on my head. I aint touch him. ... " On 08/27/10 at 1:45 PM, the surveyor interviewed EI #10, the Director of Therapy, about what happened on 08/11/10 between RI #3 and RI #2. She stated that she walked into the room to do therapy with RI #3. EI #10 said that RI #3 told her what happened. When she asked who, RI #3 replied that SOB and pointed to RI #2's bed. After RI #3 told her what happened, RI #2 came out of the bathroom and got in bed. She made no further observations of anything being out of order, and recalled that both residents started eating their supper. EI #10 mentioned that RI #2 communicates in writing. EI #10 recalled that she completed her therapy with RI #3, exited the room and went and notified the unit manager (EI #9). According to EI #10, RI #3 tells untruths all the time; but, she knew that she needed to report the allegations of abuse. EI #10 said that she did not believe that anything had happened, especially RI #2 kicking RI #3. EI #10 said that when she left both residents were alone in the room. RI #2 knocked on the table and waved; she waved back. RI #3 asked her to pull the curtain because he did not want to look at that SOB (referring to RI #2). EI #10 was asked to describe RI #3's facial expression and demeanor when he was telling her that RI #2 had kicked him. She described RI #3's facial expression as angry and his demeanor as being agitated. She further explained that RI #3 was cursing and seemed upset. EI #10 was asked what steps should be taken if staff observe or receive a report that resident-on-resident abuse has occurred. She stated staff should separate them immediately and report it. EI #10 was asked if she separated RI #2 and 3 immediately after receiving the abuse allegation. She responded that she had not. EI #10 explained that she positioned between the two residents the entire time while she was in the room. She had pulled the curtain between the two before leaving the room. She again stated that there was no indication that what RI #3 was saying was true. EI #10 was asked why it was important to separate residents after an allegation of resident-on-resident abuse. She responded that it is important to make sure residents are safe, and to prevent another occurrence of abuse between those residents. EI #10 further explained that if left alone together the residents could injury each other or someone could get seriously hurt. EI #10 was asked what the primary responsibility was of a staff member who witnesses or receives a report of abuse. She responded to protect the resident. During an interview on 08/27/10 at 11:00 AM, EI #9, the RN Unit Manager, was asked to describe what happened. EI #9 responded that she was at the nurse's station when EI #10 came and told her that RI #3 reported to her that RI #2 had kicked him in the face. After receiving the report from EI #10, EI #9 stated she went down to the resident's room. EI #9 said that both residents were in the room. She asked RI #2 if she could speak with him because he (RI #2) was up in the wheelchair and RI #3 was in the bed. EI #9 described RI #2 as being non-verbal and has to write down his answers. According to EI #9, RI #2 reported via his written statement that RI #3 jumped up, called RI #2 a name and "jumped up" on RI #2 as he (RI #2) was getting in his wheelchair. RI #2 reported that his left arm, left hand, left side of head and left chest hurt but he would wait to take his pain medication later that evening. EI #9 reported that she asked RI #2 if he (referring to RI #3) had stood up out of bed. She stated RI #2 responded yes. EI #9 asked RI #2 if he struck his roommate and he responded yes and that he had kicked him. RI #2 did not say where he kicked him. EI #9 was asked to describe RI #2's demeanor at the time she interviewed him. She stated he had a flat affect but took longer to answer questions. She was asked if the resident had any visual injuries. She responded that the resident had a red area on his left temple, an abrasion on his left forearm, and that he complained about an injury to his left chest. According to EI #9, RI #2 did not have any behavioral issues. During this same interview, EI #9 was asked about the condition of RI #3. She recalled checking on RI #3 before exiting the room with RI #2. EI #9 further explained that RI #3 was lying in bed, very agitated. RI #3 did not have any visible injuries and when she spoke to him he kept repeating he did not do anything. She reported that RI #3 was sent out of the facility. EI #9 was asked if either resident had any behavioral issues. She responded that RI #3 did and that in fact that morning he had demonstrated some aggressive behavior toward staff. According to EI #9, RI #3 came up to the nurse's station yelling and cursing complaining that his private parts were hurting. Staff attempted adjusting his adult brief and catheter. He settled down for a short time. He then came back behind the nurse's station drew back his arm, made a fist with a angry look on his face and continued yelling and cursing. EI #9 stated the resident was very agitated and that he required intense redirection. She stated these behaviors went on from around 8:00 to 8:45ish. She monitored him and checked on him while he was down in therapy. No additional behaviors were observed EI #9 was asked if RI #3 had a history of [REDACTED]. She responded that she had been told by other staff that he had a history of [REDACTED]. During the same interview on 08/27/10 at 11:00 AM, EI #9 asked if RI #2 and 3 were immediately separated. EI #9 answered that no staff member was present when she went into the room and recalled that both residents were in the room. EI #9 was asked if she observed any interventions in place to protect against the potential for further abuse. She responded that she did not observe any interventions in place and that the residents were not separated. EI #9 was asked why it is important to separate residents. She stated it is important to protect the resident and to stop the abuse. EI #9 was asked what potential negative outcomes could occur if residents were left alone together after an incident of resident-on-resident abuse. She responded that some potential negative outcomes are physical or mental injury to both residents and possible destruction of property. In an interview on 08/27/2010 at 2:40 PM, EI # 25, a Certified Nursing Assistant (CNA), was asked if she had ever provided care to RI #3 or RI #2. EI #25 recalled that on the evening of the altercation the meal trays were late, arriving around 5:40 PM or 5:50 PM. EI #25 said that she went in and saw EI #10 and RI #3 talking. She delivered both trays. She noticed that RI #3 looked angry and that he had a scowl on his face. She thought RI #3 and EI #10 were doing therapy. She left the room. A little later EI #10 came out, went up to the desk and talked with EI #9 for a little. According to EI #25, EI # 9 said that RI #3 was getting started again. EI #9 made a phone call and then went down to RI#3's room. EI #25 was asked what EI #10 should have done after RI #3 told her that RI #2 was violent towards him. EI #25 responded EI #10 should have moved the one who could come out. If she could not get one of them out safely then she should not leave the residents in the room together because you do not know what could happen. EI #25 commented that anything could happen. EI #25 was asked ultimately what the staff member failed to do. She responded that the staff member failed to protect the resident. She added that neither RI#3 nor RI#2 were safe because they were both mentally ill and capable of doing God knows what. She further explained that both residents are pretty strong and could have seriously hurt one another. In an interview on 08/27/10 at 9:45 AM, EI #11, RN Unit Manager, was asked to describe in her own words what happened between RI #3 and RI #2 on August 11, 2010. She responded that she was asked to come down and assist with getting statements. EI #11 reported that when she saw RI #2 in the hallway she saw scratches on RI #2's arm and face. She stated she went and interviewed RI #3, who according to her has a history of aggressive behavior. RI #3 did not have any visible injuries. RI #3 reported to her that RI #2 had kicked him in the head. RI #3 was given a shot and was sent out for a psychiatric evaluation. EI #11 was asked what she had been trained to do when she encounters a situation of residents being aggressive toward each other. She responded that the residents must be separated immediately and should not be left alone together for even for a minute. She was then asked why it is important not to leave them alone together. She responded it is important to protect them to make sure no more abuse occurs. In EI #11 ' s opinion, it was especially important in this case because she could clearly see that something had happened; neither