Every finding on record at Christian Health Center Corbin

Based on interview, record review, and review of the facility's policies, the facility failed to ensure that one (Resident (R) 93) of 13 sampled residents reviewed for abuse was free from abuse by another resident (R12). The facility was aware that R12 exhibited escalating behaviors toward staff and other residents, including entering other residents' rooms, physical sexual contact, and aggression since at least 08/2025. Despite documented identification of R12's ongoing behaviors, the facility failed to develop a comprehensive care plan to reflect the behaviors, so as to implement consistent behavioral interventions to protect other residents. On 01/05/2026, R12 touched and physically restrained R93 in her bed, causing R93 psychosocial harm with emotional distress and fear. The facility's failure to protect residents from abuse by promptly recognizing, assessing, and intervening to address known behaviors, resulted in Immediate Jeopardy as the deficient practice created a situation likely to cause serious harm to residents. Immediate Jeopardy (IJ) was identified on 01/17/2026 at 42 CFR S483.12 (Free from Abuse and Neglect -F600). The IJ at F600 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.12. The IJ was determined to exist on 01/05/2026 when Licensed Practical Nurse (LPN) 1 observed R12 in R93's room, positioned over R93, with one hand holding the resident's hands down and the other hand placed on the resident's left shoulder, pushing her back into her bed while attempting to get on top of her. On 01/17/2026, the Executive Director (ED), Director of Nursing (DON) and Social Services Director (SSD)/Assistant ED were provided a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template and was notified of the failure to ensure each resident was free from abuse is likely to cause serious injury, harm, impairment, or death to a resident. The facility provided an acceptable IJ removal plan on 01/19/2026. This plan alleged the IJ was removed on 01/19/2026. An Extended Survey was conducted on 01/18/2026-01/19/2026. During this survey, on 01/19/2026, the State Survey Agency (SSA) validated the immediacy of the IJ, which was removed on 01/19/2026 as alleged. The deficient practice remained at a scope and severity of Level 2 - Isolated ( D) following the removal of the immediate jeopardy.Findings include:Review of the facility's policy titled Abuse Reporting and Prevention, reviewed 07/2025, revealed abuse included physical, verbal, mental, and sexual abuse, involuntary seclusion, and mistreatment and applied to abuse perpetrated by any individual, including other residents. Further review of this policy revealed that it defined sexual abuse as nonconsensual sexual contact of any type with the resident. The policy further noted that the facility must evaluate if the resident has the capacity to consent to physical intimacy/sexual activity. Per the policy, this evaluation must be documented in the nurses' notes, clearly outlining how a decision of intimacy was determined. A review of the facility's Resident-to-Resident Altercation Guidelines, included within the Abuse Reporting and Prevention policy, revealed the policy categorized resident-to-resident altercations as mental/verbal conflict, sexual contact, and physical altercations, and identified specific circumstances that are considered reportable. The policy states that under physical altercations, Any willful act that results in physical injury, mental anguish and/or pain was reportable. The policy further states that A resident-to-resident altercation should be reviewed as a potential situation of abuse, and cautions staff to not automatically assume that abuse did not occur, especially in cases where either or both residents have a cognitive impairment or mental disorder. The policy also states that Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. The policy further revealed when behaviors related to a resident-to-resident altercation were present, An assessment of the resident and care planned interventions must be conducted. The policy revealed Redirection alone is not a sufficiently protective response to a resident who will not be deterred from targeting other residents for abuse once he/she has been redirected. The policy further revealed staff should monitor for and respond to any behaviors that may provoke a reaction by residents or others, including verbally aggressive behavior, physically aggressive behavior, sexually aggressive behavior, taking or rummaging through others' property, and wandering into other residents' rooms or space.Review of the Electronic Medical Record (EMR) revealed the facility admitted R12 on 09/25/2024 with multiple diagnoses, including schizophrenia. A review of R12's annual (comprehensive) Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/27/2025, revealed R12 had a Brief Interview for Mental Status (BIMS) score of 9/15, which indicated R12 had moderate cognitive impairment. The MDS documented that the resident had diagnoses including schizophrenia, anxiety, and depression. Per this MDS, the resident had no physical or verbal behavioral symptoms directed toward others. In addition, the MDS showed no hallucinations, delusions, or any other type of behaviors, such as rejection of care, wandering, or behaviors not directed towards others during the seven-day look back period ending on 08/27/2025. Section V of the MDS, which included the care planning summary, documented that behavioral symptoms did not trigger and this care area was not care planned.Review of R12's comprehensive care plan created in response to the 08/27/2025 MDS confirmed that a problem of behaviors was not care planned at the time of the annual comprehensive assessment.Although the 08/27/2025 MDS documented no behaviors and this area was not care planned, review of facility documentation revealed that the facility was aware of ongoing behaviors prior to this assessment. These included:a. Review of a Psychiatric Evaluation, Date of Service 08/15/2025, documented R12 had a known history of sexually inappropriate behavior and aggression, with staff reporting that R12 has a history of sexual inappropriate behavior and aggression and continued to display psychiatric symptoms including psychosis, delusions, paranoia, irritability, and agitation. The evaluation included a treatment plan directing staff to notify providers of any inappropriate sexually acting out behaviors in which redirection was unsuccessful and potentially put others at risk for harm.b. A review of a Psychiatric Periodic Evaluation, Data of Service 08/22/2025 (during the MDS look-back period), documented R12 had a history of impulsive behavior including sexually inappropriate behavior, increased aggression toward staff and other residents, yelling, physical contact with other residents, and attempts to enter other residents' rooms. Staff were noted to have attempted redirection, which was often ineffective.c. A review of a Behavioral Nursing Note, dated 08/24/2025 (during the MDS look-back period) revealed R12 was noticed by nurse to be pushing a female resident down the hallway to the female resident's room, and the nurse rerouted the residents to the dining room to sit. The residents then were found following one another back down the hallway, attempting to go back to the female resident's room together.After the failure to identify and care plan behaviors in response to annual Resident Assessment Instrument (RAI) conducted in 08/2025, R12 continued to display behaviors. These included:Review of a Psychiatric Periodic Evaluation, Date of Service 09/05/2025, documented R12 was being monitored for impulsive behavior, including sexually inappropriate behavior. The history of present illness noted that R12 continued to experience sexually inappropriate behavior at times, despite pharmacological interventions, and staff reported ongoing behavioral concerns. The Nurse Practitioner (NP)13 recommended staff to monitor for changes in mood and behaviors.Review of a behavioral nursing note, dated 09/21/2025, revealed that when a Certified Nurse Aide (CNA) entered R12's room, the resident got a hold of the CNAs arm and tried to put his arms around her. The CNA backed away from the resident and went out of the room. Then R12 came out in hallway without his walker, trying to get the CNA to come back into his room. R12 got upset when CNA would not go back to his room.A review of a Psychiatric Periodic Evaluation, Date of Service 10/03/2025, documented R12 continued to experience sexually inappropriate behavior at times, requiring ongoing monitoring.A review of R12's quarterly MDS assessment, with an ARD of 10/19/2025, revealed the facility continued to document R12 as having no behavioral symptoms. Review of R12's comprehensive care plan revealed that it continued to not address resident behaviors. A review of the facility's Behavior Review Committee documentation for R12 revealed the facility was aware of ongoing behavioral concerns. Documentation dated 11/18/2025 identified R12 with diagnoses including schizophrenia, anxiety, and dementia, and documented behaviors described as episodes of touching female caregivers inappropriately, with triggers identified as touching female caregivers during personal care. The documentation reflected that R12 was reviewed by the Behavior Committee and that recommendations included remind [R12] his behavior is inappropriate, redirect, and encourage activities and choices. However, the documentation did not include evidence of increased supervision, care approach modifications, staff assignment changes, or other protective interventions implemented to prevent further targeting of others. Additionally, the documentation did not reflect evaluation of the effectiveness of the interventions or revision of the care plan when behaviors persisted.A review of a Psychiatric Periodic Evaluation, Date of Service 11/21/2025, revealed R12 continues to exhibit episodes of aggressive behavior along with ongoing mood instability, irritability and psychotic symptoms. The evaluation further documented R12 was at risk for sexually acting out. The evaluation noted that information was obtained from chart review and nursing staff.Review of a written statement by the DON, dated 12/29/2025, revealed R12 went across the hall and stated he was just going to talk to the resident. Continued review revealed R12 entered R93's room, and R93 advised that R12 had entered her room before. Although facility documentation revealed staff knowledge for R12's behaviors over a multi-month period, review of the R12's Care Plan revealed the facility failed to develop a comprehensive care plan regarding R12's inappropriate behaviors until 01/09/2026, after R12 abused R93 and physically restrained her in bed on 01/05/2026. (Refer to F656.)Review of the EMR for R93 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia and anxiety disorder. Review of R93's quarterly MDS, with an ARD of 10/28/2025, revealed R93 had a BIMS score of 6/15, which indicated R93 was severely cognitively impaired. Review of R93's nurses notes revealed no evidence that the resident was assessed, per facility policy, for the ability to consent to sexual contact, and no such determination was recorded. Review of R93's comprehensive care plan, effective 02/19/2025 through present, also revealed no evidence that the severely cognitively impaired resident was assessed or care planned as able to provide informed consent for sexual contact.A review of a nursing progress note dated 01/05/2026, authored by LPN1, reflected R93 and the resident's family member (FM)2, had ongoing concerns regarding resident safety and fear related to another resident. The note documented that R93 was observed to be very anxious and crying, stating that there were three men outside her door on a rock who were there to harm her. The resident required reassurance that No man would be coming into her room to harm her. FM2 reported that each time R12 walked by, R93 would state He's here, he's here to hurt me. LPN2 documented that the resident was made to feel uncomfortable and scared by R12, and the concern was reported to the social worker. The documentation did not reflect implementation of immediate protective interventions, supervision measures, or environmental controls to prevent continued distress or potential harm.A review of an undated written statement authored by LPN1 revealed that while administering medications in another resident room, CNA1 alerted her that R12 was attempting to enter another resident's room and had been redirected. LPN1 then observed R12 in R93's room, positioned over R93, with one hand holding the resident's hands down and the other hand placed on the resident's left shoulder, pushing her back into the bed while attempting to get on top of her. LPN1 reported that when she asked R12 what he was doing, he did not respond, and she instructed him to leave the room. LPN1 advised R12 he was not allowed in R93's room, at which time he stated, Ok, I know, and returned to his room.A review of a written statement authored by the SSD/Assistant ED, dated 01/05/2026, documented an interview conducted with R12 regarding his entry into a female resident's (R93) room. The SSD/Assistant ED documented R12 admitted entering the female resident's room, stated he touched the resident's arm, and acknowledged that the resident had a startled reaction as a result. The statement further noted that R12 had previously visited the female resident, and although he denied sexual intent, the intervention implemented consisted of verbal instruction advising R12 not to enter female residents' rooms, especially at bedtime.A review of a Behavior Note dated 01/07/2026 at 10:29 AM, entered by LPN2, revealed R93 was observed to be very upset and crying, stating she needed to leave the facility and go home. When asked the reason for her distress, R93 stated she was fearful of that man coming into her room again, referring to R12. R93 further stated she felt uncomfortable and no longer wanted to stay at the facility. LPN2 documented that nursing staff attempted to redirect and reassure R93 by sitting with her and assuring her that no one would enter her room; however, the redirection was only temporarily effective, lasting a few minutes before R93 began crying again. A review of a Psychiatric Periodic Evaluation for R93, Date of Service 01/07/2026, revealed the resident was experiencing increased anxiety and emotional distress following the incident involving R12. Although R93 appeared calm during the evaluation, staff and family reported worsening emotional symptoms since the prior visit, including increased tearfulness, nervous behaviors, heightened anxiety, and emotional lability, particularly in the evenings and when separated from family. The evaluation further documented staff observations of increased crying, sensitivity, and anxiety over the past several weeks.Review of a Behavior Note, dated 01/16/2026, by LPN2 revealed R93 was very anxious, crying several times and stated that she need to go home and had to get out of this place.A review of Social Services documentation for R93 dated between 01/05/2026 and 01/19/2026 revealed repeated staff interventions related to emotional distress, fear, confusion, and anxiety following the incident involving R12. Documentation reflected R93 intermittently reported fear of individuals entering her room, expressed a desire to leave the facility and go home, and required frequent reassurance from Social Services staff. While some entries documented periods in which R93 appeared calm or without tearfulness, the repeated need for staff intervention, reassurance, and monitoring demonstrated ongoing emotional impact and psychological distress following the incident involving R12.During an interview on 01/07/2026 at 3:20 PM, FM2 stated that on 01/05/2026, R12 repeatedly approached R93's room, stood at the doorway, and looked inside before returning to his room across the hall. FM2 stated that R12 was also observed pacing up and down the hallway while looking into R93's room, which made FM2 feel uncomfortable. FM2 stated that she reported these concerns to LPN1 and requested that R12 be kept out of R93's room. FM2 stated that LPN1 assured her that R12 would be kept out of R93's room.During an interview on 01/07/2026 at 7:37 PM, LPN1 stated that on 01/05/2026, R12 had been exhibiting unusual behavior throughout the day, including repeatedly standing in his doorway and pacing the hall while looking into R93's room before returning to his room. LPN1 stated that R93's family member observed this behavior and requested that staff ensure R12 did not enter R93's room after the family member departed. LPN1 further stated that after being notified by CNA1 that R12 entered R93's room, she immediately exited the room she was in and went to R93's room. LPN1 stated that upon entering the room, she observed R12 physically positioned over R93, with one leg raised onto the bed and actively pushing R93 down into the bed. LPN1 stated that she notified the Social Services Director (SSD) and the DON of the incident and was told the situation was speculation and advised not to make a mountain out of a molehill. LPN1 further reported that CNA1 observed R12 running rapidly across the hallway toward R93's room immediately prior to the incident, describing his movement as purposeful and urgent.During an interview on 01/07/2026 at 6:45 PM, LPN2 stated she had been informed of the incident involving R12 and R93 that occurred on 01/05/2026. LPN2 stated that on 01/06/2026, she observed R93 exit her room, appearing visibly distressed and stating that that man was in her room, referring to R12. LPN2 stated that R93 had not been observed in this level of distress previously and reported that R93 expressed that she was no longer comfortable remaining in the facility due to fear of R12. LPN2 stated that while R93 has had crying episodes in the past, the behavior observed on 01/06/2026 was different and represented a new fear response. During this interview, LPN2 further stated that multiple staff members had reported to her that R12 touched staff inappropriately, including touching buttocks and breasts and making sexual advances. LPN2 stated that although she had heard these reports on multiple occasions, she was not aware of actions taken by the administrative team to address these behaviors.During an interview on 01/09/2026 at 3:45 PM, CNA 6 stated R12 had grabbed her legs and buttocks numerous times during 12/2025, while she was providing resident care for R12's roommate. CNA 6 stated she would move R12's roommate's bed out of R12's reach to ensure R12 was not able to touch her while she was providing care to R12's roommate. CNA 6 stated the DON implemented a buddy system for female staff when entering R12's room; however, it was not documented anywhere to notify staff; was not included in the CNA Kardex (a care plan summary used by nursing staff and nurse aides as a quick reference tool for resident's care and needs); and interventions were not developed to address behaviors toward other residents.During an interview on 01/10/2026 at 12:27 PM, Speech Language Pathologist (SLP) 1 stated that while she was in R12's room, sitting in his recliner in December of 2025, R12 came out of the restroom, and walked toward her. SLP1 stated she started to stand up but was unable to because R12 was leaning over her and kissed her face. She stated she notified the Unit Manager, and, after the incident, she did not enter R12's room alone.During an interview on 01/13/2026 at 2:54 PM, R12 stated he had gone into R93's room on Thanksgiving, Christmas, and a few other times after it had gotten dark. R12 stated that when facility staff would see him in R93's room they would tell him to go back to his house.During an interview on 01/07/2026 at 1:35 PM, FM1 stated R93 and her roommate had been telling the family for several months that a man had been coming into their room. During an interview with R93's FM2 on 01/07/2026 at 3:20 PM, she stated R93 has had increased episodes of crying and asking to leave the facility because she did not feel safe because of that man. FM2 stated that R93 became more upset when R12 walked past her room. During an interview with the SSD/Assistant ED on 01/14/2026 at 4:33 PM, she stated the facility's policy for suspected abuse was to gather the information, discuss it as a team, and then decide if it should be reported to the Office of Inspector General (State Survey Agency). The SSD stated that the ED, SSD, and DON decided that the incident regarding R12 and R93 did not need to be reported to the appropriate agencies because they did not feel it met the definition of abuse.(Refer to F609.) Interview with the SSD/Assistant ED revealed her belief that R93, who was severely cognitively impaired, could consent to being touched.Interview with the ED, on 01/07/2026 at 2:10 PM, revealed that R12 was placed on 1:1 supervision after the incident on 01/05/2026. During an additional interview with the ED on 01/15/2026 at 5:24 PM, she stated she was the facility's abuse coordinator. She stated that she, the SSD/Assistant ED, and the DON were responsible for conducting the facility's abuse investigations. The ED stated the facility's policy included if abuse was suspected, the facility had 2 hours to report allegations to state agencies. However, she continued, there had not been any recent incidents that required reporting to the appropriate agencies, as she, the DON, and SSD/Assistant ED had not determined that abuse had occurred. Further interview with the ED revealed she was aware of different types of abuse, including physical, mental, and sexual. However, she continued, they had decided the 01/05/2026 did not rise to the level of abuse because R93 had consented to R12 being in her room, Further interview with the ED revealed the belief that R93, who was assessed as severely cognitively impaired, could consent to the male resident (R12) coming into her room and touching her. However, she could provide no evidence to support this belief. During an interview with the DON on 01/16/2026 at 1:40 PM, the DON stated behavioral care plans were expected to be reviewed and revised when an incident was reported. The DON stated that it would have been important for the facility to have a behavioral care plan in place for R12 so that staff would be aware of his care needs and behavioral risks. The DON further stated that the facility failed to document R12's behaviors in the Kardex to protect staff and residents. The DON stated she assumed the Unit Manager was updating R12's care plan and Kardex but acknowledged that she did not review either and stated that she should have. The DON stated she did not know how it was possible that R12 did not have a behavioral care plan until 01/09/2026. Further interview with the DON revealed that she had not identified this incident as abuse because of her belief that the severely cognitively impaired resident could consent to being touched.