one of them wanted to be alone with the other. EI #11 was asked to review the Kindred Healthcare Center Witness Statement completed by EI #9 and EI #10 on 8/11-12/10 to determine if the documentation in the statement indicated that the situation was handled in accordance with the standard abuse protocol. EI #11 responded that it was not because the residents were left alone together; and, there was a gap in time when the residents could have continued to fight and or abuse one another. EI #11 was asked what potentially negative outcomes could occur if residents are left alone together after a resident-on-resident altercation occurs. She responded the residents can hurt one another; residents are suppose to be protected and made safe. On 08/28/10 at 5:02 PM an interview was conducted with EI #14, the facility's former social worker. She was asked to please tell the surveyor about what she knew about the incident between RI #3 and RI #2. According to EI #14, she was told that RI #3 reported to EI #10 that he had been kicked in the head by his roommate (RI #2). She stated this surprised her because RI #3 is always being aggressive. She stated RI #3 usually is the one cursing, making fist and telling people he is strong and knows how to fight. EI #14 said that RI #2 does not have a history of physical aggression; he (RI #2) usually just likes to seclude himself away in his room. She stated that when she returned to work on 08/12/2010 , she read the nurse's notes in both resident's charts and found out that RI #2 had been hit and kicked by RI #3 and that he then kicked RI #3 to protect himself. She stated that when she met with RI #2, he was still expressing fearfulness in his demeanor and in the notes he wrote her on his tablet. He wrote at the time of the incident that he was afraid that RI #3 was going to kill him and that he got so afraid he froze up and could not think straight. RI #2 indicated that he wanted to leave the room but did not want to turn his back to RI #3. He wrote that he knew he could not move that fast, and by the time he got up the courage to make it to the door, the unit manager (EI #9) came in to rescue him. EI #14 stated that she never got a change to talk to RI #3, because he had been sent out the night before. She recalled being told that RI #3 was so upset and denying doing anything. EI #14 remembered EI #9 reported that RI #3 had to be given a shot of [MEDICATION NAME] to calm him down before being sent out to a local hospital for extreme agitation and aggression. EI #14 was asked what some potential negative outcomes that could occur if residents are left alone together after a resident-on-resident altercation. She responded the residents could hurt each other, possibly do some more serious physical harm to each other, and could even accidently kill the other resident. EI #14 added that practically any negative outcome imaginable could occur. During an interview on 08/30/10 at 11:00 AM, EI #19, facility Assistant Director of Nursing, was asked based on what she knew of the incident that occurred on 08/11/2010 with RI #3 and RI#2 were the residents left alone together at any point in time after a facility staff member was made aware of an allegation of resident-on-resident abuse by RI #3. She affirmed that from reading EI #10's witness statements that RI #2 and RI #3 were left alone in the room together while EI #10 reported the incident. EI #19 was asked if either of the residents had aggressive behavior she responded that RI# 3 had episodes of past aggression with staff and that RI #3 could get agitated easily. EI #19 was asked what some negative outcomes that could occur if residents are left alone together after a report of resident-on-resident abuse is received. She responded the residents could become more aggressive towards one another and start back to fighting or hurting one another. In an interview on 08/30/10 at 10:20 AM, EI #15, facility Director of Nursing, was asked based on what she knew of the incident that occurred on 08/11/2010 with RI #3 and RI #2 were the residents left alone together at any point in time after a facility staff member was made aware of an allegation of resident-on-resident abuse by RI #3. She responded that the residents were left alone together. EI #15 was asked what some negative outcomes that can occur if residents are left alone together after a report of resident-on-resident abuse is received. She responded the residents could have had another altercation and more serious injuries could have occurred. In an interview on 08/31/10 at 10:05 AM, EI #18, the facility Executive Director, was asked based on what she knew of the incident that occurred on 08/11/2010 with RI #3 and RI#2 were the residents left alone together at any point in time after a facility staff member was made aware of an allegation of resident on resident abuse by RI #3. She responded that EI #10 did not separate the residents and that they were left in the room alone together. EI #18 was asked what some negative outcomes that can occur if residents are left alone together after a report of resident on resident abuse is received. She responded they could continue to fight and they could hurt themselves or the other resident. On 09/02/2010, the surveyor was presented a letter on facility letterhead signed by EI #18 (Executive Director) and dated 09/02/2010. The letter reads as follows: "To Who It May Concern: (Name of EI #10), Rehab Manager, was suspended pending investigation, September 2, 2010, at approximately 1030." Attached to this letter was a document entitled, "Performance Improvement Form", with a revised date of 9/2007. This Kindred Healthcare Performance Improvement Form corroborates that EI #10 received a written warning and suspension on 09/02/10, and re-education on abuse with focus placed on protection of residents 08/31/10. This deficiency is written as a result of the investigation of complaint / report #AL 098. ********************************************** Allegation of Compliance (AOC) - F 223 On 8/11/2010 When the RN Unit manager was notified of altercation she separated RI # 2 and RI #3, the residents were kept separated until RI #3 was discharged to the hospital per physician orders. RI # 3 was readmitted on [DATE] to room [ROOM NUMBER] A, RI #2 resided in 310A at this time. On 8/20/2010 RI #3 was discharged home with family. Abuse training that focused on separation of residents that involved resident to resident altercation was initiated at 10:00am and 2pm on 8/30/10 by the staff development coordinator and assistant director of nursing. The training occurred again at 10:00pm on 8/30/2010, and again on 8/31/2010 at 6am. The staff that received the initial training were the staff currently on duty: Therapy Manager, social service director, maintenance director, dietary director, licensed nursing, nursing aides, housekeeping, dietary, activities, administrator, director of nursing were given education and training, on abuse policy and procedure - see attached document A. As mentioned above, therapy manager, was trained at 8 PM on separation of residents involved in resident to resident altercation. Signs were posted to on-coming staff that mandatory training was required before they could report to duty. Phone calls were placed to staff to notify that training was required before working with residents. Calls were placed by the staff development coordinator, the staffing coordinator and the assistant director of nurses. This training was conducted by the staff development coordinator and assistant director of nursing. A roster of attendees was initiated by the staff development coordinator and updated as staff attended. Roster is attached - see attached document B. Medical Director was notified of the immediate jeopardy citation and he met with administrator and director of nursing and approved above mentioned training on 8/31/10. On 8/31/2010 the facility implemented monitoring and education to alleviate the immediate jeopardy to its residents. Mandatory in-service training on abuse was implemented immediately for all staff, Therapy Manager, social service director, maintenance director, dietary director, licensed nursing, nursing aides, housekeeping, dietary, activities, administrator, director of nursing. Rehab manager effecting RI # 2 & 3 was trained on abuse policy and procedure on 8/30/2010. On 9/2/2010 the Rehab Manager has been suspended pending further investigation. In-services initiated at 8PM 8/30/2010, further in-services scheduled for 10:30 and 6 AM. Mandatory in-services were/will be provided 8 hours for the next 72 hours (8/30/2010- 9/2/2010) by Staff Development Coordinator and the assistant director of nursing.. Signature roster will be kept in staff development coordinator's office along with abuse quiz. Training will consist of identifying types of