Based on record review, staff interview, and facility documentation, the facility failed to immediately report allegations and incidents of potential abuse, as well as injuries of unknown origin, to appropriate external authorities, including law enforcement and/or the State Survey Agency (SSA), in accordance with facility policy and federal regulations. This failure involved eight (Resident (R) 12, R19, R30, R67, R84, R87, R90, R93) of 13 sampled residents reviewed for abuse. The failure to immediately report allegations as required included a witnessed incident on 01/05/2026 when R12, who had a history of sexual behaviors, physically restrained R93 in her bed, causing R93 psychosocial harm with emotional distress and fear. The facility's failure to immediately report all allegations of abuse resulted in Immediate Jeopardy as the deficient practice created a situation likely to cause serious harm to residents.Immediate Jeopardy (IJ) was identified on 01/17/2026 at 42 CFR S483.12 (Freedom from Abuse, Neglect, and Exploitation -F609) at the highest scope and severity S/S of a J. The IJ at F609 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.12. The IJ was determined to exist on 01/05/2026 when the facility failed to immediately report an allegation of abuse when R12 was witnessed physically restraining R93 in her bed.On 01/17/2026, the Executive Director (ED), Social Services Director (SSD)/Assistant ED, and Director of Nursing (DON) were provided with a copy of the CMS IJ Template and notified that the failure to ensure allegations of abuse, as exhibited by the 01/05/2026 incident involving R12 and R93, were immediately reported to all required parties, constituted immediate jeopardy at F609.An Extended Survey was conducted on 01/18/2026 - 01/19/2026. The facility presented an acceptable plan for removal of the IJ on 01/19/2026. On 01/19/2026, the survey team validated the immediate jeopardy was removed on 01/19/2026 as alleged, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a D (isolated with potential for minimal harm) scope and severity following the removal of immediate jeopardy.Findings include:Review of the facility's policy titled Abuse Reporting and Prevention, reviewed 07/2025, revealed abuse includes physical, verbal, mental, and sexual abuse, neglect, involuntary seclusion, and mistreatment, and applies to abuse perpetrated by any individual, including other residents.Continued review of the facility's policy revealed that All facility staff are required to report any observation, suspicion or information otherwise obtained related to possible abuse to their supervisor, Department Head or Executive Director (ED), or designee, immediately. The policy further revealed This requirement relates to abuse of any kind by anyone. Additionally, the policy stated, The Executive Director, or designee, reports the incident to the appropriate state agencies and initiates an in-house investigation. The policy noted that, All alleged abuse (verbal, mental, sexual, and physical) must be reported within two hours of becoming aware of the incident or allegation.A review of the facility's Resident-to-Resident Altercation Guidelines, included within the Abuse Reporting and Prevention policy, revealed the policy categorizes resident-to-resident altercations as mental/verbal conflict, sexual contact, and physical altercations, and identified specific circumstances that were considered reportable. The policy stated that under physical altercations, Any willful act that results in physical injury, mental anguish and/or pain is reportable. 1. A review of an undated written statement authored by Licensed Practical Nurse (LPN) 1 revealed that she observed R12 (a male resident) in the room of R93 (a female resident assessed as severely cognitively impaired, per a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/2025). LPN1 stated R12 was positioned over R93, with one hand holding the resident's hands down and the other hand placed on the resident's left shoulder, pushing her back into the bed while attempting to get on top of her. (Refer to F600.)Interview with LPN1, on 01/07/2026 at 7:37 PM, revealed that the incident described in the undated written statement occurred on 01/05/2026. According to LPN1, upon entry to R93's room, she observed R12 physically positioned over R93, with one leg raised onto the bed and actively pushing R93 down into the bed. LPN1 stated that she notified the SSD/Assistant ED and the DON of the incident and was told the situation was speculation and advised not to make a mountain out of a molehill. LPN1 stated when she reported behaviors of residents to facility management, she felt the concerns were swept under the rug, were not addressed, and were not reported to the appropriate agencies.Review of facility documentation and SSA records revealed no evidence that the allegation, which LPN1 witnessed and reported to the DON and SSD/Assistant ED was reported to any outside agencies, including law enforcement and/or the SSA.During an interview with the SSD/Assistant ED on 01/14/2026 at 4:33 PM, she stated the facility's policy for suspected abuse was to gather the information, discuss it as a team, and decide if it should be reported to the Office of Inspector General (SSA). The SSD/Assistant ED stated that the team, which also included the ED and DON, decided that the incident between R12 and R93 did not need to be reported to the appropriate agencies because they did not feel it met the definition of abuse, explaining her belief that R93, who was assessed as severely cognitively impaired, could consent to being touched.Interview with the ED, on 01/15/2026 at 5:24 PM, revealed she was the facility's abuse coordinator and was aware of different types of abuse, including physical, mental, and sexual. She stated that she, the SSD/Assistant ED, and the DON, were responsible for conducting the facility's abuse investigations. The ED stated the facility's policy included if abuse was suspected, the facility had 2 hours to report allegations to state agencies. However, she continued, there had not been any recent incidents that required reporting to the appropriate agencies, as she, the DON, and SSD/Assistant ED had not determined that abuse had occurred. Regarding the failure to report the allegation that R12 abused R93, the ED stated they had decided the 01/05/2026 incident did not rise to the level of abuse because R93 had consented to R12 being in her room. Further interview with the ED revealed the belief that R93, who was assessed as severely cognitively impaired, could form consent to the male resident (R12) coming into her room and touching her. However, she could provide no evidence to support this belief. During an interview with the DON on 01/16/2026 at 1:40 PM, the DON stated that she was unsure whether the incident involving R12 and R93 should have been reported to reporting agencies or law enforcement, explaining that she had not identified this incident as abuse because of her belief that the severely cognitively impaired resident could consent to being touched. However, after a review of the facility's Abuse and Reporting Policy, the DON stated that one of the facility leadership members (ED, DON, or SSD/Assistant ED) should have reported the incident. The DON confirmed that incidents involving alleged sexual misconduct between residents should be reportedDuring an additional interview on 01/17/2026 at 11:11 AM, the ED further stated she often reached out to corporate for direction.Interview on 01/17/2026 at 2:49 PM with the Director of Clinical Reimbursement (DCR - a corporate representative) revealed that if the facility feels they have an occurrence of abuse, they will contact the corporate team and ask their opinion. She further stated an allegation of abuse should be reported to state agencies within two hours; however, she was aware the facility would investigate and see what happened before reporting. The facility, with corporate input, determines what abuse is. Although the DCR confirmed that allegations of abuse were to be reported within two hours, the DCR indicated it was the next day (more than two hours) before the facility contacted the Chief Executive Officer for guidance about the alleged incident between R12 and R93. Per the DCR, at this time it was determined to not be a reportable allegation, adding, We did not see that any abuse had occurred.I would not consider it a reportable offense if it was just touching. 2. Review of a notepad document, with Investigation written on the page, which was dated 12/26/2025 at 12:30 PM and authored by the DON, revealed R90 was found in the floor in her room by a laundry aide. R90 stated that her roommate pushed her down.During an interview on 01/16/2026 at 11:14 AM with Laundry Aide (LA) 1, she stated that upon entering R90's room, R90 was lying on the floor between the bed and recliner. LA 1 stated she went to R90, who stated her roommate (R67) had pushed her down. LA1 stated she immediately reported to the nurse on duty.Review of facility documentation and SSA records revealed no evidence that R90's allegation of abuse by her roommate (R67) was reported to the SSA as required. 3. Review of R30's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses of delusional disorders, and spondylosis (age-related spinal degeneration). Review of R30's MDS, with an ARD of 11/04/2025, revealed a Brief Interview for Mental Status (BIMS) score of 7/15, which indicated severe cognitive impairment.Review of an incident report, dated 01/01/2026 at 2:07 PM, revealed R30 was noted to have dark, purple bruising to her inner left thigh down to her knee and a small bruise to the outer of her left thigh. R30 was unable to state the cause of the bruising. Review of facility documentation and SSA records revealed no evidence that this injury of unknown origin was reported to the SSA as required. 4. Review of R19's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses of dementia, cerebral infarct and contractures. Review of R19's MDS, with an ARD of 06/09/2025 revealed a BIMS score of 3/15, which indicated R19 was severely cognitively impaired.A review of a handwritten statement, dated 07/16/2025 and authored by the DON, revealed R19 had a bruise to the left outer knee, pale yellow in color. The statement noted an incident ten days earlier (07/06/2025) when R19 was aggressive with staff and hit her hand (not her knee) on the table. Registered Nurse (RN) 1 had noted that on 07/06/2025 during the incident, R19 had been kicking her legs but RN1 did not witness R19 kicking anything.Review of facility documentation and SSA records revealed no evidence that this injury of unknown origin was immediately reported to the SSA as required at the time it was first identified. 5. Review of R87's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses of Alzheimer's, atrial fibrillation and impulse disorder. Review of R87's Quarterly MDS, with an ARD of 09/09/2025, revealed staff assessed the resident as severely cognitively impaired.Review of a handwritten notepad document dated 12/12/2025 at 5:00 PM, with Investigation written on the page, revealed the DON was made aware of a bruise to R87's right eye/cheek area. Although the DON ultimately made the determination that the root cause was R87 was rubbing his face, review of facility documentation and SSA records revealed no evidence that R87's injury of unknown origin was immediately reported to the SSA as required at the time it was first identified. 6. Review of R84's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses of Parkinsons, contractures of the muscles and neurocognitive disorder with Lewy bodies.Review of a handwritten notepad document dated 01/12/2026 at 10:15 AM and authored by the DON, revealed staff reported to her that R84 had a bruise to left upper arm. Although the DON conducted interviews with staff and ultimately concluded no suspicion of abuse, review of facility documentation and SSA records revealed no evidence that R84's injury of unknown origin was immediately reported to the SSA as required at the time it was first identified. During an interview on 01/14/2026 at 4:33 PM with the SSD/Assistant ED, she stated that she, the ED, and DON, reviewed the incidents detailed in Examples #2- #6 (which included injuries of unknown origin and an allegation of resident-to-resident physical abuse) and determined they did not need to be reported to the appropriate agencies because they did not feel they met the definition of abuse.During an interview on 01/17/2026 at 10:20 AM, the DON stated that she was not aware that she was supposed to report allegations or suspicions of alleged abuse immediately to the appropriate State agencies.interview on 01/07/2025 at 2:10 PM with the ED revealed the facility investigated incidents and if the facility substantiated the incident, they would report to the State Agency and document in the Electronic Medical Record (EMR). However, review of facility policy and federal regulations require that all alleged violations of abuse, including injuries of unknown origin, be immediately reported, rather than waiting to determine if the facility substantiated the allegation.An additional interview with the ED, on 01/15/2026 at 5:24 PM, revealed she was the facility's abuse coordinator. The ED stated the facility's policy included if abuse was suspected, the facility had two hours to report allegations to state agencies. The ED stated there had not been any recent incidents that required reporting to the appropriate agencies, adding that the decision to not report the incidents was determined by herself, the SSD/Assistant ED, and the DON. During an additional interview on 01/17/2026 at 11:11 AM, the ED further stated she often reached out to corporate for direction.Interview on 01/17/2026 at 2:49 PM with the DCR (corporate representative) confirmed if the facility feels they have an occurrence of abuse, they will contact the corporate team and ask their opinion. She further stated an allegation of abuse should be reported to state agencies within two hours. However, she continued, she was aware the facility would investigate and see what happened before reporting.