abuse, ie, physical, sexual, verbal, mental, emotional and misappropriation of funds, separation and protection of residents. Abuse training will be mandatory for orientation of new staff. Residents were given information on abuse during the resident council meeting on 8/31/2010. Volunteers, family members, visitors will be given a document see attachment C- which defines abuse and what to report and to whom- the volunteers and visitors will sign roster upon receipt of types of abuse and who to report it to which is the administrator, director of nursing, or assistant director of nursing. Mailing of information and hand outs of information began 9/1/2010. Rosters of residents and sponsors who were sent documentation on abuse will be kept in the business office. Business office manager will maintain roster. All documents will be reviewed by director of nursing or administrator, assistant director of nursing monthly. The updated roster will be included in the minutes of the monthly performance improvement committee which is maintained in the administrator's office. Letters will be given to residents upon admission that explains types of abuse and to whom to report it to. Resident council meeting on abuse were held 8/31/10 at 1030 AM. Minutes of resident council will be kept in activities. Reflections manager or designee will review resident council minutes monthly and report to administrator. Mandatory abuse training will be held by Staff Development coordinator monthly times three months then quarterly. All staff in building will be required to have abuse training no less than quarterly. Administrator or director of nursing will ensure that appropriate investigation and follow up is complete. The monitoring of the investigations will be verified by signing of roster by director of nursing. A pre-test and post-test will be administered- see document D. Passing score of 100% is required- if 100% is not achieved, then reeducating and retaking of quiz will be required. Staff who do not att

Based on interview and record review, Employee Identifier (EI) number (#) 10, the Director of Therapy, did not initiate the protection component of facility's abuse policy and procedure by not moving Resident Identifier (RI) #3 to safety after RI #3 told her RI #2 kicked him. RI #2 admitted to kicking RI #3. RI #2 reported to facility staff that he had been jumped on by RI #3. After becoming aware of an allegation of physical abuse between RI #2 and 3, EI #10 left both residents alone in their room while she went to the nurse's station to report it to the Registered Nurse (RN) Unit Manager, EI #9. EI #10's failure to implement the protection component of facility's abuse policy and procedure increased the likelihood that further abuse could occur between the two residents, and posed an immediate threat to their health and safety on 08/11/10. This deficient practice affected RI #3 and RI #2, two of seven sampled residents, and had the potential to affect all 141 residents in the nursing home facility at the time of the survey. On 08/30/2010 at 5:55 PM, the facility's Executive Director, the Director of Nursing (DON), and Assistant Director of Nursing (ADON) were made aware that the survey team had identified deficient practice at an Immediate Jeopardy (IJ) level in the area of abuse (F 226). The IJ began on 08/11/10, and was relieved on 08/31/10, when the facility implemented immediate corrective actions to rmove the immediacy. Findings Include: During an abbreviated survey, the survey team reviewed the facility's investigation reports of all abuse allegations reported to the State Agency within the past year. During this review, the survey team discovered a "Final Investigation Report" of resident-on-resident abuse involving RI #2 and RI #3, which occurred on 08/11/10. This "Final Investigation Report" dated 08/18/10, was signed by EI #15, the facility's Director of Nursing (DON). According to this investigation report, RI #3 entered the facility on 07/16/10, with [DIAGNOSES REDACTED]. This report further describes RI #3 as having episodes of disorganized speech. RI #3 is identified as having moderately impaired cognitive skills for daily decision making, with short and long term memory problems. This report describes RI #2 as being independent in cognitive skills for daily decision making, with no short/long term memory problems. RI #2 is identified as being admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. This final investigation report contained the following summary of events: "...On August 11, 2010 at approximately 6:00 PM, it was reported to nursing staff that there was an altercation between residents, (Name of RI #2 and Name of RI #3). The residents were separated immediately and investigation began. Nurse assessed both residents. (Name of RI #3) had a small red mark and red area to left side of face. (Name of RI #2) had red areas noted to left forearm and left side of forehead. ..." Review of the facility document titled " Protection of Resident During an Investigation " (undated) revealed ... " Reasonable measures are taken to protect a resident during an investigation of abuse ...3. Residents involved in resident -to resident altercations will be immediately separated until a resolution can be determined. This separation may involve a temporary transfer to another room. " Review of the facility document titled " Responding to and Investigating an Abuse Allegation (undated) ...Alleged Physical Abuse 1. Diffuse the situation, and remove the aggressor from all resident contact. The undated facility document titled " Abuse Prevention revealed " ...8. Identify concerns/problems and take corrective action to assist in preventing re-occurrences, actions may include:... d. Separating residents who become agitated when they are in close proximity of each other. The surveyor reviewed the facility copy of all abuse allegations reported to the state over the past year. During the review of the facility ' s report regarding resident on resident abuse involving RI # 2 and RI #3 the following statement was noted on the document title " Final Investigative Report dated 08/18/2010 " ... "On August 11, 2010 at approximately 6:00 PM, it was reported to nursing staff that there was an altercation between residents, (Name of RI #2 and Name of RI #3). The residents were separated immediately and investigation began. Nurse assessed both residents (Name of RI #3) had a small red mark and red area to left side of face. (Name of RI #2) had red areas noted to left forearm and left side of forehead " This document was signed by Employee Identifier number (EI #) 15, the facility's Director of Nursing (DON). Further review of the facility's report revealed a document titled " Kindred Healthcare Center Witness Statement for Any Events" with a date of 8/12/2010 was noted. Review of the statement that had been completed by EI #10, the Director of the Therapy Department revealed "On 8-11-10 I entered room [ROOM NUMBER]. (Name of RI #2) was in the bathroom (door partially open) and (Name of RI #3) was lying askew on his bed. I asked (Name of RI #3) why he was in his bed in that manner. He replied " he hit me ...no one else was in the room I asked for clarification (Name of RI #3) responded verbally while pointing to (Name of RI #2's) bed " that S.O.B. kicked me in my face. I do not like that G.D. S.O.B. " (Name of RI #2) came out of the bathroom and got in his bed. (Name of RI #3) did not say any more about (Name of RI #2). The two men ate their meals. (Name of RI #3) was on the side of his bed while (Name of RI#2) was lying on his bed. (Name of RI #3) requested the curtain be drawn prior to me leaving the room. I said good-bye to both gentlemen and exited the room. I informed the unit manager of the accusation ... " Another document titled " Kindred Healthcare Center Witness Statement for Any Events" with a date of 8/11/2010 at 1800 that was completed by EI # 9, the third floor RN Supervisor, revealed the following "(Name of EI #10) ...came to the nursing station reporting that (Name of RI #3) told her that his roommate kicked him in the face I went down to room ...separated the 2 men and took RI #2 out ... " During an interview on 08/27/2010 at 1:45, EI #10 she was asked did she separate the residents immediately. EI #10 responded that she did not because there was no indication that what RI #3 said was true. The surveyor asked EI #10 if during the training she received regarding abuse if they taught her to only separate if you believe it is true or if you should separate any time an allegation is made. EI #10 responded that she was trained to only separate if abuse is witnessed, and to report it if an allegation of abuse is received. When asked who provided this training EI #10 stated EI #14, the former facility social worker. EI #10 was asked did she follow the facility's abuse policy and procedure. She