Based on interview, record review, and review of facility's policies, the facility failed to develop and implement a comprehensive care plan to meet resident-specific needs for one (Resident (R) 12) of 13 sampled residents reviewed for abuse. The facility was aware that R12 exhibited escalating behaviors toward staff and other residents, including physical sexual contact and aggression, since at least 08/2025. Despite documented identification of these behaviors, the facility failed to develop a comprehensive care plan which reflected the behaviors, reflected measurable goals, and included person-centered consistent behavioral interventions to protect other residents from R12's behaviors. Care planning for R12's behaviors did not occur until 01/09/2026, after an incident on 01/05/2026 where R12 touched and physically restrained R93 in her bed, causing R93 psychosocial harm with emotional distress and fear. The facility's failure to develop and implement a care plan to meet R12's behavioral needs resulted in Immediate Jeopardy as the deficient practice created a situation likely to cause serious harm to residents. Immediate Jeopardy (IJ) was identified on 01/17/2026 at 42 CFR S483.21 (Comprehensive Care Plan - F656). The IJ was determined to exist on 01/05/2026 when, after failing to develop and implement a care plan in response to behaviors, Licensed Practical Nurse (LPN) 1 observed R12 in R93's room, positioned over R93, with one hand holding the resident's hands down and the other hand placed on the resident's left shoulder, pushing her back into her bed while attempting to get on top of her. On 01/17/2026, the Executive Director (ED), Director of Nursing (DON), and Social Services Director (SSD)/Assistant ED were provided a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template and was notified of the failure to develop and implement a comprehensive care plan for each resident is likely to cause serious injury, harm, impairment, or death to a resident. The facility provided an acceptable IJ removal plan on 01/19/2026. This plan alleged the IJ was removed on 01/19/2026. An Extended Survey was conducted on 01/18/2026-01/19/2026. During this survey, on 01/19/2026, the State Survey Agency (SSA) validated the immediacy of the IJ was removed on 01/19/2026 as alleged. The deficient practice remained at a scope and severity of Level 2 - Isolated ( D) following the removal of the immediate jeopardy. Findings include:A review of the facility's Resident-to-Resident Altercation Guidelines, included within the Abuse Reporting and Prevention policy, reviewed 07/2025, revealed when behaviors related to a resident-to-resident altercation are present, An assessment of the resident and care planned interventions must be present. Per the policy, Staff must evaluate the effectiveness of the interventions, and Staff must provide immediate interventions to assure the safety of the residents. The policy revealed Redirection alone is not a sufficiently protective response to a resident who will not be deterred from targeting other residents for abuse once he/she has been redirected. The policy further revealed staff should monitor for and respond to any behaviors that may provoke a reaction by residents or others, including verbally aggressive behavior, physically aggressive behavior, sexually aggressive behavior, taking or rummaging through others' property, and wandering into other residents' rooms or space.Review of the facility's Care Planning policy, revised 03/24/2024, revealed it was the policy of the facility to develop and implement a baseline and Comprehensive Person-Centered Care Plan for each resident, reflecting the resident's medical, nursing, mental, and psychosocial needs. Further review revealed the Comprehensive Care Plan would be adjusted by Licensed Nurses as the resident's needs changed. Additionally, the Comprehensive Care Plan would be reviewed and revised by the Interdisciplinary Team (IDT) after each Resident Assessment Instrument (RAI). Review of the Electronic Medical Record (EMR) revealed the facility admitted R12 on 09/25/2024 with multiple diagnoses, including schizophrenia. Review of facility documentation for 08/2025 revealed that the facility was aware that R12 was displaying behaviors. For example, review of a Psychiatric Evaluation, Date of Service 08/15/2025, revealed R12 had a known history of sexually inappropriate behavior and aggression, with staff reporting that R12 has a history of sexual inappropriate behavior and aggression and continued to display psychiatric symptoms including psychosis, delusions, paranoia, irritability, and agitation. The evaluation included a treatment plan directing staff to notify providers of any inappropriate sexually acting out behaviors in which redirection was unsuccessful and potentially put others at risk for harm. A Psychiatric Periodic Evaluation, Data of Service 08/22/2025, also documented R12 had a history of impulsive behavior including sexually inappropriate behavior, increased aggression toward staff and other residents, yelling, physical contact with other residents, and attempts to enter other residents' rooms. Staff were noted to have attempted redirection, which was often ineffective.A Behavioral Nursing Note, dated 08/24/2025, documented R12 was noticed by nurse to be pushing a female resident down the hallway to the female resident's room, and the nurse rerouted the residents to the dining room to sit. The residents then were found following one another back down the hallway, attempting to go back to the female resident's room together.A review of R12's annual (comprehensive) Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/27/2025, revealed R12 had a Brief Interview for Mental Status (BIMS) score of 9/15, which indicated R12 had moderate cognitive impairment. The MDS documented that the resident had diagnoses including schizophrenia, anxiety, and depression. Although the facility was aware of behaviors, including the Psychiatric Evaluation dated 08/22/2025 and the Behavioral Note dated 08/24/2025 (both within the 7-day assessment period ending 08/27/2025), the facility documented R12 as having no physical or verbal behavioral symptoms directed toward others. In addition, the MDS showed no hallucinations, delusions, or any other type of behaviors, such as rejection of care, wandering, or behaviors not directed towards others. Section V of the MDS, which included the care planning summary, documented that behavioral symptoms did not trigger and this care area was not care planned.Review of R12's comprehensive care plan created in response to the 08/27/2025 MDS confirmed that a problem of behaviors, including aggression and sexual aggression, was not care planned at the time of the annual comprehensive assessment.Further review of R12's record revealed that, after the failure to care plan this problem area, the resident continued to display ongoing behaviors. (Refer to F600 for specifics of each record.) Documentation of these behaviors included Psychiatric Periodic Evaluations for Date of Service on 09/05/2025, 10/03/2025, and 11/21/2025; a Behavioral Nursing Note dated 09/21/2025, and Behavior Review Committee documentation dated 11/18/2025. The records documented R12 was at risk for sexually acting out, and displayed sexually inappropriate behavior including touching of others, impulsive behavior, aggressive behavior, ongoing mood instability, irritability, and/or psychotic symptoms. Further review of the documentation revealed that it described needed approaches which the facility should provide, such as ongoing monitoring of mood and behaviors, redirection, reminding the resident the cognitively impaired resident that his behavior was inappropriate, and encouraging activities and choices. Although this documentation continued to demonstrate staff knowledge of R12's behaviors over a multi-month period, as well as the need for person-centered interventions to deal with the behaviors, review of the resident's Care Plan revealed that, as of 01/05/2026, the facility failed to develop a comprehensive care plan regarding R12's behaviors.A review of an undated written statement authored by LPN 1 revealed that she observed R12 in R93's room. R12 ( a male resident), was positioned over R93 (a female resident), with one hand holding the resident's hands down and the other hand placed on the resident's left shoulder, pushing her back into the bed while attempting to get on top of her.During an interview on 01/07/2026 at 7:37 PM, LPN1 confirmed that the incident between R12 and R93 (referenced in the undated written statement) occurred on 01/05/2026. LPN1 stated that R12 was exhibiting unusual behavior throughout the day, including repeatedly standing in his doorway and pacing the hall while looking into R93's room, before returning to his room. LPN1 stated that R93's family member observed this behavior and requested that staff ensure R12 did not enter R93's room after the family member departed. LPN1 further stated that after being notified by Certified Nursing Aide (CNA)1 that R12 entered R93's room, she immediately exited the room she was in and went to R93's room. LPN1 confirmed that upon entering the room, she observed R12 physically positioned over R93, with one leg raised onto the bed and actively pushing R93 down into the bed. (Refer to F600.)Further review of R12's comprehensive care plan revealed the problem of behaviors, with approaches to ensure safety of other residents, as well as R12, was not initiated until 01/09/2026, after State Survey Agency (SSA) intervention.Interview with the Unit Manager (UM) on 01/11/2026 at 5:35 PM, confirmed that R12 did not have a behavioral care plan prior to the 01/05/2026 incident between R12 and R93. She stated that she, as well as the DON, should have been updating the care plan; however, they did not. The UM stated that the DON asked her to not document resident behaviors, and if she did, the documentation was changed, explaining that this was also some of the reason that she did not create a behavioral care plan for R12.Interview with the Director of Clinical Reimbursement (DCR) on 01/16/2026 at 2:15 PM revealed that she did not remember ever seeing a behavioral care plan for R12.Interview with MDS1 on 01/16/2026 at 2:17 PM revealed she did not ever remember seeing a care plan for R12 and that she had never been told by the DON or Nursing staff that the resident needed one.During an interview with the DON on 01/16/2026 at 1:40 PM, the DON stated behavioral care plans were expected to be reviewed and revised when an incident is reported. The DON stated that it would have been important for the facility to have a behavioral care plan in place for R12 so that staff would be aware of his care needs and behavioral risks. The DON further stated that the facility failed to document R12's behaviors in the Kardex (an informal document used by nursing staff and nurse aides as a quick care plan reference tool for resident's care and needs) to protect staff and residents.) The DON stated she assumed the Unit Manager was updating R12's care plan and Kardex but acknowledged that she did not review either and stated that she should have. The DON stated she did not know how it was possible that R12 did not have a behavioral care plan until 01/09/2026.Interview on 01/17/2026 at 11:11 AM with the ED revealed that the DON and Nursing team were responsible for care plans. She said that having correct and updated care plans was important for residents to ensure their needs were being met.