responded by stating that she had not because she failed to separate the residents immediately. During an interview on 08/28/2010 at 5:02 PM EI #14, the former facility social worker, was asked if during any of her training sessions did she ever tell any facility staff members that if they observed resident on resident abuse they have to remove one of the residents but if they only receive a report of resident on resident abuse from a resident all they have to do is make a report regarding what they have been told. EI #14 responded by saying that she would not have ever said anything like that and that it did not even make sense. She stated she always trained staff to immediately protect the residents involved to prevent any further abuse once they receive a report of any kind of abuse; otherwise, more abuse or injury could occur. That is the facility's policy. In an interview on 08/27/2010 at 11:00 AM, EI #9, RN Unit Manager, was asked to review her and EI #10's Kindred Healthcare Center Witness Statements, 8/11/2010 and 8/12/10, to determine if the documented information in the witness statements indicated that the facility's abuse policies and procedures were followed. EI #9 responded that based on information documented, EI #10 did not separate the residents and that the facility abuse policy says one must protect the resident and that the residents have to separated. EI #9 further commented that EI #10 obviously did not do this based on what she wrote. In a follow-up interview on 09/02/10 at 10:10 AM, EI # 9 (RN Unit Manager) was asked what EI #10 ultimately failed to do when she did not separate RI #2 and RI #3 after she received the abuse allegation from RI #3. EI #9 responded that EI #10 failed to provide for the safety of the resident and failed to follow our abuse policy. During an interview on 08/27/10 at 9:45 AM, EI # 11, Unit Manager, was asked to review the Kindred Healthcare Center Witness Statements of EI #9 and EI #10, dated 8/11/10 and 8/12/10, to determine if the information documented in the statements indicated that the staff handled the situation in accordance with the facility's abuse policy and procedure. EI #11 responded that it was not because the residents were left alone together and because there was a gap in time when the residents could have continued to fight and or abuse one another. EI #11 stated it was especially important to separate the residents in this situation because they were both still mad when she (EI #11) got to the scene at around 7:30 PM. On 08/31/10 at 12:15 PM, an interview was conducted with EI #26, a Certified Nursing Assistant (CNA). EI #26 was asked ultimately what an employee is failing to do if they do not separate resident's after a report of resident-on-resident abuse is made. EI # 26 responded that if the residents are not separated, staff are not doing their job to protect the resident. She added that staff are not doing what they were taught to do and are not following the facility's policy and procedure. On 09/03/10 at 9:02 AM, an interview was conducted with EI # 27, a facility Occupational Therapist. She was asked ultimately what the staff member was failing to do when a staff member does not separate once an allegation of abuse is made. She responded that they are failing to follow our policy and to protect the resident. On 09/03/2010 at 11:18 AM, an interview was conducted with EI #28, a facility Occupational Therapist. She was asked ultimately what the staff member was failing to do when the staff member fails to separate once an allegation of abuse is made. She responded that they are failing to protect and serve the patient. She also said that they were failing to follow the facility's abuse policy and procedure. On 08/30/2010 at 11:10 AM an interview was conducted with EI # 19, the facility's Assistant Director of Nursing. EI #19 was asked what the facility staff member (EI #10), who received the report from RI #3, fail to do. EI #19 responded she (EI #10) failed to separate the residents upon receipt of the report and failed to activate the abuse policy correctly. EI #19 was asked if she felt the staff member (EI #10) needed some additional training. EI #19 responded obviously EI #10 needs some additional training because she (EI #10) could have caused a resident to get hurt. On 08/30/10 at 10:20 AM an interview was conducted with EI #15, the facility's Director of Nursing. EI #15 was asked what the facility staff member (EI #10), who received the report from RI #3, fail to do. EI #15 responded EI #10 failed to immediately separate the residents and did not correctly activate the facility abuse protocol. She explained that EI #10 failed to ensure the safety of both of the residents. EI #15 was asked if she felt the staff member needed some additional training. EI #15 responded that she was not sure of how much training EI #10 needed; but, EI #10 did need some additional training. In an interview on 08/31/2010 at 10:05 AM, EI #18, the facility Executive Director, was asked what EI #10, the facility staff member who received the report from RI #3, fail to do. EI #18 responded that the employee failed to separate and failed to follow the abuse protocol correctly. EI #18 was asked if she felt the staff member needed some additional training. EI #18 responded anytime any kind of incident occurs they have to retrain especially when a failure of this magnitude occurs. On 09/02/2010, the surveyor was presented a letter on facility letterhead signed by EI #18 (Executive Director) and dated 09/02/2010. The letter reads as follows: "To Who It May Concern: (Name of EI #10), Rehab Manager, was suspended pending investigation, September 2, 2010, at approximately 1030." Attached to this letter was a document entitled, "Performance Improvement Form", with a revised date of 9/2007. This Kindred Healthcare Performance Improvement Form corroborates that EI #10 received a written warning and suspension on 09/02/10, and re-education on abuse with focus placed on protection of residents 08/31/10. This deficiency is written as a result of the investigation of complaint / report #AL 098. ********************************************** Allegation of Compliance (AOC) - F 226 Immediate response- F226 On 8/11/2010 When the RN Unit manager was notified of altercation she separated RI # 2 and RI #3, the residents were kept separated until RI #3 was discharged to the hospital per physician orders. RI # 3 was readmitted on [DATE] to (numerical location), RI #2 resided in (numberical location) at this time. On 8/20/2010 RI #3 was discharged home with family. Abuse training that focused on separation of residents that involved resident to resident altercation was initiated at 8 PM, 8/30/10 by the staff development coordinator and assistant director of nursing. Current staff that were on duty include:: Therapy Manager, social service director, maintenance director, dietary director, licensed nursing, nursing aides, housekeeping, dietary, activities, administrator, director of nursing were given education and training, on abuse policy and procedure - see attached document A. Staff development coordinator has counseled and in-serviced staff members involved in this event and investigation on the abuse policy and the correct procedures to follow starting 8 PM 8/30/10 (housekeeping, dietary, therapy, administrative, maintenance, nursing and all contracted staff). Staff were not and will not be allowed to work until they have completed training on abuse. As mentioned above, therapy manager, was trained at 8 PM on facility policy and the need for separation of residents involved in resident to resident altercation. Signs were posted to on-coming staff that mandatory training was required before they could report to duty. Phone calls were placed to staff to notify that training was required before working with residents. Calls were placed by the staff development coordinator, the staffing coordinator and the assistant director of nurses. This training was conducted by the staff development coordinator and assistant director of nursing. A roster of attendees was initiated by the staff development coordinator and updated as staff attended. Roster is attached - see attached document B. Medical Director was notified of the immediate jeopardy citation and he met with administrator and director of nursing and approved above mentioned training on 8/31/10. On 8/31/2010 the facility implemented mandatory staff education and training to prevent immediate jeopardy to the residents in the facility. AOC Staff development or nursing management will in-service all staff on the abuse policy with emphasis on the prevention, intervention, separation, and reporting components starting 8/30/10 and be completed 9/02/10. In-service documentation will be kept in the staff development coordinator ' s office. The administrator or designee