Based on interview, record review, and review of facility's documents, the facility failed to ensure that it was administered in an effective manner to meet the needs of each resident, in the areas of developing/implementing care plans, freedom from abuse, and immediate reporting of alleged incidents of abuse. This failure affected two (Resident (R) 12 and R93) of 13 sampled residents reviewed for abuse. The facility was aware that R12 exhibited escalating behaviors toward staff and other residents, including physical sexual contact and aggression, since at least 08/2025. Despite documented identification of these behaviors, the facility failed to develop and implement a comprehensive care plan to protect residents from the potential for abuse. On 01/05/2026, R12 touched and physically restrained R93 in her bed, causing R93 psychosocial harm with emotional distress and fear. This allegation of abuse was immediately reported to administrative staff by the staff person who witnessed it. However, the Administrative staff then failed to identify the reported incident as an allegation of abuse. In addition, the Administrative staff failed to report the allegation as required by facility policy and federal regulation, based on their determination that R93, a severely cognitively impaired resident, had consented to being touched. The failure to immediately report all allegations of abuse, as well as injuries of unknown origin, also affected six additional sampled residents reviewed for abuse (R19, R30, R67, R84, R87, R90). The facility's failure to be administered effectively so as to develop and implement comprehensive care plans, take affirmative steps to prevent abuse, and report all allegations of abuse resulted in Immediate Jeopardy as the deficient practice created a situation likely to cause serious harm to residents. Immediate Jeopardy (IJ) was identified on 01/17/2026 at 42 CFR S483.70 (Administration - F835). The IJ was determined to exist on 01/05/2026 when, after Administrative staff failed to ensure the development and implementation of a care plan in response to behaviors, and failed to prevent abuse, Licensed Practical Nurse (LPN) 1 observed R12 in R93's room, positioned over R93, with one hand holding the resident's hands down and the other hand placed on the resident's left shoulder, pushing her back into her bed while attempting to get on top of her. The IJ at F835 also included the failure of administrative staff to immediately report this allegation to all required authorities, including the State Survey Agency (SSA).On 01/17/2026, the Executive Director (ED), Director of Nursing (DON), and Social Services Director (SSD)/Assistant ED were provided a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template and was notified that the failure to administer the facility in an effective manner to meet each resident's needs is likely to cause serious injury, harm, impairment, or death to a resident. The facility provided an acceptable IJ removal plan on 01/19/2026. This plan alleged the IJ was removed on 01/19/2026. An Extended Survey was conducted on 01/18/2026-01/19/2026. During this survey, on 01/19/2026, the State Survey Agency (SSA) validated the immediacy of the IJ was removed on 01/19/2026, as alleged. The deficient practice remained at a scope and severity of Level 2 - Isolated ( D) following the removal of the immediate jeopardy. Findings include:Review of the facility's document, titled Position Identification: Executive Director, revised 01/2023, revealed the ED was responsible for taking all reasonable steps to ensure optimal quality of care was delivered to the residents; responsible and accountable for functions and activities of the entire staff while appropriately integrating these activities with all other departments in the facility that contribute to resident care; plan and organized systems of care, objectives, policies, procedures, staffing patterns, and staff development based on the needs of the facility within the framework of the established budget while maintaining compliance with all applicable laws, and regulatory and organizational standards. Furthermore, the ED was responsible for the day-to-day operations to include quality, safety, occupancy, resident satisfaction, expense management, and compliance. Additionally, the ED performed job duties without posing a significant risk of substantial harm to the health or safety of himself/herself or others while maintaining compliance with all policies and procedures of the facility and within the parameters of the organization's mission, vision, and values. Review of the facility's document, titled Position Identification: Director of Nursing, revised 08/2025, revealed the DON was responsible for the overall direction of an effective, ongoing nursing program to assess, measure, and improve quality of nursing care delivered to residents by directing staff and other assigned professionals while maintaining compliance with all applicable laws, and regulatory and organizational standards. Additionally, the DON performed job duties without posing a significant risk of substantial harm to the health or safety of himself/herself or others while maintaining compliance with all policies and procedures of the facility and within the parameters of the organization's mission, vision, and values. Review of the facility document, titled Position Identification: Social Services Director, revised April 2021, revealed the SSD was responsible for evaluating prospective residents by performing on-site clinical and financial assessments to determine appropriateness of admission ensuring an efficient admission process by working with the residents and their families initially, while maintaining compliance with all applicable laws, regulatory, and organizational standards. Additionally, the SSD performed job duties without posing a significant risk of substantial harm to the health or safety of himself/herself or others while maintaining compliance with all policies and procedures of the facility and within the parameters of the organization's mission, vision, and values. 1. Refer to F656 - Failure to develop and implement care plans.Review of the Electronic Medical Record (EMR) revealed the facility admitted R12 on 09/25/2024 with multiple diagnoses, including schizophrenia. A review of R12's annual (comprehensive) Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/27/2025, revealed the facility failed to identify that R12 displayed documented behavioral symptoms towards others, including sexually inappropriate behavior and aggression. This documentation was noted in Documentation from Psychiatric Evaluations, with Dates of Service of 08/15/2025 and 08/22/2025 , as well as a Behavioral Nursing Note, dated 08/24/2025 (during the MDS look-back period). Section V of the MDS, which included the care planning summary, documented that behavioral symptoms did not trigger and this care area was not care planned. Review of R12's comprehensive care plan, created in response to the 08/27/2025 MDS, confirmed that a problem of behaviors was not care planned at the time of the annual comprehensive assessment.After the failure to identify and care plan behaviors in response to annual Resident Assessment Instrument (RAI) conducted in 08/2025, R12 continued to display behaviors. Documentation included a Psychiatric Periodic Evaluation, Date of Service 09/05/2025, Behavioral nursing note, dated 09/21/2025, Psychiatric Periodic Evaluation, Date of Service 10/03/2025, Behavior Review Committee documentation dated 11/18/2025, and Psychiatric Periodic Evaluation, Date of Service 11/21/2025, which revealed R12 continues to exhibit episodes of aggressive behavior along with ongoing mood instability, irritability and psychotic symptoms. The evaluation further documented R12 was at risk for sexually acting out.Although facility documentation revealed staff knowledge for R12's behaviors over a multi-month period, review of R12's care plan revealed the facility failed to develop a comprehensive care plan regarding R12's inappropriate behaviors until 01/09/2026, after an incident on 01/05/2026. Per interview with LPN1 on 01/07/2026 at 7:37 PM, on 01/05/2026, she was in R93's room and witnessed R12 physically positioned over R93, with one leg raised onto the bed and actively pushing R93 down into the bed. Review of facility documentation, including a Behavior Note dated 01/07/2026 at 10:29 AM, a Psychiatric Periodic Evaluation for R93 for Date of Service 01/07/2026, a Behavior Note, dated 01/16/2026, and Social Services documentation for R93 dated between 01/05/2026 and 01/19/2026 revealed that after the 01/05/2026 incident, R93 was very upset and crying, fearful, uncomfortable and no longer wanted to be at the facility, displaying increased anxiety and emotional distress, and/or displayed worsening emotional symptomsInterview with the Unit Manager (UM) on 01/11/2026 at 5:35 PM, confirmed that R12 did not have a behavioral care plan prior to the 01/05/2026 incident between R12 and R93. She stated that she, as well as the DON, should have been updating the care plan; however, they did not. The UM stated that the DON asked her to not document resident behaviors, and if she did, the documentation was changed, explaining that this was also some of the reason that she did not create a behavioral care plan for R12.During an interview with the DON on 01/16/2026 at 1:40 PM, the DON stated behavioral care plans were expected to be reviewed and revised when an incident is reported. The DON stated that it would have been important for the facility to have a behavioral care plan in place for R12 so that staff would be aware of his care needs and behavioral risks. The DON further stated that the facility failed to document R12's behaviors in the Kardex (an informal document used by nursing staff and nurse aides as a quick care plan reference tool for resident's care and needs) to protect staff and residents.) The DON stated she assumed the Unit Manager was updating R12's care plan and Kardex but acknowledged that she did not review either and stated that she should have. The DON stated she did not know how it was possible that R12 did not have a behavioral care plan until 01/09/2026, four days after the incident occurred on 01/05/2026, and two days after the SSA began its investigation of the incident.Interview on 01/17/2026 at 11:11 AM with the ED revealed that the DON and Nursing team were responsible for care plans. She said that having correct and updated care plans was important for residents to ensure their needs were being met. 2. Refer to F600 - Failure to ensure residents are free from abuse.A review of an undated written statement authored by LPN1 revealed that she observed R12 (a male resident) in the room of R93 (a female resident assessed as severely cognitively impaired, per a quarterly MDS with an ARD of 10/28/2025). LPN1 stated R12 was positioned over R93, with one hand holding the resident's hands down and the other hand placed on the resident's left shoulder, pushing her back into the bed while attempting to get on top of her.Interview with LPN1, on 01/07/2026 at 7:37 PM, revealed that the incident described in the undated written statement occurred on 01/05/2026. According to LPN1, upon entry to R93's room, she observed R12 physically positioned over R93, with one leg raised onto the bed and actively pushing R93 down into the bed. LPN1 stated that she notified the SSD/Assistant ED and the DON of the incident and was told the situation was speculation and advised not to make a mountain out of a molehill. LPN1 stated when she reported behaviors of residents to facility management, she felt the concerns were swept under the rug, were not addressed, and were not reported to the appropriate agencies.During an interview with the SSD/Assistant ED on 01/14/2026 at 4:33 PM, she stated that she, the ED, and DON decided that the incident regarding R12 and R93 did not feel the witnessed incident on 01/05/2026 (in which R12 held R93 down, pushing her back into her bed while attempting to get on top of her), met the definition of abuse. Further interview with the SSD/Assistant ED revealed her belief that R93, who was assessed as severely cognitively impaired, could consent to being touched.Interview with the ED, on 01/15/2026 at 5:24 PM, revealed she was the facility's abuse coordinator. She stated that she, the SSD/Assistant ED, and the DON were responsible for conducting the facility's abuse investigations. The ED stated that, regarding the 01/015/2026 incident between R12 and R93, she, the DON, and SSD/Assistant ED had not determined that abuse had occurred. Further interview with the ED revealed she was aware of different types of abuse, including physical, mental, and sexual. However, she continued, they had decided the 01/05/2026 did not rise to the level of abuse because R93 had consented to R12 being in her room. Further interview with the ED revealed the belief that R93, who was assessed as severely cognitively impaired, could consent to R12 coming into her room and touching her. However, she could provide no evidence to support this belief. During an interview with the DON on 01/16/2026 at 1:40 PM, the DON revealed that she had not identified this incident as abuse because of her belief that the severely cognitively impaired female resident (R93) could consent to being touched by the male resident (R12). 3. Refer to F609 - Failure to immediately report all allegations of abuse, including injuries of unknown origin.a. Review of facility documentation and SSA records confirmed that the 01/05/2026 allegation of abuse of R93 by R12, which LPN1 witnessed and reported to the DON and SSD/Assistant ED, was not reported to any outside agencies, including law enforcement and/or the SSA.During an interview with the SSD/Assistant ED on 01/14/2026 at 4:33 PM, she stated the facility's policy for suspected abuse was to gather the information, discuss it as a team, and decide if it should be reported to the Office of Inspector General (SSA). The SSD/Assistant ED stated that the team, which also included the ED and DON, decided that the incident between R12 and R93 did not need to be reported to the appropriate agencies because they did not feel it met the definition of abuse, explaining her belief that R93, who was assessed as severely cognitively impaired, could consent to being touched.Interview with the ED, on 01/15/2026 at 5:24 PM, revealed the facility's policy included if abuse was suspected, the facility had 2 hours to report allegations to state agencies. Regarding the failure to report the allegation that R12 abused R93, the ED stated they had decided the 01/05/2026 incident was not reportable as it did not rise to the level of abuse because R93 had consented to R12 being in her room and could form consent to the male resident (R12) coming into her room and touching her.During an interview with the DON on 01/16/2026 at 1:40 PM, the DON stated that she was unsure whether the incident involving R12 and R93 should have been reported to reporting agencies or law enforcement, explaining that she had not identified this incident as abuse because of her belief that the severely cognitively impaired resident could consent to being touched. However, after a review of the facility's Abuse and Reporting Policy, the DON stated that one of the facility leadership members (ED, DON, or SSD/Assistant ED) should have reported the incident. The DON confirmed that incidents involving alleged sexual misconduct between residents should be reportedDuring an additional interview on 01/17/2026 at 11:11 AM, the ED further stated she often reached out to corporate for direction on reporting requirements.Interview on 01/17/2026 at 2:49 PM with the Director of Clinical Reimbursement (DCR - a corporate representative) revealed that if the facility feels they have an occurrence of abuse, they will contact the corporate team and ask their opinion. Although the DCR confirmed that allegations of abuse were to be reported within two hours, the DCR indicated it was the next day (more than the two hours required for immediate reporting to the SSA) before the facility contacted the Chief Executive Officer for guidance about the alleged incident between R12 and R93. Per the DCR, at this time the allegation was determined to not be a reportable allegation, adding, We did not see that any abuse had occurred.I would not consider it a reportable offense if it was just touching. b. Further review of facility investigations revealed that additional allegations of abuse or injuries of unknown origin, which did not rise to the level of IJ, were also not immediately reported to the SSA. These included allegations of resident-to-resident abuse of R90 by R67 on 12/26/2025, and injuries of unknown origin identified for R30 on 01/01/2026, R19 on 07/16/2025, R87 on 12/12/2025, and R84 on 01/12/2026.During an interview with the DON on 01/17/2026 at 10:20 AM, she stated that she was not aware that she was supposed to report allegations or suspicions of alleged abuse immediately to the appropriate State Agencies.During an interview with the ED, on 01/15/2026 at 5:24 PM, she stated there had not been any recent incidents that required reporting to the appropriate agencies. The ED stated that she, the SSD/Assistant ED, and the DON make the decisions to not report incidents. During an additional interview on 01/17/2026 at 11:11 AM, the ED further stated she often reached out to corporate for direction.Interview on 01/17/2026 at 2:49 PM with the DCR revealed that an allegation of abuse should be reported to state agencies within two hours; however, she was aware the facility would investigate and see what happened before reporting.

Based on interview, record review, and review of facility documentation and policies, the facility failed to conduct a thorough investigation in response to incidents of potential abuse and/or injuries of unknown origin involving six (Resident (R) 19, R30, R67, R84, R87, R90) of 13 sampled residents reviewed for abuse. The facility failed to thoroughly investigate alleged incidents and/or injuries of unknown origin so as to learn facts, determine if abuse had occurred, and identify actions to prevent the potential for further abuse.Findings include:Review of the facility's policy titled Abuse Reporting and Prevention, reviewed 07/2025, revealed that if abuse is reported by the resident, a full investigation of the allegation would be conducted by the Executive Director (ED), and/or designated facility staff. In addition, the policy noted that any resident injury of undetermined origin would be investigated in-house to rule out the possibility of physical abuse. Per the policy, as soon as possible, all information related to a report of abuse, et al, shall be obtained from all persons with knowledge of the reported incident. Pertinent interviews were to be conducted and put in writing, and may include the resident, if possible, the individual reporting the event, all staff on duty at the time of the event with any probable first-hand information, and other individuals present in the area at this time of the reported incident. Further review of the policy revealed upon receiving a verbal or written report of suspected or observed abuse, et al, the nursing home staff (Charge Nurse, Supervisor, Department Head, etc.) would immediately examine the resident for any sign of injury and inform the ED or designee. All statements during the course of the investigation were to be put in writing. 1. During an interview on 01/16/2026 at 11:14 AM with Laundry Aide (LA) 1, she stated upon entering R90's room, R90 was lying on the floor between the bed and recliner. LA1 stated she went to R90, who stated her roommate (R67) had pushed her down. LA 1 stated she immediately reported this allegation of resident-to-resident abuse to the nurse on duty.Review of a notepad document, with Investigation written on the page, dated 12/26/2025 at 12:30 PM and authored by the Director of Nursing (DON), revealed R90 was found on the floor in her room by a laundry aide. R90 stated that her roommate pushed her down. Further review of the document revealed R67 stated R90 was upset because [Resident name] married me and not her. However, R67 stated she did not push her down. The document concluded that, based on a reenactment by staff, the allegation could not have happened as described by R90. However, review of the investigation revealed no evidence of a written statement from LA1, and there was no evidence that a skin assessment (to observe for signs of injury) was completed for either R90 or R67. 2. Review of a handwritten statement, dated 07/16/2025, authored by the Director of Nursing (DON), revealed R19 had a bruise on the left outer knee, pale yellow in color. Further review of the statement revealed that R19 had an incident on 07/06/2025 when R19 was aggressive with staff and hit her hand (not her knee) on the table. Registered Nurse (RN) 1 had noted that on 07/06/2025 during the incident, R19 was kicking her legs; however, RN1 did not witness R19 kicking anything. In this note, the DON also documented R19 often pulled her legs up in a scrunched position in the wheelchair. Review of the facility documentation revealed that it failed to include a thorough investigation into the injury of unknown origin, in accordance with facility policy. There was no evidence of witness statements, or any interviews from other staff who may have provided care to R19 on the incident date, or in the ten days after the 07/06/2026 incident to determine possible timing and etiology of the bruise/injury. There was no evidence that a skin assessment of R19 was completed. Further review of the investigation revealed the conclusion that the cause of the bruising was based on an incident that happened ten days prior was made without sufficient facts that supported the conclusion and without ensuring that no other possible scenarios were responsible for the injury of unknown origin. 3. During a review of an incident report dated 01/01/2026 at 2:07 PM, Licensed Practical Nurse (LPN) 6 documented that R30 was noted to have dark, purple bruising on her inner left thigh down to her knee and a small bruise to the outer of her left thigh. R30 was unable to state the cause of the bruising. Review of the incident report revealed no skin assessment was completed and no statements from direct care staff were obtained to complete a thorough investigation into this injury of unknown origin. 4. Review of a notepad document with Investigation written on the page, on 12/12/2025 at 5:00 PM and authored by the DON, revealed the DON was made aware of a bruise to R87's right eye/cheek area. Staff interviews were conducted, and the DON determined the root cause was R87 was rubbing his face. There was no documented evidence of a thorough investigation as evidenced by a lack of written witness statements, or a complete skin assessment for R 87. 5. Review of a handwritten notepad document, dated 01/12/2026 at 10:15 AM and authored by the DON, revealed staff reported to her that R84 had a bruise to the left upper arm. The DON conducted interviews with staff and concluded no suspicion of abuse, determining R84 had contractures and the bruise happened during a gown change. There was no documented evidence that the incident was thoroughly investigated as evidenced by no written statements were obtained from staff that provided direct care and no evidence that a skin assessment was completed for R84. During an interview with the Social Services Director (SSD)/Assistant ED on 01/14/2026 at 4:33 PM, she stated the facility's policy for suspected abuse was to gather the information and discuss it as a team.During interview with the ED on 01/15/2026 at 5:24 PM, she stated she was the facility's abuse coordinator and that she, the SSD/Assistant ED, and the DON were responsible for conducting the facility's abuse investigations. The ED stated they interviewed staff and residents during their investigations.During an interview with the DON on 01/16/2026 1:40 PM, the DON stated that during the facility investigation, they determined how the injuries happened and therefore did not require any further investigation. The DON provided no further information to explain how these determinations were made when the facility investigations did not contain all information required by policy, nor why this information was not obtained.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure its residents were free from medication errors for 1 of 3 sampled residents, Resident (R)85.Following a medication observation with Registered Nurse (RN)2 it was determined she had crushed Pantoprazole 40 milligram (mg) Delayed Release (DR) tablet and an Isosorbide 30 mg Extended Release (ER) Tablet and administered them to R85. According to the pharmacy's instructions on the medication label, both medications should have been administered whole.The findings include:Review of the facility's policy titled, Medication Administration, effective date 08/2025 revealed medications were administered by licensed nurses, or other staff legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Further review of the policy revealed medications would be administered in accordance with the manufacturer's specifications and to crush medications as ordered. Do not crush medications with do not crush instructions.Observation on 01/13/2026 at 8:51 AM revealed RN2 had crushed one Pantoprazole 40mg Delayed Release (DR) tablet and one Isosorbide 30 mg Extended Release (ER) Tablet and administered them to Resident (R)85.Review of the medication administration directions on the medication labels on the unit dose packaging for R85's Pantoprazole 40mg DR tablet and Isosorbide 30 mg tablet revealed do not crush indications. During an interview on 01/13/2026 at 10:00 AM with RN2, she stated she knew the Isosorbide medication was labeled ER, but she did not notice it at the time of the medication pass. RN2 further stated she knew any medication labeled extended release was not supposed to be crushed. She stated she was surprised the Pantoprazole was also delayed release.During an interview on 01/15/2026 at 1:24 PM with Licensed Practical Nurse (LPN) 3, she stated any drug listed as ER or DR designated meds would not get crushed. LPN3 also stated that she would contact the provider if she noticed a resident who was supposed to have medications crushed had an order for ER or DR medications. LPN3 stated if ER or DR medications were given crushed, the resident could receive too much of the medication at one time and that it could throw the dosage out of range causing the resident harm.During an interview on 01/15/2026 at 1:31 PM with LPN 2, she stated ER and DR medications were not to be crushed and if a resident had an order to receive medications crushed, she would contact pharmacy for an alternate dosage or route. LPN2 further stated the possible outcome of a resident receiving an ER or DR medication crushed would be all the medication would be released at one time instead of over an extended period which could cause harm to the resident.During an interview in 01/13/2026 at 10:45 AM with the Pharmacist he stated any ER or DR medications should not be crushed but administered whole to the resident to maintain its effectiveness. The Pharmacist stated if crushed, the medications would not deliver to the resident over an extended period of time, were broken down faster and could potentially wear off faster. He stated the instructions stating do not crush the medications were located on the medication label which was attached to the box of medication and the label would also include the resident's name, prescription number, name of medication, strength, dosage instructions, name of the ordering physician, and the number of refills.During an interview on 01/16/2026 at 8:37 AM with the Director of Nursing (DON) she stated any medication designated as ER or DR should not be crushed and her expectation was the nurse would get recommendations from the doctor or the pharmacy to change the medication to another medication that could be crushed or get a different consistency for the same medication as needed. The DON stated ER or DR medications should not be crushed as the resident would get too much of the medication at one time as opposed to the dose being dispersed in the body over a certain period of time. Lastly, the DON stated she expected the nurses would check the drug guide located in all of the medication rooms which gave the nurses more information on which medications could be crushed.During an interview on 01/16/2026 at 9:29AM with the Administrator she stated her expectation was medications labeled ER or DR were not to be crushed.

Based on observations, interviews, record review, and review of the facility's policy the facility failed to 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 diseases and infections. The findings include:Review of the facility's policy, titled Policy and Procedure: Transmission-Based Precautions, revised 04/01/2024, revealed droplet precautions referred to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Continued review of the policy revealed that anyone entering a resident's room in droplet precaution should perform hand hygiene and don (put on) a face mask. Additionally, if there was a substantial risk of exposure to mucous membranes or spraying of respiratory secretions, then personal protective equipment (PPE) should also include a gown, gloves, face shield, and/or goggles. Review of the facility's policy, titled Policy and Procedure: Infection Prevention and Control, revised 10/2025, revealed the facility's infection prevention and control program (IPCP) was based upon information which followed national standards and guidelines to prevent, recognize, and control the onset and spread of infection and communicable diseases whenever possible. Observation of Resident (R) 80's room on 01/12/2026 at 11:18 AM revealed a sign outside of the room for droplet precautions. Continued observation of the room revealed the outside door was left open. and there was no clear curtain pulled around the bed to prevent droplets from spreading.Observation of R80's room on 01/12/2026 at 12:05 PM and at 1:02 PM revealed the outside door remained opened. There was no curtain around the resident's bed. Observation of R80's room on 01/12/2026 at 1:02 PM revealed the Scheduler took a lunch tray into R80's room, which was a droplet precaution room without donning PPE prior to entering the room. Continued observation of R80's room revealed the Scheduler came out of the room and obtained another tray from the meal cart and proceeded back into the room to deliver a lunch tray to the other resident without donning PPE. Additionally, the Scheduler came out and obtained another lunch tray and proceeded to enter another resident's room. Observation of Licensed Practical Nurse (LPN) 5 on 01/12/2026 at 1:10 PM revealed LPN5 rolled the treatment cart into a resident's room to complete a treatment. Observation revealed LPN5 failed to clean the cart after leaving the resident's room.During an interview with LPN5 on 01/12/2026 at 1:18 PM, she stated she used the treatment cart to lay her supplies on and when she came back out of the room with the treatment cart, the cart did not require any special cleaning. Continued interview with LPN5 revealed LPN5 did not feel the need to clean the treatment cart after it had been in a resident's room. During an interview with the Infection Preventionist (IP) on 01/16/2026 at 9:29 AM, the IP stated she trained staff on infection control issues such as PPE donning and doffing (removing), hand hygiene, and general infection control topics during orientation for new hires, annually, and as needed for any changes or concerns. The IP stated it was her expectation that all staff follow policies and procedures for all infection control practices. During the interview the IP stated any staff entering a droplet precaution room should have the door closed unless the resident was a fall risk, and then staff would pull a clear curtain around the resident. The IP stated it was her expectation that staff either closed the door or pulled the clear curtain around the resident in droplet precaution. Additionally, the IP stated it was her expectation that any staff entering the room would clean their hands and don PPE which should include a gown, mask, and gloves at the very least. The IP stated when staff left the room, they should remove their PPE and clean their hands. She stated any cart whether it was a medication cart or a treatment cart, it was her expectation that the cart be cleaned with the purple Sani wipes as it was a microbial disinfectant, after it was brought out of a resident's room to prevent the spread of infection. During an interview with the Director of Nursing (DON) on 01/17/2026 at 10:20 AM, she stated it was her expectation that all staff follow all policies related to infection control. The DON stated all staff had to wear PPE when entering and exiting a resident's room who was on droplet precaution. She stated the risk for not following the facility's policy could result in cross contamination and the further spread of infection.During an interview with the Scheduler on 01/19/2026 at 9:30 AM, she stated she did not pay attention to the sign on the outside of the door which indicated droplet precautions. The Scheduler stated she did not gown up or wear any PPE when she took the trays into room [ROOM NUMBER] and room [ROOM NUMBER]. The Scheduler stated she should have worn a mask, gown, and gloves when entering the rooms as she did not want to risk spreading infections to other residents in her care. She stated the biggest risk was possible spreading of infections to other residents and that she had been trained on how to prevent the spread of infection, but just did not pay attention to the sign.

Based on observation, interview and review of the facility's policy, the facility failed to ensure all medications were labeled at a minimum of the medication's name (generic and/or brand), prescribed dose, strength, the expiration date when applicable, the resident's name, and route of administration; and include an opened date if indicated for three (3) of six (6) sampled medication carts and 1 of 2 sampled medication refrigerators. The findings include:Review of the facility's policy titled, Storage and Expiration Dating of Medication and Biologicals dated as effective 12/01/2007 and revised on 06/30/2025 revealed the policy set forth procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles.Additional review of the policy revealed the facility should ensure medications and biologicals that had an expired date on the label or had been retained longer than recommended by the manufacturer or supplier guidelines were stored separate from other medications until destroyed or returned to the pharmacy/supplier.Further review of the policy revealed once any medication or biological package was opened, facility staff would record the opened date on the primary medication container.Lastly, review of the policy revealed if a multi-dose vial of an injectable medication had been opened or accessed, the vial should be dated and discarded within twenty-eight (28) days unless the manufacturer specified a different date for that opened vial. Observations on 01/12/2026 at 3:40 PM of the third-floor north medication cart revealed one opened bottle of Lactulose 10gm/15ml (gram/milliliter) Liquid 16 ounces with an open date of 05/08/2025 and a manufacturer's expiration date of 12/2025. Further observation revealed an open bottle of Nystatin 100,000 units/ml 16 ounces and an opened bottle of Guaifenesin DM 16 ounces both with no open dates.Observation on 01/13/2026 at 4:15 PM of the third-floor east medication cart revealed one opened bottle of Lantanoprost 0.005% Opthalamic solution 2.5ml with no open date.Observation on 01/13/2026 at 4:15 PM of the third-floor west medication cart revealed one opened Glarine U-100 insulin pen with no resident label and no open date.Observations of the third-floor medication room refrigerator revealed one opened Insulin Lispro Kwik Pen with no resident label. An opened bottle of Tubersol Purified Protein derivative 1ml multi-dose vial was observed with no open date.During an interview on 01/15/2026 at 1:24 PM with Licensed Practical Nurse (LPN) 3 she stated expired medications/narcotics were wasted by the unit supervisor. She stated pharmacy audited the medication carts, but she was not sure how often. LPN3 stated the nurses checked medication expiration dates every shift. She stated a multi-use vial, or an insulin pen should be dated when opened and could be used for thirty (30) days.During an interview on 01/15/2026 at 1:31 PM with LPN2 she stated nurses should be checking the medication carts for expired medications daily. She stated expired medications or narcotics were removed by a nurse and given to the DON or floor supervisor. LPN2 stated pharmacy also audited the med carts. She stated multi-use medications and insulin pens were dated when opened and were able to be used for twenty-eight (28) days.During an interview in 01/13/2026 at 10:45 AM with the Pharmacist stated the facility performed audits of the medication carts, medication rooms and the medication refrigerators for expired and unlabeled medications. He stated this was important to avoid the use of expired medications which could either be ineffective for the resident's condition or could cause unwanted side effects.During an interview on 01/16/2026 at 8:37 AM with the Director of Nursing (DON) she stated her expectation was the nurses checked for expired medications during their medication passes. The DON stated the pharmacy also audited the medication carts for expired medications during monthly visits to prevent expired medications from being used.During an interview on 01/16/2026 at 9:29 AM with the Administrator she stated her expectation was expired medications were removed from the medication cart, medication room and medication refrigerators to avoid them being given to a resident. She stated that all medications should be labeled with an open date so staff would know whether or not the medication was in date and safe to use.

Based on observation, interview, and record review it is determined the facility failed to evaluate Resident (R1) for the ability to safely self-administer medications for one of 31 sampled residents. During an observation on 3/10/2025 at 3:43 PM, an open bottle of prescribed Nystatin Powder (an antifungal medication that treats skin infections caused by yeast) was found on R1's bed. R1 stated she applied the medication herself throughout the day. However, facility staff found no documentation or assessment to indicate the interdisciplinary team had evaluated and determined R1's ability to safely self-administer medications. The findings include: A review of the facility's policy titled Self-Administration of Medications revised date 11/29/2022, revealed, It is the policy that allows residents who have been assessed by the interdisciplinary team upon admission, quarterly, and with change of condition as clinically appropriate to self-administer their own medications or medicated treatments. The policy further revealed that the medications must be kept in a locked area. A review of R1's Admission Face Sheet revealed the facility admitted the resident on 01/04/2016 with the primary diagnosis of Hemiplegia and hemiparesis following cerebral infarction affect left non-dominant side, and dementia. A review of R1's Minimum Data Set (MDS) revealed that the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 on 12/23/2024, which indicated the resident was cognitively intact. A review of R1's Assessments revealed that the facility had not assessed the resident for self-administration of medications. Observation on 03/10/2025 at 3:20 PM, revealed one opened bottle of prescribed Nystatin Powder in a clear plastic container on R1 's bed. The medication label directed that the powder should be applied as needed. During an interview with R1 on 03/10/2025 at 3:20 PM, R1 stated she applied the Nystatin Powder to various areas of her body as she needed it. During an interview with Registered Nurse (RN) 1 on 03/10/2025 at 3:43 PM, she stated that the Interdisciplinary team had not completed a self-administration medication evaluation on R1. RN1 continued to state that R1 should not have Nystatin Powder at the bedside or self-apply it. RN1 further stated that the potential risk of R1 self-administering medication was the resident could apply the wrong amount or consume it. During an observation on 03/11/2025 at 8:25 AM, RN6 entered R1's room with the resident's morning medications. RN6 told R1 that she couldn't leave her cup of medicines on the table for R1 to take when she wanted due to state surveyors being in the building. During an interview with RN6 on 03/11/2025 at 8:29 AM, she stated that she routinely left R1's medications on her bedside table because R1 didn't like to take them during the scheduled medication pass, allowing R1 to take them when she was ready. RN 6 further stated the potential risk of R1 self-administering medications was the resident could forget to take the drugs or another resident could accidentally take them. During an interview with the Administrator on 03/12/2025 at 10:57 AM, she stated that residents were not supposed to have medications at the bedside due to the risk of another resident taking them. The Administrator further stated that the facility had no residents that self-administered their medications.