will review each investigation at least daily while it is being conducted to ensure full implementation of the policy. Corrective action (counseling or disciplinary action by his supervisor) will be taken for elements found not being fully implemented. Training will consist of identifying types of abuse, ie, physical, sexual, verbal, mental, emotional and misappropriation of funds, separation and protection of residents. Abuse training will be offered upon orientation of new staff and residents will receive information on abuse. Volunteers, family members, visitors will be given a document see document C- which defines abuse and what to report and to whom- the volunteers and visitors will sign roster upon receipt of types of abuse and who to report it to which is the administrator, director of nursing, or assistant director of nursing. Rosters of residents and sponsors who were sent documentation on abuse will be kept in the business office. Business office manager will maintain roster. All documents will be reviewed by director of nursing or administrator, assistant director of nursing monthly. The updated roster will be included in the minutes of the monthly performance improvement committee which is maintained in the administrator ' s office Director of nursing will monitor staff development performance. Staff development coordinator ' s credentials are: prior critical care training, previous advanced cardiac life support training. telemetry nurse, registered nurse for five years, intensive care nurse. Director of nursing credentials are: long term care [AGE] years, PRN hospital nurse. The administrator or director of nursing will review investigations conducted over the past two months starting 8/31/10 and be completed by 9/7/10 to ensure full implementation of the facilities policies was achieved. Double check system will be in place to include the administrator or director of nursing- see attachment F. If any discrepancies are found, addendums will be submitted to the state complaint department. Counseling and in-services will be conducted on any noted discrepancies The administrator or designee will monitor a thorough record review at least monthly for three months and then quarterly to assure all components of the abuse policy are fully implemented. Documentation will be kept in the administrators office in the performance improvement meeting minutes Abuse follow up log sheet will be kept in performance improvement minutes and will be utilized for every abuse investigation- The medical director will review Performance improvement minutes quarterly. ******************************************* Starting 8/30/10 through 9/03/10, various staff members, including Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, and Therapy Staff Members were interviewed regarding in-services received on the topic of abuse. Staff interviews revealed that they had received additional training and that the in-services were provided by either EI #20,the Staff Development Coordinator, or EI # 19, the facility Assistant Director of Nursing. Staff members were able to answer questions appropriately. Also copies of some of the pre-test and post test were reviewed. On 9/03/10 at 1:30 PM, after the facility implemented corrective actions according to their AOC, the State survey team notified the Executive Director, ADON, and DON that the IJ in F 226 was relieved on-site, with the scope/severity level lowered to a "D" level to allow the facility time to monitor and revise their corrective actions as needed to establish substantial compliance with F 226.

Based on interview and record review, it was determined a Registered Nurse (Employee Identifier #7) assigned on [DATE] to Resident Identifier (RI) #1 found him unresponsive (without respiration and a pulse). Employee Identifier (EI ) #7 failed to initiate CPR (Cardiopulmonary Resuscitation) by providing the resident with any breaths or chest compressions. The facility's policy and procedure for "Cardiopulmonary Resuscitation (CPR), dated [DATE], indicated, "Rationale Residents that are a full code status or their code status are unknown that are without pulse and/or respirations receive basic life support to establish circulation and/or ventilation..." EI #6, an Licensed Practical Nurse (LPN), was first notified by EI #7 of RI #1 being unresponsive. EI #6 reported that EI #7 left the room without providing CPR to RI #1, and and did not return. EI #6 who was not assigned to RI #1, stated she was providing medication on the floor (4th floor) where RI #1 resided. EI #6 stated she was casually summoned by EI #7 to RI #1's room. EI #6 stated when she entered RI #1's room she observed RI #1 lying in bed on his side. This LPN (EI #6) stated RI #1 did not respond to his name being called. EI #6 stated she attempted to arouse RI #1 by providing sternal rubs; again, RI #1 did not respond. EI #6 stated she did not see EI #6 in the room so she called for assistance (Code Blue), went out the room to retrieve the crash cart, and started chest compressions. EI #6 stated she could not locate the back board on the cash cart therefore failing to provide a hard surface for the chest compression. This LPN stated she too was unable to locate the Ambu Bag to administer air to RI #1. According to the American Heart Association BLS (Basic Life Support) for Healthcare Providers Student Manual" copyright date "2006 Part 2 CPR for Adults 1-Rescuer Adult CPR Sequence Putting It All Together page 9, documents: "Follow these steps to perform 1-rescuer CPR Step 1 - Assess the victim for a response. If no response, shout for help. Step 2 - If you are alone, activate the emergency response system and ... Step 3 - Open the victim's airway and check breathing ... Step 4 - If no adequate breathing, give 2 breaths. Step 5 - Check the victim's pulse ... Step 6 - If you do not definitely feel a pulse, perform 5 cycles of compressions and ventilations (30:2 ration). Part 5 2-Rescuer CPR for Adults and Children page 25 When a Second Rescuer Arrives - When another rescuer is available to help, that second rescuer should activate the emergency response system and get the AED. The first rescuer should remain with the victim to begin CPR immediately ... ." RI #1 was pronounced dead at the facility after arrival of the paramedics. The paramedic run log, dated [DATE], indicated, "Pt (patient) apneic, pulseless. Rigor mortis appeared to have set in. Pt's temp (temperature) 90 (degrees), tympanic. Asystole in all leads..." The facility's policy and procedure for "Cardiopulmonary Resuscitation (CPR), dated [DATE], revealed, "... Rigor mortis-postmortem rigidity due to buildup of lactic acid, which causes "the actin and myosin filaments of the muscle fibers (to) remain linked until the muscles begin to decompose. Immediately following death the body is flaccid. It becomes increasingly rigid over time due to lack of [MEDICATION NAME] and buildup of lactic acid. This process happens in stages over the first thirty-six hours post mortem..." This affected RI (Resident Identifier) #1, one of one sampled residents, and had the potential to affect 111 residents with a full code status. On [DATE] at 5:55 PM, the facility's EI # 18, the Executive Director, EI #15, the Director of Nursing, and EI #19, the Assistant Director of Nursing were made aware that the survey team had identified deficient practice at an Immediate Jeopardy level in the area of (F309). The Immediate Jeopardy began on [DATE] and continued until [DATE] when the facility implemented immediate corrective actions to remove the Jeopardy and to prevent any future reoccurrence. Findings include: The facility report to the Alabama Department of Health Care Facilities the following allegation, " ...On [DATE] ,[DATE] nurse went into residents room to give medication, found resident (RI #1) unresponsive 911 was called CPR started immediately, CPR was continued until emergency response team arrived then took over the code. At 8:07 PM resident was pronounced (dead) by EMT's CPR stopped. Physician and family were notified ... " RI #1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #1's Significant Change MDS (Minimum Data Set), dated [DATE], revealed the resident had a legal guardian and had a full code status. The resident required assistance with ADLs (Activities of Daily Living) and was continent of bowel and bladder. A Court of Probate form titled, "LETTERS OF GUARDIANSHIP," dated [DATE], was reviewed and listed RI #1's daughter as Guardian and signed by the Judge of Probate. RI #1's Medical Record revealed an Advance Directives dated [DATE], indicating Guardian. The facility's policy on, "Advance Directives," dated [DATE], revealed, "Rationale The resident has the right to establish advance directives as to his/her wishes regarding treatment options and end of life care. Procedure 1. On admission, furnish the resident information regarding the right to accept or refuse treatment and the right to formulate an advance directive. 