Based on interview, record review, and facility policy review it was determined the facility failed to allow a resident to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States for 1 of 1 sampled resident (Resident (R) 1). The facility must protect and promote the rights of the resident. Although R1 had not been assessed as an elopement risk and did not consent for wander guard placement, the facility placed a wander guard on R1 on 08/01/2024. The findings include: Review of the facility policy, titled Policy and Procedure: Resident Rights, revised 09/29/2022, revealed residents have the right to be treated with respect and to be free from abuse and neglect. Continued review of the facility policy revealed nursing homes cannot keep a resident apart from everyone else against their will. Review of R1's Face Sheet revealed the facility admitted the resident on 07/11/2024 with diagnoses of metabolic encephalopathy, essential (primary) hypertension, depression, and muscle weakness. Review of R1's Admission Minimum Data Set (MDS), dated [DATE], revealed R1 had a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen, which indicated R1 was moderate cognitively impaired. Review of R1's follow-up BIMS evaluation, dated 08/30/2024, entered by Social Services Director (SSD), revealed R1 had a BIMS score of twelve out of fifteen, which indicated R1 was moderate cognitively impaired. Review of R1's Comprehensive Care Plan (CCP), undated, revealed R1 had interventions of wander system bracelet applied, ensure wander system bracelet was checked every shift for placement, and to give R1 activities for diversion. Review of R1's Progress Notes, dated 08/30/2024, entered by SSD, revealed R1 was educated to sign out at the nurses' station anytime he plans to go out of the facility. Review of R1's Elopement Risk Assessment Document, dated 08/02/2024, revealed R1 had been assessed to have a total score of 1, which indicated minimal risk for elopement. During an interview with R1 on 09/03/2024 at 1:40 PM, he stated he had walked out of the facility because he had wanted to talk to a friend that she had assisted both him and his wife in the past. R1 stated he had removed his wander guard bracelet prior to leaving the facility with a family friend. R1 stated he was a grown man, and he was not a prisoner at the facility. R1 further stated he was a free man in the United States and did not want the wander guard bracelet put on him. During an interview with Family Member (FM) 1 on 09/03/2024 at 1:49 PM, she stated R1 had called her to let her know a friend had picked him up and took him to a local Church to help him get some more clothes. She continued to state R1 called the facility to let them know he had left the facility and staff picked him up and brought him back to the facility. She further stated that R1 had told her that he did not like the wonder guard bracelet on him and did not know why he had it because he had signed himself out in the past with no problems and had signed himself into the facility for therapy and could sign himself out when he wanted to leave. During an interview with Licensed Practical Nurse (LPN)1 on 09/03/2024 at 2:05 PM, she stated R1 had a wander guard bracelet on prior to him leaving the facility. LPN1 stated R1 had signed himself into the facility and had signed himself out of the facility on multiple occasions. LPN1 continued to state R1 could easily live outside the facility with someone safely. LPN 1 further stated R1 was in his right mind and had the ability to sign himself out at any time and had done so on numerous occasions to visit with either his wife or friends. Interview with Certified Nursing Assistant (CNA)1 on 09/03/2024 at 2:14 PM, she stated she had seen R1 sign himself out of the facility and go visiting with his wife on numerous occasions. During an interview with LPN2 on 09/03/2024 at 4:06 PM, she stated R1 was a strong willed person and if he wants to do something he will, and if he doesn't, he won't. LPN2 further stated R1 does not like having a wander guard bracelet on him and prefers to come and go at the facility. During an interview with the Director of Nursing (DON) on 09/03/2024 at 4:45 PM, she stated the facility was trying to find an apartment for R1 and his wife.The DON stated the wander guard was placed due to R1 wanting to leave the facility to be with his wife. However, she further stated she was aware R1 had signed himself into the facility and did not think about R1's right to refuse treatment. The DON continued to state R1 had been assessed as a low risk for elopement with fairly high BIMS score and she now realized the facility should have called the doctor to have R1 assessed before placing the wonder guard on R1. The DON further stated the doctor would have probably discharged the resident. During an interview with the Medical Director (MD) on 09/03/2024 at 5:13 PM, he stated both him and his Nurse Practitioner (NP) had seen R1 in the facility and was aware of R1 wanting to be with his wife. The MD stated R1 had signed himself into the facility and was able to sign out of the facility at any time. The MD stated he really didn't understand why the facility had placed the wander guard bracelet on R1 and further stated, he's not a prisoner there. The MD continued to state R1 was safe enough to leave the facility at any time and had came to the facility for therapy. During an interview with the Administrator on 09/03/2024 at 5:40 PM, she stated the wander guard bracelet was first applied on R1 when he started talking about leaving the facility to be with his wife. She continued to state the facility could not hold R1 against his will and now believes the staff should have called the Medical Director to alert him that R1 wanted to leave the facility. The Administrator stated that R1 had signed himself into the facility and had the right to leave the facility at any time. The Administrator further stated R1 had signed himself out on occasion to visit with wife with no issues and that R1 was not a prisoner of the facility. She further stated that residents have the right to refuse treatment.

Based on observations, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-seven (27) sampled residents received adequate supervision to prevent accidents. The facility assessed Resident #8 to be at risk for elopement and was to wear a wander bracelet (a device worn that emits a sound when passed through an alarmed door). However, observations on 02/05/2020 revealed the resident was not wearing the bracelet as required. The findings include: Review of the facility's policy, Elopement, undated, revealed care plans for residents assessed to be at risk for elopement would include individualized interventions. Review of Resident #8's medical record revealed the facility admitted the resident on 09/21/2017 with [DIAGNOSES REDACTED]. Review of Resident #8's Minimum Data Status (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5), indicating the resident was severely cognitively impaired. Review of an Elopement Risk Assessment for Resident #8 dated 01/06/2020 revealed the resident was at risk for elopement due to having cognitive impairment with poor decision-making skills and being independently ambulatory. Review of Resident #8's care plan, last evaluated on 02/05/2020, revealed that interventions implemented related to the resident being at risk for elopement included the resident wearing a wander bracelet. Further review of the care plan revealed staff were to monitor placement of the bracelet every shift, to ensure the bracelet was in place on the resident. Observations of Resident #8 on 02/05/2020 at 1:34 PM and 2:35 PM revealed the resident was not wearing a wander bracelet. However, review of the resident's Treatment Administration Record (TAR) for 02/05/2020 revealed documentation for the 7AM-3PM shift indicating the resident was wearing the bracelet and that it was functioning. Interview with LPN #1 on 02/05/2020 at 2:35 PM revealed Resident #8 was supposed to be wearing a wander bracelet; however, upon checking the resident LPN #1 was unable to locate a wander bracelet on the resident. Interview with RN #1 on 02/06/2020 at 2:18 PM revealed she had removed Resident #8's wander bracelet at approximately 10:00 AM on 02/05/2020 due to a recent skin tear on the resident's left wrist, and had not replaced the bracelet. Further interview with RN #1 revealed the RN failed to place another wander bracelet on the resident. Interview with the Unit Manager on 02/06/2020 at 2:50 PM revealed RN #1 should have immediately replaced the wander bracelet for Resident #8.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman of the intent to transfer one (1) of three (3) sampled residents (Resident #1). The facility issued a discharge notice for Resident #1 to Resident #1's family on 06/28/18; however, the facility failed to ensure the correct contact information (address and telephone number) for the Ombudsman was provided on the discharge notice. The findings include: Review of the facility's Discharge Policy, revised (MONTH) (YEAR), revealed a resident would be notified in writing of a discharge, and the facility must send a copy of the notice to a representative of the office of the State Long-Term Care Ombudsman. Review of Resident #1's medical record revealed the facility admitted Resident #1 on 06/28/17. The resident's [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was eleven (11). Review of a Notice of Intent to Discharge revealed the facility issued a discharge notice to Resident #1's sons on 06/28/18. The notice stated the facility planned to discharge Resident #1 effective 07/28/18. Further review of the notice revealed the incorrect contact information (address and telephone number) was listed for the Office of the Ombudsman. In addition, there was no documented evidence that the facility issued a copy of the notice to the Ombudsman. Interview with the Social Worker on 07/24/18 at 9:17 AM revealed a discharge notice had been issued to Resident #1's family due to non-payment. She stated the notice originated in the business office, then she was supposed to receive a copy of the discharge letter to send to the Ombudsman. However, the Social Worker stated she was not aware that a letter was sent to Resident #1's family and did not send a notice to the Ombudsman when the first notice was issued. Further interview revealed the Social Worker was not aware the contact information on the facility's discharge letter was incorrect until the Ombudsman contacted her after Resident #1's family had contacted the local Ombudsman. Interview with the Billing Specialist on 07/24/18 at 9:36 AM revealed the facility sent a letter to Resident #1's two (2) sons, but did not give Resident #1 the notice because she was told Resident #1 would not understand the notice. Continued interview revealed the thirty (30) day discharge notice was issued due to non-payment. Interview with the Administrator on 07/24/18 at 10:14 AM revealed the correct contact information for the State Long-Term Care Ombudsman should have been included in the discharge notice and the notice should have been sent to a representative of the Office of the State Long-Term Care Ombudsman.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to review and revise the comprehensive person-centered care plan with interventions to secure the indwelling urinary catheter for one (1) of nineteen (19) sampled residents (Resident #43). Review of the facility's catheter care policy revealed urinary catheters were required to be secured to prevent unnecessary pulling. However, a review of Resident #43's comprehensive care plan revealed the facility failed to develop interventions to address securing the resident's indwelling urinary catheter to prevent trauma, and observation on 12/19/17 revealed the resident's indwelling urinary catheter was not secured. The findings include: Review of the facility's policy titled Catheter Care-Indwelling, with a revision date of 01/23/12, revealed the facility's policy was to secure catheter tubing to avoid any unnecessary pulling on the tubing. Review of the facility's policy titled Care Planning, undated, revealed the facility would develop and implement a comprehensive person centered care plan for each resident, which reflected the resident's medical, mental, and psychosocial needs. Review of Resident #43's medical record revealed the facility admitted the resident on 12/19/14, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of Resident #43's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12), and an indwelling urinary catheter. Review of the care plan for Resident #43 dated 05/12/16 revealed ongoing interventions related to the resident's indwelling urinary catheter. However, there was no evidence the facility reviewed/revised the comprehensive care plan to include interventions to secure Resident #43's indwelling urinary catheter to prevent trauma. Observation of indwelling urinary catheter care for Resident #43 on 12/19/17 at 9:23 AM revealed the urinary catheter was not secured to prevent trauma. State Registered Nursing Assistant (SRNA) #1 provided catheter care but did not ensure the urinary catheter was secured after providing care. Interview with the MDS Coordinator on 12/20/17 at 2:00 PM revealed she was a member of the interdisciplinary team and the team was responsible for developing residents' comprehensive plans of care. The MDS Coordinator stated the facility should have reviewed and revised Resident #43's care plan to include an intervention to ensure the resident's catheter tubing was secured to prevent trauma. Interview with the Director of Nursing (DON) on 12/20/17 at 1:30 PM revealed she attended all care plan meetings and was responsible for ensuring resident care plans were reviewed and revised, but was not aware that Resident #43's care plan did not include an intervention to secure the resident's urinary catheter.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of nineteen (19) sampled residents (Resident #43) received appropriate treatment and services for an indwelling urinary catheter. Observation of indwelling urinary catheter care for Resident #43 on 12/19/17 revealed staff failed to secure the indwelling urinary catheter to prevent trauma as required by the facility's policy. The findings include: A review of the facility's policy titled Catheter Care-Indwelling, with a revision date of 01/23/12, revealed the facility's policy was to secure urinary catheter tubing to avoid any unnecessary pulling on the tubing. However, observation of indwelling urinary catheter care for Resident #43 on 12/19/17 at 09:23 AM revealed the resident's catheter was not secured, and State Registered Nursing Assistant (SRNA) #1 did not secure the catheter after providing incontinence care. Further observation on 12/20/17 at 9:00 AM revealed the resident's urinary catheter was not secured. An interview with SRNA #1 on 12/20/17 at 1:10 PM revealed the SRNA was aware that Resident #43's catheter was required to be secured. SRNA #1 stated nurses were required to apply catheter securing devices and the SRNAs were only allowed to attach the catheter tubing to the device once the device was in place. SRNA #1 stated she reported to Registered Nurse (RN) #1 on 12/19/17 that the resident did not have a catheter securing device. An interview conducted with RN #1 on 12/20/17 at 1:20 PM revealed the facility utilized a velcro type securing device to secure indwelling urinary catheters. RN #1 stated SRNAs were required to report to Nursing when a urinary catheter was not secured and there must have been some miscommunication with the SRNA because the RN was not aware that Resident #43 did not have a urinary catheter securing device. An interview with Unit Manager (UM) #1 on 12/20/17 at 1:25 PM revealed she monitored daily to ensure catheters were secured but was not aware Resident #43's catheter was not secured. An interview with the Director of Nursing (DON) on 12/20/17 at 1:30 PM revealed staff were required to use catheter securing devices or tape to ensure residents' indwelling catheters were secured. The DON stated she made rounds twice daily but had not identified that Resident #43's catheter was not secured.

Based on observation, interview, record review, facility policy review, and a review of the facility's investigation, it was determined the facility failed to ensure staff provided care in accordance with the written plan of care for one (1) of eighteen (18) sampled residents (Resident #3). Review of Resident #3's care plan dated 02/07/14 revealed the facility had assessed the resident to require the assistance of two (2) persons for transfers. However, review of a fall investigation dated 02/03/16 revealed on 02/03/16, at 2:00 PM, State Registered Nursing Assistant (SRNA) #1 transferred the resident unassisted, resulting in the resident being lowered to the floor and sustaining an abrasion to the back. The findings include: Review of the facility policy titled, Care Plan, undated, revealed a care plan would be developed for all residents of the facility and would provide guidance to all staff that provided care for the resident. Review of the medical record revealed the facility admitted Resident #3 on 06/04/09 with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment for Resident #3 dated 12/06/15, revealed the facility assessed Resident #3 to require the extensive assistance of two persons with transfers. The assessment also revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. Review of Resident #3's care plan dated 02/07/14 revealed staff was to transfer the resident with the assistance of two staff members. Review of a fall investigation dated 02/03/16 revealed on 02/03/16, at 2:00 PM, State Registered Nursing Assistant (SRNA) #1 transferred Resident #3 unassisted, resulting in the resident having to be lowered to the floor, sustaining an abrasion to his/her back. Observation and interview with Resident #3 on 10/20/16, at 8:00 AM, revealed he/she could not remember the fall that occurred on 02/03/16. Interview conducted with Registered Nurse (RN) #1 on 10/20/16, at 10:55 AM, revealed SRNA #1 had transferred the resident from the wheelchair to the bedside commode without obtaining assistance from another staff member as required by the resident's plan of care. The RN stated all staff was required to review each resident's care plan prior to providing care to the resident at the beginning of each shift. Interview conducted with RN #2 on 10/20/16, at 11:10 AM, revealed SRNA #1 was no longer employed at the facility. Interview conducted with the Administrator on 10/20/16, at 11:15 AM, revealed all SRNAs were required to review resident care plans prior to providing care to residents. The Administrator stated she had not identified any concerns related to staff failure to provide assistance or care in accordance with the plan of care prior to the fall incident with Resident #3 on 02/03/16.

Based on observation, interview, record review, facility policy review, and review of a facility investigation, it was determined the facility failed to ensure adequate supervision and assistance was provided for one (1) of eighteen (18) sampled residents (Resident #3) to prevent accidents. Review of a fall investigation dated 02/03/16 revealed on 02/03/16, at 2:00 PM, State Registered Nursing Assistant (SRNA) #1 was transferring Resident #3 unassisted when the resident lost his/her balance. SRNA #1 lowered the resident to the floor and the resident sustained [REDACTED]. Review of Resident #3's care plan dated 02/07/14 revealed the facility assessed Resident #3 to require the assistance of two (2) persons for transfers. The findings include: Review of the facility's policy titled, Falls Prevention, undated, revealed interventions would be implemented to provide supervision and assistance to residents in an effort to avoid falls and minimize injury that may result from a resident falling. A review of Resident #3's medical record revealed the facility admitted Resident #3 on 06/04/09 with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set (MDS) assessment for Resident #3 dated 12/06/15 revealed the facility assessed Resident #3 to require the extensive assistance of two persons with transfers. The MDS also revealed the facility had assessed Resident #3 to have a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. A review of a fall investigation dated 02/03/16 revealed on 02/03/16, at 2:00 PM, Resident #3 had been transferred by State Registered Nursing Assistant (SRNA) #1 unassisted and the resident lost his/her balance, requiring SRNA #1 to lower the resident to the floor. The resident was assessed to have sustained an abrasion to his/her back measuring 4 centimeters. Observation of and interview with Resident #3 on 10/18/16, at 11:05 AM, revealed the resident was observed to be sitting in his/her wheelchair in the dining room drinking coffee. Interview with Resident #3 on 10/20/16, at 8:00 AM, revealed he/she could not remember the fall that occurred on 02/03/16. An interview conducted with Registered Nurse (RN) #1 on 10/20/16, at 10:55 AM, revealed she was responsible for Resident #3 on 02/03/16. RN #1 stated SRNA #1 had transferred the resident from the wheelchair to the bedside commode unassisted. The RN also stated that Resident #3 was required to have two staff members assist with transfers. Interview with the Administrator on 10/20/16, at 11:15 AM, revealed SRNA #1 was no longer employed at the facility. The Administrator stated she conducted observations of resident care throughout the day in an effort to ensure each resident's care needs were met and staff was providing the required assistance to each resident. The Administrator stated she had not identified any concerns related to staff failure to provide assistance or care in accordance with Resident #3's plan of care prior to the incident on 02/03/16.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to provide services in accordance with the written plan of care for one (1) of eighteen (18) sampled residents (Resident #11). Review of Resident #11's Comprehensive Care Plan revealed fall interventions for Resident #11 were to have a low bed and to have a pressure pad alarm to his/her bed. However, observation on 09/23/15 revealed Resident #11's bed was not in the lowest position and the bed sensor alarm was not present to his/her bed. The findings include: Review of the facility policy, Implementation of Plan of Care, dated May 2014, revealed all staff was to follow the Plan of Care as written for each resident to ensure consistency and correct approach for each resident's care. Review of Resident #11's medical record revealed the facility admitted Resident #11 on 06/04/09 with [DIAGNOSES REDACTED]. Review of Resident #11's Significant Change Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #11 to have a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #11 was moderately impaired cognitively. Further review of Resident #11's MDS assessment revealed Resident #11 had sustained a fall with a fracture within the last month. Continued review of Resident #11's medical record revealed Resident #11 had fallen on 05/27/15 and as a result sustained a tibia (shinbone) and fibula (calf bone) fracture. Review of Resident #11's Comprehensive Care Plan, undated, revealed Resident #11 to be at risk for falls with interventions of a low bed and a bed sensor alarm. Observation on 09/23/15 at 3:30 PM revealed Resident #11 to be in bed with the bed not in the lowest position. Continued observation of Resident #11 revealed no bed sensor alarm present on his/her bed. Interview with State Registered Nurse Aide (SRNA) #1 on 09/23/15 at 4:13 PM revealed that he was assigned to the hall where Resident #11 resided. SRNA #1 stated if a resident had an intervention on his/her care plan to have a low bed, then the bed should have been in the lowest position. Continued interview with SRNA #1 revealed he looked at a resident's nurse aide care plan in the computer to find out what care was to be provided for each resident. Further interview with SRNA #1 revealed he did not know why Resident #11's bed was not in the lowest position and also did not know why Resident #11 did not have a bed sensor alarm present on his/her bed. Interview with SRNA #2 on 09/23/15 at 4:28 PM revealed making sure care plan interventions were followed was both a nurse aide and nurse responsibility. Continued interview with SRNA #2 revealed if a resident had an intervention for a low bed the bed should be in the lowest position. Interview with Licensed Practical Nurse (LPN) #1, the nurse assigned to care for Resident #11, on 09/23/15 at 4:28 PM revealed that an intervention for a low bed meant that a resident's bed should have been in the lowest position. Continued interview with LPN #1 revealed she did rounds daily to ensure care plans were being followed. Further interview with LPN #1 revealed she was not aware of Resident #11's bed not being in the lowest position and was also not aware that Resident #11 did not have a bed sensor alarm present to his/her bed. LPN #1 stated she expected nurse aides to look at each resident's nurse aide care plan to ensure proper care had been provided. Interview with the Second Floor Unit Manager (UM) on 09/23/15 at 4:33 PM revealed nurse aides should have checked for alarms to ensure that they were present on Resident #11's bed. Continued interview with the UM revealed the low bed intervention listed on Resident #11's care plan was not a fall intervention and that all nonambulatory residents in the facility have their beds placed in the lowest position at night. Further interview with the UM revealed she was not sure why Resident #11 did not have a bed sensor alarm in place. Interview with the Second Floor UM on 09/24/15 at 1:49 PM revealed she conducted spot checks on approximately ten resident rooms weekly to ensure care plans had been followed and had not identified any concerns. Further interview with the UM revealed the facility quality assurance committee conducted monthly audits to ensure care plans were being followed. Continued interview with the UM revealed nurses and nurse aides should look at each resident's care plan daily. Interview with the facility Director of Nursing (DON) on 09/24/15 at 2:23 PM revealed she conducted rounds with the facility administrator daily to ensure residents' care plans were being followed and that the quality assurance committee met monthly to ensure care plans were being followed. Continued interview with the DON revealed a morning meeting was conducted daily to discuss any concerns, updates, and/or revisions that may need to be made to a resident's care plan. Continued interview with the DON revealed that low bed means a resident's bed should be in the lowest position possible. Further interview with the DON revealed Resident #11's low bed had not been intended to be an intervention related to falls. Further interview with the DON revealed the bed sensor alarm was not intended to be a long-term intervention for Resident #11 and that it was just an intervention put in place when Resident #11 returned to the facility from the hospital.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure residents were as free of accident hazards as possible and that assistive devices were provided to prevent accidents for one (1) of eighteen (18) sampled residents (Resident #11). Review of Resident #11's Comprehensive Care Plan revealed fall interventions for Resident #11 were to have a low bed and to have a pressure pad alarm to his/her bed. However, observation on 09/23/15 revealed the fall interventions for Resident #11 were not implemented. The findings include: Review of the facility policy, Falls Prevention, undated, revealed through assessment and intervention the facility would provide supervision and assistance to residents in an effort to avoid falls and minimize injury that may result from a resident falling. Review of Resident #11's medical record revealed the facility admitted Resident #11 on 06/04/09 with [DIAGNOSES REDACTED]. Review of Resident #11's Significant Change Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #11 to have a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #11 was moderately impaired cognitively. Further review of Resident #11's MDS assessment revealed Resident #11 had sustained a fall with a fracture within the last month. Continued review of Resident #11's medical record revealed Resident #11 had fallen on 05/27/15 and as a result sustained a tibia (shinbone) and fibula (calf bone) fracture. Review of Resident #11's Comprehensive Care Plan, undated, revealed Resident #11 to be at risk for falls with interventions for a low bed and a bed sensor alarm. Observation on 09/23/15 at 3:30 PM revealed Resident #11 to be in bed with the bed not in the lowest position. Continued observation of Resident #11 revealed no bed sensor alarm was present on his/her bed. Interview with State Registered Nurse Aide (SRNA) #1 on 09/23/15 at 4:13 PM revealed he was assigned to the hall where Resident #11 resided. SRNA #1 stated that if a resident had an intervention on his/her care plan to have a low bed, then the bed should have been in the lowest position. Further interview with SRNA #1 revealed he looked at a resident's nurse aide care plan in the computer to find out what care was to be provided for each resident. Continued interview with SRNA #1 revealed he did not know why Resident #11's bed was not in the lowest position and also did not know why Resident #11 did not have a bed sensor alarm present on his/her bed. Interview with SRNA #2 on 09/23/15 at 4:28 PM revealed making sure care plan interventions were followed was both a nurse aide and nurse responsibility. Further interview with SRNA #2 revealed if a resident had an intervention for a low bed then the bed should be in the lowest position. Interview with Licensed Practical Nurse (LPN) #1 on 09/23/15 at 4:28 PM revealed that an intervention for a low bed meant that a resident's bed should have been in the lowest position. Further interview with LPN #1 revealed she did rounds daily to ensure care plans were being followed. Continued interview with LPN #1 revealed she was not aware of Resident #11's bed not being in the lowest position and was not aware that Resident #11 did not have a bed sensor alarm present to his/her bed. LPN #1 stated she expected nurse aides to look at each resident's nurse aide care plan to ensure proper care had been provided. Interview with the Second Floor Unit Manager (UM) on 09/23/15 at 4:33 PM revealed nurse aides should have checked for alarms to ensure that they were present on Resident #11's bed. Further interview with the UM revealed the low bed intervention listed on Resident #11's care plan was not a fall intervention and that all nonambulatory residents in the facility have their beds placed in the lowest position at night. Continued interview with the UM revealed she was not sure why Resident #11 did not have a bed sensor alarm in place. Interview with the Second Floor UM on 09/27/15 at 1:49 PM revealed she conducted spot checks on approximately ten resident rooms weekly to ensure fall interventions were in place and had not identified any concerns. Continued interview with the UM revealed the facility quality assurance committee conducted monthly audits to ensure fall interventions were in place. Further interview with the UM revealed nurses and nurse aides should look at each resident's care plan daily. Interview with the facility Director of Nursing (DON) on 09/24/15 at 2:23 PM revealed she conducted rounds with the facility administrator daily to ensure residents' care plans were being followed and that the quality assurance committee met monthly to ensure fall interventions were in place. Continued interview with the DON revealed a morning meeting was conducted daily to discuss any concerns, updates, and/or revisions that may need to be made to a resident's care plan/interventions. Further interview with the DON revealed that low bed means a resident's bed should be in the lowest position possible. Continued interview with the DON revealed Resident #11's low bed had not been intended to be an intervention related to falls. Further interview with the DON revealed the bed sensor alarm was not intended to be a long-term intervention for Resident #11 and that it was just an intervention put in place when Resident #11 returned to the facility from the hospital.

Based on interview, record review, and a review of the facility policy it was determined the facility failed to ensure all allegations involving mistreatment or abuse were reported immediately to the Administrator of the facility and to other officials in accordance with State law for one (1) of five (5) sampled residents (Resident #4). Interviews with Resident #4 and facility staff conducted on 11/24/14 and 11/25/14 revealed the resident voiced concerns of mistreatment by facility staff, related to an incident that occurred on 11/21/14. However, an interview with staff and the facility Administrator revealed the allegation was not reported or investigated, and residents were not protected as required by the facility's policy. The findings include: A review of the facility policy titled "Abuse Reporting and Prevention," last updated July 2001, revealed staff was required to report any observation, suspicion, or information obtained related to possible abuse to their supervisor immediately. The policy further stated if an employee received a verbal or written report of suspected or observed abuse, the employee should immediately examine the resident for any sign of injury, and inform the Administrator or designee. A review of Resident #4's medical record revealed the facility admitted the resident on 07/11/14 with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident required limited assistance with ambulation and toileting. The MDS further revealed staff had assessed the resident to be interviewable with a Brief Interview for Mental Status (BIMS) score of 15. An interview with Resident #4 on 11/24/14 at 4:05 PM revealed an incident had occurred on 11/21/14, involving a staff member (later identified as Registered Nurse #3). Continued interview revealed the resident told Registered Nurse (RN) #3, "you could have drowned me, and I want to speak to your boss." However, the resident stated no staff member, identified as the RN's supervisor, came to discuss the incident with the resident as requested. Continued interview revealed Resident #4 had also reported the incident to Physical Therapy Assistant (PTA) #1 on the morning of 11/24/14. An interview with RN #3 on 11/25/14 at 10:30 AM confirmed Resident #4 had requested to speak with RN #3's supervisor on 11/21/14. RN #3 stated Resident #4 had told her that she (RN #3) "tried to kill" Resident #4 and told RN #3 to "call the supervisor." RN #3 stated she failed to contact the supervisor as the resident requested because the resident "calmed down." The RN stated she should have reported the incident to her supervisor as the resident had requested. An interview with PTA #1 on 11/25/14 at 10:06 AM confirmed Resident #4 had voiced concerns with treatment he/she had received from facility staff and stated "someone had just dumped water" into his/her nose. The PTA stated she offered to have the facility Social Worker speak with the resident; however, the resident declined. The PTA stated even though she had been trained to report allegations of abuse and mistreatment, she failed to report the incident. The PTA stated she should have reported the incident to Administrative staff as required. An interview with the Administrator on 11/25/14 at 4:15 PM revealed staff had been educated to report allegations of abuse and or mistreatment, which involved facility residents. Continued interview revealed RN #3 should have contacted the supervisor as requested by the resident. He also stated PTA #1 should have reported the allegation voiced by Resident #4 to Administrative staff as required.