2. If an advance directive exists, obtain a copy of Advance Directives from the resident and/or health care proxy, durable power of attorney/healthcare or legal guardianship. 3. Place a copy of existing advance directives such as health care proxy, durable power of attorney/healthcare or legal guardianship in the resident's medical record..." A review of a "RESIDENT PROGRESS NOTES," dated [DATE], revealed, "Soc Ser (Social Service)...Discuss code status with Resident and Daughter (Guardian) request code status to remain full-code." The physician's orders [REDACTED]. RI #1's Medication Record, dated [DATE] to [DATE], indicated resident was a "FULL CODE," with an initial date of [DATE]. The Care Plan for RI #1 was reviewed and revealed, "Date of problem/Problem [DATE] I AM A LONG-TERM RESIDENT, I REQUIRE 24-HOUR SUPERVISION. MY FAMILY IS UNABLE TO PROVIDE CARE IN HOME. I AGREE TO LTC (Long Term Care) PLACEMENT. I WANT CPR. MY GUARDIAN MAKES MY DECISION Goal I WANT MY ADVANCE DIRECTIVES TO BE FOLLOWED PER MY REQUEST... Approach ... [DATE] CPR Care plan (upward arrow) dated [DATE]" At 3:40 PM on [DATE], EI #4, a Certified Nursing Assistant, was interviewed and asked about incident with RI #1 on [DATE]. EI #4 indicated he was making his final rounds between 8 PM and 8:30 PM when he saw 2 nurses come out of RI #1's room. He stated one of the nurses was EI #7, an RN, and he could not remember the second nurse's name. EI #7 called him to come in and one of the nurses (nurse name he can not remember) started doing CPR. The nurse whose name he could not remember went out the room to call code and get the crash cart. He stated he checked for a pulse on RI #1's wrist while the nurse did compressions. EI #4 stated another staff came into the room with crash cart and continued to do CPR until EMS showed up. EI #4 stated after the code completed, he along with CNAs, EI #1 and EI #2 cleaned and preparing RI #1 for this family to view him. On [DATE] at 5:55 PM, a LPN, EI #16, was interviewed. EI #16 was asked how a resident's code status was determined. He stated by looking in the chart there was a sticker that indicates "Full Code," if the chart doesn't have a sticker it means don't code; should be a DNR (Do Not Resuscitate) sticker. He was asked where the resident's code status is documented. EI #16 stated it should be in the chart up front. EI #16 was asked what he do if he identified a resident with no pulse or respiration. He stated the first thing is check respiration and pulse, grab the crash cart and yell for help, then determine the code status; if full code, start code; if not, don't start code. EI #16 was asked to define start code. He stated start compressions, tell people around what to do, help should be on the way, and as soon help gets there start ambu bag and oxygen. Thirty compressions to 2 breaths are done. EI #16 was asked what a full code was. He replied, doing everything to bring the person back. He was asked what DNR means. His responses was do not resuscitate, let them go, no CPR. He was then asked was there a difference in the interventions for full code and DNR. EI #16 indicated DNR means don't do anything. EI #16 was asked why was it essential to have the resident's code status established. He stated because if they don't want to be resuscitated, a person can get in a lot of trouble if it's done and would be in big trouble again if the person is a full code and you do not initiate measures to revive the resident. He was asked when was the last in-service provided by the facility on code status/advance directive. EI #16 stated he hadn't been in serviced on code status and advanced directives. EI #16 was asked when was the last in-service on CPR. He indicated the facility had not provided in-services on CPR. During this interview, EI #16 was asked about the incident involving RI #1 on [DATE]. He stated he heard code blue 4th floor and he took the stairs. EI #7 (RN) was on the phone calling 911 and he entered the resident's room and saw EI #6 (LPN) doing compressions. EI #16 stated he then took over providing chest compressions to RI #1 because he had a lot of stamina and he instructed her to get the oxygen and ambu bag going. He reported while he continued chest compression, the nurse went to the crash cart and grabbed the ambu bag and oxygen and placed it on the resident's face. EI #16 indicated emergency personnel arrived and took over and he stepped aside. EI #16 stated he think at 8:07 p.m. the paramedics stated RI #1 had a flat line. EI #16 stated she recalled the paramedics pronouncing the resident On [DATE] at 11:10 AM, EI #6, an LPN, was interviewed and asked how a resident's code status was determined. EI #6 stated it is on the MAR (Medication Administration Record) and the resident's face sheet in the chart. EI #6 was asked what was the facility's policy and procedure for obtaining the resident's code status/advance directive. She indicated that it's done through Admissions. She stated if the resident is alert and oriented, it is initiated once the resident makes their needs known and the doctor writes an order. EI #6 was asked where the resident's code status was documented. EI #16 stated on the MAR and on the face sheet in the chart. She was then asked who was responsible for ensuring the resident's code status is established. She indicated once the status is known the physician gives the order for the status and the nurse relays the code request- DNR or full code to the physician. EI #16 stated, it should be checked initially when the resident comes in at admission. EI #6 was asked what she would do if she identifies a resident with no respirations or pulse. She indicated establish what the code status is and then initiate care based on what their code status is. EI #6 was asked what a full code was. She replied, when a resident wants everything done to save his or her life, they want all measures. She was asked what does DNR mean and she stated do not resuscitate. EI #6 was asked were there different interventions for full code and DNR. She indicated with a full code initiate CPR right away and if the resident is a DNR, notify the family that resident has expired and did not initiate CPR. During this interview, EI #6 was asked did she recall occurring [DATE] with RI #1. EI #6 stated she was standing in the hall with her medcart (medication cart) sometime after 7:00 PM and was about to start her 8:00 PM medications. She indicated EI #7, an RN, was standing in the doorway of RI #1 with her medcart in front of her. EI #7's back was to the resident. EI #6 indicated EI #7 was looking down at her medcart and called her name while looking at the cart. EI #6 stated EI #7 called her name again and motioned with her hand for her to come there. EI #6 stated after EI #7 beckoned for her (EI #6) to come there, EI #7 continued to do her meds on her medcart. EI #6 stated she approached EI #7 and EI #7 stated, " I went to give (name of RI #1) his meds but he wouldn't wake up." EI #6 stated she and EI#7 walked into RI #1's room towards his bed and he was lying on his side. EI #6 indicated EI #7 crouched down to RI #1's face then looked up at her then back to RI #1. EI #6 stated she asked EI #7 if RI 1 was breathing and EI #7 said, "I don't know." EI #6 stated EI #7 began backing away from the resident. EI #6 stated she shook RI #1 twice and called his name twice and the resident did not respond. EI #6 stated she asked EI #7 what the resident ' s code status was and EI #7 stated she did not know. EI #6 stated she instructed EI #7 to find out RI #1 code status. RI #6 stated EI #7 left the resident's room and went to the nurse's station. EI #6 stated she went to the MAR on EI #7's med cart and determined RI #1's code status. EI #6 stated she yelled for a code and to call 911, went back into RI #1's room, shook the resident, and performed a sternal rub. EI #6 stated RI #1 did not respond. EI #6 then went out into the hall to get the emergency cart and brought it back into the room. She indicated the resident's room was close to the nurse's station. She brought the emergency cart close to the resident's side but not all the way due to a wheelchair being in the way. She stated she went for the backboard and the ambu bag but they were not there. EI #6 stated a CNA, EI #1, came into the resident's room and she told EI #1 she needed a back board and an ambu bag. EI #6 stated she instructed EI #1 to go call a code overhead while she initiated chest compressions. EI #6 stated she kept yelling to call a code. She stated she went to start doing chest compressions on the resident and saw a lump on his breast bone area, to the side a little. She stated it was a lump of money. She stated she removed the money for the resident ' s shirt pocket, dropped the money on the table and started doing chest compressions. EI #6 stated then other staff came into RI #1's room with another emergency cart and she hooked the ambu bag to the oxygen. EI #4, a CNA, entered the room and brought in a back board and placed it under the resident. EI #6 stated she began chest compressions again. EI #6 stated that EI #16, an LPN, came in with another nurse, an LPN, and she did about 15 compressions by the time EI #16 got there. EI #16 brought the ambu bag in with them. EI #6 stated EI #16 (LPN) relieved her of chest compressions. EI #6 stated it appeared to her that RI #1 was getting air so she showed EI #5 (LPN) how to adjust the ambu bag with a tighter seal. EI #5 continued to provide air to RI #1 using the ambu. EI #6 stated she stepped back, the paramedics came off the elevator as she was coming out of the room, and she explained to the paramedics what was going on. The paramedics asked how long the resident had been down and she told them about 20 minutes. EI #6 stated the paramedic requested a face sheet on the resident. She stated EI #7, RI #1's nurse, was just standing at the nurse's station and did not move or do anything. EI #6 stated she had to go around the nurse's station to get to RI #1's chart to obtain the face sheet for the paramedic. RI #6 stated after she gave the paramedics RI #1's face sheet, EI #6 went back to her medcart. EI #6 was asked to confirm how EI #7 summoned her to her (EI #7) med cart. EI #6 stated with her hand she very calmly beckon for me to come to her. EI #6 stated she was unaware there was anything wrong. EI #6 was asked what sense of urgency was in EI #7's voice when she said RI #1 couldn't be awakened. EI #6 stated EI #7 did not display any sense of urgency. EI #6 stated, EI #7 said, "I came in here to give him his meds but he wouldn't wake up." EI #6 stated that EI #7 acted like it was no big deal. EI #6 was asked in her opinion what did EI #7 fail to do. EI #6 stated EI #7 failed to react the way she should have when she found the resident unresponsive rather than going back to prepare her medicines, she should have yelled for help, yell for the cart, get someone to get the cart, initiate CPR right away, call a code, and know what the resident's code status was especially with the MAR being right there. EI #6 indicated EI #7 was too calm and non-chalant about it. EI #6 stated she couldn't understand it and that she should have tried to arouse him. She was asked what EI #7 was doing at the nurse's station during the code. EI #6 stated the second time she told her to call a code, EI #7 was on the phone and stated she (EI #7) was calling 911. EI #6 stated she did not know what EI #7 was doing at the nurse's station and each time she saw her, EI #7 was at the nurse's station. EI #6 stated a CNA told her that EI #7 was on the phone because the CNA needed to use the phone that EI #7 was using in order to call a code overhead. EI #6 indicated that EI #7 never went back to RI #1's room. EI #6 was asked where was the back board and the ambu bag for the 4th floor crash cart. She stated she didn't see the ambu bag or back board on the cart and that EI #4 (CNA) brought the back board into the resident's from quickly. EI #6 stated the back board could have been lying against the wall, but she didn't see it. EI #6 was asked when she had been in-serviced or trained on the use of the contents of the crash cart. EI #6 stated she has never been inserviced by the facility. EI #6 stated she had been oriented where the cart was located, but not on how to use the emergency cart. On [DATE] at 12:45 PM, EI #1, a CNA, was interviewed in regards to incident with RI #1. She stated that she was his aide the evening of [DATE] and between 6:00 PM and 7:00 PM she was getting meal trays together. She noticed a strong smell from RI #1's room. EI #1 and EI #2, a CNA, entered the room to find feces on the floor and the toilet and stated that was out of character for the resident. She indicated RI #1 was able to use the bathroom himself. EI #1 cleaned up the bathroom and put the resident's clothes in the hamper. She stated she asked him if he was ok and how was he feeling. He only looked at her but did not respond but blinked his eyes at her. She instructed him to call her if he needed anything and she left to continue passing out meal trays. She had fed 2 residents and began picking up dinner trays when she noticed the smell again. She went into his room and an LPN was saying, "(Resident's name) you ok?" The LPN stated the resident was not responding. She asked EI #1 if she knew CPR. EI #1 indicated the nurse ran to get the crash cart and instructed her to call code blue. EI #1 went and called code blue and stated other nurses were coming from the other floor. EI #1 indicated the nurses switched doing chest compression. EI #16, who came from another floor, began doing chest compressions. The other nurse, EI #5, was doing the air bag. EI #1 stated that she and EI #16 were doing chest compressions and switched up and the ambulance came. She stated that EI #16's arms were getting tired so she took over doing compressions for him and the LPN from her floor was doing the ambu bag with the nurse from the other floor. EI #1 indicated that EI #7 was RI #1's nurse and stated when she first saw EI #7 was when EI #6 told her to go call code blue and EI #7 was at the nurse's station on the phone. She did not know what EI #7 was doing and EI #1 told EI #7 that she needed the phone to call code blue. She called another floor to get them to call code blue. EI #1 stated she never saw EI #7 do CPR and that EI #6 was the one who took the initiative to tell everybody what to do. She indicated she does not know if EI #7 went back to the resident's room after RI #1 passed and that the aides told EI #7 to call his daughter. EI #1 indicated that she, EI #2, and EI #4, cleaned the resident up. At 4:15 PM on [DATE], EI #4, a CNA, was interviewed and asked about the incident involving RI #1 on [DATE]. He stated he worked 2PM to 10PM that day and came out of another room when he noticed nurses coming out of RI #1's room. EI #4 stated EI #7 went to get the crash cart and call the code and the other nurse told him to come to the room with her. He reached for RI #1's wrist to check his pulse and the nurse started doing CPR. EI #4 stated they came in with a crash cart and he backed out of the way. He stated he did not bring the back board into the room and was unsure where the back board came from, but he assisted in placing the back board under RI #1. EI #4 stated he saw 2 crash carts and was not sure who brought the first cart but that EI #16 brought the 2nd cart. He stated he did not think there was an ambu bag on the first cart. EI #4 was asked had any in-services been provided since the incident. EI #4 stated, not yet. He was asked had there been any changes since the incident and he stated not to his knowledge. On [DATE] at 10:02 AM, EI #5, an LPN, was interviewed. EI #5 stated she was working on the 3rd floor when she heard code blue paged overhead for 4th floor (Floor where RI #1 resided). EI #5 stated the code occurred around 7:30 PM to 8:00 PM. EI #5 stated she grabbed a crash cart and went to 4th floor and asked where the code was. She stated she was directed to a room near the nurse's station. She went to the resident's room and saw a nurse pumping on RI #1's chest. She stated there was a nurse by the crash cart looking for the ambu bag. She stated this nurse was unable to locate the ambu bag so she retrieved the ambu bag from the cart she brought from the 3rd floor. EI #5 stated she opened the ambu bag because the nurse was having trouble getting it open. EI #5 stated they continued with CPR until the paramedics got there. EI #5 stated she and EI #16 (LPN) were doing CPR. EI #16 was doing chest compressions when she got there and EI #7 (RN) was standing in the room observing. EI #16 stated EI #7 was not doing anything. EI #5 stated she thought this resident was the other nurse's (EI #7) because she was active and on the crash cart. EI #7 was only observing. EI #5 stated the paramedics took over so she got out of the way. The paramedics took vital signs and said the temperature was 91 degrees and the paramedics couldn't get anything on the resident. She stated during the time they did CPR, RI #1 did not have a pulse and couldn't get an O2 (oxygen) reading on the resident. She and EI #16 (LPN) was standing in the doorway with EI #7 (RN). EI #5 stated she asked EI #7 if she called the family but EI #7 did not respond. EI #5 stated EI #7 was calm, like she didn't hear her. At that time, EI #5 left to go back to her floor. On [DATE] at 10:15 AM, EI #7 (RN) was interviewed. EI #7 was asked what occurred on [DATE] in regards to RI #1. EI #7 stated she went into his room to pass meds and said his name but he did not respond. EI #7 stated said his name again, no response, shook him again and no response. She yelled for the other nurse and she came in to check to see if the resident had a pulse or respiration. EI #7 stated the other nurse who responded started chest compressions and she (EI #7) left the room to call 911. EI #7 stated she checked for a pulse and respiration before the other nurse came in but could not remember if she felt a pulse. She stated when the other nurse came in other nurse checked the resident for a pulse and respirations. EI #7 stated she and the other nurse placed the resident on his back and one of the aides brought in a crash cart. EI #7 stated she called 911 at the nurse's station, which was located right outside the resident's room, after positioning RI #1on the back board. She stated there were 5 people in the room at this point in time and could not remember how much time had elapsed. EI #7 indicated that staff came from other floors because a code was called overhead and one of the CNAs called it while she was on the phone with 911. She stated 911 were called first, then the code, then 3 calls to the MD (Medical Doctor). EI #7 stated she spoke with the CRNP (Certified Registered Nurse Practitioner) and told her what was going on with the resident. She stated CPR was still going on when the EMTs (Emergency Medical Technician) showed up and took over. EI #7 stated she was the first person to check him for breathing and when she discovered he was not breathing, she called for one of the other nurses. She was asked what she should do if she identifies a resident with no respiration or pulse. EI #7 stated she should check and see what their code status was. She was asked when was the last in-service provided on code status/advance directives. She replied she had never received an in-service on code and advance directives. EI #7 was asked when was the last in-service on CPR. She stated she could not remember the date. EI #7 was asked as a licensed professional, what she failed to do. She stated she would have stayed in the room the entire time and would have been more hands on. She was asked what did the resident's body feel like and she indicated he was not sweaty, he was cool she guessed. She stated the fact that the resident did not respond when she told him she had his meds made her think something was wrong. She was asked how many times she called the other nurse before she came. EI #7 stated the nurse responded after being called once. She was asked how many breaths she gave RI #1. She stated she did not give RI #1 any breaths. She was then asked how many chest compressions she did on RI #1. EI #7 stated she did not do any compressions. EI #7 was asked where did she get the resident's code status and she indicated she looked for it on the cart, that she left the room and checked the cart. She also stated she wished she would have stayed with him and sent the other nurse to check his code status. EI #7 further stated she wished that when she found him unresponsive she would have gone ahead and started CPR while she was yelling for the other nurse. She stated she had lost sleep every night over this. EI #7 was asked what could happen when CPR was delayed for a full code resident. She stated it could decrease the chances of a successful or a good outcome. On [DATE] at 11:28 AM, EI #17, Medical Director, was interviewed and asked where was the resident's code status documented. He indicated inside of the clinical chart. Living Will and DNR signed agreements are in the chart. He was asked what changes or interventions had been implemented as a result of the incident involving RI #1 and he stated he was not aware of any. On [DATE] at 3:15 PM, EI #15, Director Of Nursing, was interviewed and asked when was the last in-service provided on code status/advance directive and CPR. She stated recently, however was unable to provide an exact date. EI #15 was asked who initiated CPR on RI #1 and she indicated EI #6(LPN). She was asked what should have EI #7 (RN) have done when she found RI #1 unresponsive. EI #15 stated she should have called for help, try to arouse the resident and then she should have asked for someone to get code status and initiate CPR. EI #15 was asked what could happen when CPR was delayed for a resident with a full code status. She stated it decreases the ability to revive them. EI #15 was asked why EI #7 was terminated and she indicated for failure to respond timely to a code. EI #15 was asked if it compromised the health and safety of resident and she responded yes. On [DATE] at 4:40 PM, EI #15 was interviewed and asked who was responsible for ensuring that staff was trained to respond to emergency events. She indicated the Staff Development Coordinator (EI #20) was responsible. EI #6 was interviewed again on [DATE] at 9:30 AM, regarding the events surrounding RI #1. EI #6 was interviewed and asked how many breaths she gave to RI #1. EI #6 stated she did not give any breaths. She was asked when she started chest compressions why didn't she put the resident on the floor. She stated when she positioned him on his back, she thought the back board would be on the crash cart but it wasn't. The CNA, EI #4 ran out to get the back board. She was asked where the back board was. EI #6 stated she did not know. EI # #6 was asked how many breaths did EI #7 (RN) give to RI #1. EI #6 stated none. She indicated EI #5 gave breaths after the ambu bag was brought in with 2nd floor's crash cart. EI #6 was asked how many times EI #7 called her name. EI #6 stated the first time her name was called she looked up and EI #7 was looking down at med cart. EI #6 stated she looked back down at her MARs and was getting ready to go to the other end of the hall. EI #6 stated she heard her name called a second time and she looked up and EI #7 motioned with her hand for her to come there. EI #6 was asked how much time elapsed between first hearing her name and the second time she heard her name called by EI #7. EI #6 stated it was less than a minute. She was asked if she recalled seeing RI #1 at any time that day prior to the code and she stated she did not recall seeing him. She was then asked if she recalled anything about his stool. EI #6 stated she smelled a strong odor and thought it was another resident but it wasn't and she thought it might be a plumbing problem. She indicated it was a strong odor that could be smelled all the way down the hall and that it smelled like raw sewage. One of the CNAs assigned to RI #1 stated the resident went to the bathroom but did not flush the toilet. She indicated this was not long before the code. EI #6 was asked how many minutes between smelling the feces odor and the code. EI #6 stated 30 to 45 minutes before the code. A review of the 911 log run for RI #1 on [DATE] revealed, "TIMES Disp (Dispatch) Notified [DATE] 19:53:00 (7:53 PM) Unit Notified [DATE] 19:53:00 Enroute [DATE] 19:53:00 Arrive Scene [DATE] 19:57:00 (7:57 PM) Arrive Patient [DATE] 19:57:00 Left Scene [DATE] 20:13:00 (8:13 PM)... Complaint/Symptoms/Impressions Chief complaint: [MEDICAL CONDITION], Primary Symptom: Death, Location: General/Global, System: Global, Secondary Symptom(s): Death, Primary Impression 427.50- [MEDICAL CONDITION], Secondary Impression 780.09- Altered Level of Consciousness Injuries Injury:No; Cardiac [MEDICAL CONDITION]: Yes, Prior to EMS (Emergency Medical Service) Arrival; Est (Estimate) Time Prior to EMS: > (greater) 20 Minutes; Etiology: Presumed Cardiac; First Monitored Rhythm: Asystole; Return of Circulation: No; VITAL SIGNS [DATE] 20:13:00 BP/POR ,[DATE] 0 Pulse 0 Respiration Absent ... Narrative Aos to find 83 yo (year old) BM (black male) laying in bed in nursing home. Pt apneic, pulseless. Rigor mortis appeared to have set in. Pt's temp, 90. tympanic. Asystole in all leads. Staff stated they had just talked to him and were performing CPR. Med control contacted and (name of doctor) advised us to discontinue resuscitation efforts." On [DATE] at 10:22 AM, the Firemedic who participated in the emergency response for RI #1, was interviewed. The Firemedic was asked to review the emergency run log for RI #1. The Firemedic stated when he responded to the 911 code he was informed by the nursing home staff that the resident had been down for about ,[DATE] minutes. He was asked to explain what the rigor mortis state, documented on RI #1's run log narrative meant. The Firemedic stated the resident's arms felt slightly stiff and was cool to touch. He pulled a sheet over the resident up to his neck. He indicated his partner did compressions while he placed the 3 leads on the resident. Once the 3 leads were put on, the resident had asystole. The firemedic was asked to define asystole. He stated asystole means no cardiac output or rhythm and was checked with 3 leads. The Firemedic stated they received the order to cease resus