Based on interview, record review, and a review of the facility's grievance procedure it was determined the facility failed to follow up with one (1) of five (5) sampled residents (Resident #1) who voiced a grievance related to facility response time to call lights. Interview with Resident #1 on 11/24/14 revealed the resident had voiced concerns to the facility Director of Nursing (DON) and the facility Ombudsman in October 2014 about his/her concerns with call lights. The resident stated no one had followed up with him/her related to the concerns and call lights continued to be left unanswered and/or call lights were turned off, even though the resident's needs were not met. The findings include: A review of the facility's grievance procedures, not dated, revealed anytime a resident felt they were not treated fairly, or if they felt an employee had mistreated them in any way, residents could take steps to correct or eliminate the problem. Residents were to notify the appropriate Nurse Manager/Director of Nursing or Social Services Representative, who would assist the residents in investigating and solving the problem. A review of the facility's grievance investigation form revealed facility staff should document that they followed up with the resident after an investigation of the concern was conducted. A review of the medical record for Resident #1 revealed the facility admitted the resident on 04/24/14, with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident required limited assistance with dressing and bathing. The MDS further revealed staff had assessed the resident to be interviewable with a Brief Interview for Mental Status (BIMS) score of 15. An interview with Resident #1 on 11/24/14 at 9:20 AM revealed, "Call lights are an ongoing problem here." The resident further stated the concern with call lights had been discussed with the facility Ombudsman on two different occasions. Resident #1 was unsure of the exact dates but stated the first discussion with the Ombudsman was in early October 2014. Resident #1 further stated the call light concern had also been discussed with the DON approximately three weeks earlier. The resident stated the DON had not followed up with the resident to ensure the call light concern had been resolved and stated, "Nothing's changed with the call lights." An interview with the DON on 11/25/14 at 2:50 PM confirmed the facility Ombudsman had notified her on two different occasions in October of Resident #1's complaints related to call lights not being answered in a timely manner (10/10/14 and 10/28/14). The DON further stated Resident #1 had voiced in October 2014 that he/she "felt like the call lights took a little time to be answered." The DON stated she had interviewed other residents (unsure of which residents or exact dates) but identified no other concerns. The DON further stated she had conducted call light audits, which were initiated on 11/20/14 (41 days after the resident's initial concern was voiced), and no concerns had been identified through the audits. The DON stated that she had not followed up with the resident, but she had not been notified that Resident #1 was "still complaining about the call lights." An interview with the Administrator on 11/25/14 at 4:15 PM revealed the Ombudsman had notified him of call light concerns voiced by Resident #1, in October 2014. The Administrator stated the Ombudsman had "looked into and unsubstantiated the resident's concerns that day, and I thought everything was fine." The Administrator further stated he felt like it was the Ombudsman's responsibility to "check the complaints out." There was no evidence that indicated facility staff had conducted a follow-up interview with Resident #1 to ensure the resident's grievance was resolved.

Based on interview, medical record review, policy review, review of American Heart Association Basic Life Support for healthcare providers, Kentucky Board of Nursing Advisory Opinion Statement, and review of the ambulance transfer report it was determined the facility failed to ensure staff assessed one of twenty-one sampled residents (Resident #1) when the resident had a change of condition and failed to ensure staff immediately initiated emergency medical care when the resident stopped breathing. On [DATE], family members noted a change in Resident #1's condition and summoned Licensed Practical Nurse (LPN) #1 to the resident's room. At 5:35 PM, while LPN #1 was in the resident's room, the family reported to the nurse that Resident #1 had stopped breathing. LPN #1 left Resident #1's room to check the resident's code status without first assessing the resident's condition and initiating emergency care as needed. According to documentation from the ambulance service, 911 was called at 5:38 PM on [DATE], three minutes after Resident #1 experienced the change of condition. Nursing notes revealed staff did not start Cardio [MEDICAL CONDITION] Resuscitation (CPR) until 5:40 PM, approximately five minutes after Resident #1 experienced a change of condition. Resident #1 was pronounced dead upon arrival to the emergency room at 6:22 PM. The failure of the facility to ensure residents who experienced a change of condition were assessed promptly and immediately provided emergency medical care as needed placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy and Substandard Quality of Care was identified on [DATE], and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. Immediate Jeopardy was verified to be removed on [DATE], as alleged prior to exiting with the facility on [DATE], with remaining noncompliance at 42 CFR 483.25 Quality of Care, with a scope and severity of "D" while the facility develops and implements a Plan of Correction and the facility's Quality Assurance. The findings include: A review of the facility's policy, "New Symptoms, Signs and other Changes of Condition," dated [DATE], revealed it was the goal of the facility for a licensed nurse to do a thorough assessment on each resident as their condition changed and to notify the resident, responsible party and the physician. A review of the facility's policy, "Full Code Status verses No Code-DNR," not dated, revealed if a resident did not have a "no code-DNR" physician's orders [REDACTED]." "Upon finding the resident with no pulse and not breathing," a Full Code was required to be initiated with chest compression and breaths, and 911 was to be called immediately. A review of the facility's policy, "Guidelines to take in a full code situation," dated [DATE], revealed the first nurse responder was to verify code status, by checking the resident's medical record to ensure the resident was a Full Code and then was to direct the actions of other staff members. A review of the American Heart Association (AHA), Basic Life Support (BLS) for Healthcare Providers, Guidelines for CPR 2010, revealed a critical concept for high quality CPR was to start compressions within ten seconds of recognition of [MEDICAL CONDITION]. According to the AHA, the first step for adults is to assess the victim for response and look for normal or abnormal breathing. If there is no response and no breathing or no normal breathing, shout for help. The healthcare provider should not delay activating the emergency response system but should check the victim simultaneously for response and breathing. The rescuer should activate the emergency response system and begin CPR if the adult victim is unresponsive and not breathing or not breathing normally and has no pulse. If within ten seconds no pulse is found or if the rescuer is not sure of a pulse begin chest compression. A review of KRS 314.021(2) revealed all individuals licensed under provisions of this Chapter shall be responsible and accountable for making decisions that are based upon the individual's educational preparations and experience in nursing and shall practice nursing with reasonable skill and safety. A review of the Kentucky Board of Nursing Advisory Opinion Statement, AOS #36 Resuscitation (approved ,[DATE]) revealed the accountability would include the responsibility of knowing the code status of the nurse's assigned patients. A review of the facility's investigation revealed on [DATE], at approximately 5:35 PM, LPN #1 and Resident #1's family were in the resident's room. LPN #1 touched the resident's wrist to get a pulse and noticed the resident's forearms were moist underneath and swollen. Further review revealed the LPN was going to obtain a blood glucose machine (machine that checks the blood sugar level) and as she turned to leave the room the family members stated, "Ma'am, Ma'am, (Resident #1's) not breathing." According to the investigation, LPN #1 stated she turned and saw the resident taking "shorter more shallow breaths," and one of the family members started chest compressions as the LPN ran out into the hallway. A review of Resident #1's medical record revealed the resident was admitted on [DATE], with a [DIAGNOSES REDACTED]. Interview with LPN #1 on [DATE], at 8:41 AM, revealed she was in Resident #1's room discussing the resident's condition with the resident's family at approximately 5:35 PM on [DATE], when the LPN noticed the resident's arms were [MEDICAL CONDITION] and the right arm was cool and moist to touch. LPN #1 stated she explained to the family that she was going to check the resident's blood glucose level when she noticed the resident's respirations were shallow. The LPN proceeded to leave the room but a family member said, "Ma'am, Ma'am." The nurse turned around and said she was going to check the resident's code status. According to LPN #1, family member #1 stated Resident #1 was a Full Code, and that Resident #1 was "not breathing." LPN #1 stated when she looked at the resident she did not see the resident breathing, and one of the family members started CPR. LPN #1 stated she left the room. Interview further revealed the LPN went to the nurses' desk to verify the resident's code status and then proceeded to send another nurse into the room to start CPR while LPN #1 paged the "code" over the intercom, and called 911. Further interview with LPN #1 revealed it was two to three minutes from the time she was in the room and the resident's family stated the resident was not breathing until another staff member went into the room to perform CPR. Further interview with LPN #1 on [DATE], at 3:24 PM, revealed when a resident stopped breathing it was considered a change in condition, and when a resident experienced a change in condition, the nurse was required to assess the resident. LPN #1 further stated when a resident stopped breathing the nurse should go to the resident, say the resident's name, and attempt to arouse the resident. LPN #1 stated she assessed the resident by standing approximately five feet away and observed for respirations when the family stated the resident was not breathing. LPN #1 further stated after she observed Resident #1 with "shallow breathing all I was worried about was finding out (his/her) code status" (during the first interview with LPN #1 two days prior, she stated the resident was not breathing when she left the room). Interview revealed the LPN left the resident's room without first assessing the resident's change in condition and without initiating emergency medical interventions. A review of Resident #1's nursing notes dated [DATE], at 5:35 PM, revealed LPN #1 was in the room with Resident #1 and the resident's family members when the LPN felt the resident's right arm and noted the arm to be cool to touch with moisture under the forearm. The nurse was leaving the room to obtain a blood glucose machine when the resident's respirations "became shallow." The nurse then left the room to check the resident's medical record for the resident's code status. At 5:40 PM, the nurse's notes stated a code was called, along with the ambulance service, and CPR was initiated by other nurses. Interview with Resident #1's family member #1 on [DATE], at 4:25 PM, revealed she and another family member visited with Resident #1 on [DATE]. Family member #1 stated when she walked into the resident's room the resident was "unresponsive" and oxygen was being administered. Family member #1 stated the nurse was asked to come to the room immediately after the family members observed the resident. Family member #1 stated she had called earlier in the day on [DATE], to inquire about the resident and was told by the resident's nurse that she (the nurse) had been off for a while and did not know anything about the resident. The family member proceeded to explain to LPN #1 that "this ain't right," that the resident was at the facility for rehab to strengthen the legs, and the resident was alert and talking when the resident was admitted two days prior. Family member #1 stated she told the nurse she "had to get (Resident #1) out of here" and when she touched the resident the resident was "clammy, sticky." Family member #1 further stated that family member #2 informed the nurse the resident's eyes were "fixed" and the resident was "not breathing." According to family member #1, LPN #1 did not assess the resident for breathing and instead left the room after she was informed the resident was not breathing. The two family members proceeded to lay the resident's bed back and family member #2 initiated CPR. Family member #1 stated at one point while family member #2 was performing CPR, Resident #1 "gulped," trying to get air, and they turned the resident to a side lying position because the resident had "all kinds of stuff" in the resident's lungs. Family member #1 stated it was three to four minutes before facility staff re-entered the resident's room to provide emergency care. Interview with Resident #1's family member #2 on [DATE], at 11:32 AM, revealed he and another family member visited Resident #1 on [DATE]. The family member stated the two family members and the LPN were in the room, and Resident #1 had labored breathing and audible gurgling in the airway. Family member #2 stated to LPN #1 that the resident's eyes were "fixed" and then said, "Ma'am, (Resident #1) isn't breathing." Family member #2 stated the nurse proceeded to leave the room. Interview further revealed family members #1 and #2 proceeded to lay the bed back. Then family member #2 started chest compressions, and after giving one breath, family member #2 stated Resident #1 made a face as if maybe the resident had gotten air. Family member #2 proceeded to give another round of compressions and when he was preparing to give another breath Resident #1 gasped. Family member #1 and family member #2 proceeded to roll the resident into a side position. The family member stated he then rolled the resident onto the back side again and gave another round of compressions. Family member #2 further stated he performed three sets of thirty compressions and breaths, which took approximately two minutes, and repositioned the resident two times before facility staff came into the room to assume CPR. Further interview revealed when the family member told the nurse the resident was not breathing the nurse did not assess the resident's status, nor did the nurse do anything to provide immediate intervention for Resident #1. A review of the ambulance report dated [DATE], revealed the facility called ambulance Dispatch at 5:38 PM (three minutes after Resident #1 experienced a change in condition per nursing notes) to request assistance at the facility. The ambulance arrived at the facility at 5:41 PM. Interview with Paramedic #1 on [DATE], at 12:00 PM, revealed his team was dispatched to the facility at 5:38 PM, and arrived at 5:41 PM. Upon entering the room, he observed staff performing CPR. Paramedic #1 stated Resident #1 was ashen color, and he was told by a staff member the resident had "been down" about 15 minutes and family had initiated CPR. Further interview revealed the paramedic suctioned "quite a bit" of "brown colored" secretions from the resident's mouth. Paramedic #1 stated Resident #1 was intubated by the paramedics and the resident's pacemaker still showed a rhythm on the monitor, but that Resident #1 was asystole (no heart beat). A review of the hospital report from [DATE], revealed Resident #1 was pronounced dead at 6:22 PM upon arrival to the hospital. Interview with Resident #1's physician on [DATE], at 10:55 AM, revealed [DATE] was the first time the physician had treated Resident #1. Further interview revealed when the physician saw the resident on [DATE], Resident #1 was "not very coherent" and the physician felt the resident may have been oversedated. Interview further revealed he would "assume" facility staff was aware of each resident's code status and would start emergency procedures when needed. The physician stated facility staff could not leave the room during an emergency and that they needed to have "some way of knowing" each resident's code status. The physician stated three minutes was too long to wait to begin CPR. Interview with the Director of Nursing (DON) on [DATE], at 5:25 PM, revealed LPN #1 followed the facility's policy by leaving the room when the resident ceased to breathe on [DATE]. The DON further stated the nurse was always supposed to look at the resident's medical record to verify the resident's code status prior to initiating resuscitative measures. The DON further stated it was acceptable to leave Resident #1 not breathing because "the new standards in CPR" were to "call 911 first." The DON further stated on [DATE], at 4:30 PM, that a resident's respiratory status could be visualized from five feet away by observing if the chest was rising. The DON further stated that LPN #1 had listened to Resident #1's chest at "supper time" and did not expect her to assess the lung sounds again when the family told LPN #1 that the resident was not breathing. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) was submitted by the facility on [DATE], which alleged removal of IJ effective [DATE]. A standard health/extended survey was conducted on ,[DATE]-,[DATE], which determined the IJ was removed on [DATE] as alleged. --A review of the AOC revealed the following: On [DATE], the Unit Managers (UM) and Staff Development Coordinator (SDC) audited all resident charts to ensure the physician's orders [REDACTED]. On [DATE], the Administrator and Director of Nursing (DON) reviewed and revised the facility's Code Status policy to include the utilization of yellow wristbands to designate Full Code status for residents. On [DATE], the Medical Director reviewed and approved the revised Code Status policy. On [DATE], the SDC verified current cardiopulmonary (CPR) certifications for all current licensed nurses providing direct care for residents. On [DATE], a licensed nurse began rounds to ensure no residents were in any acute cardiac or respiratory distress and a CNA continued to make 30-minute rounds until all residents that were Full Code status had a yellow wristband in place. On [DATE], a licensed nurse completed a cardio/pulmonary assessment on all residents. On [DATE], the UM or the SDC placed a yellow wristband on the arm of all residents with a verified Full Code status. Beginning on [DATE], nursing staff checked all residents with yellow wristbands every four hours to ensure the wristband remained in place. The 4-hour checks continued for the next 72 hours. Then a licensed nurse checked all residents with yellow wristbands every shift to ensure the wristband remained in place, and documented on the resident's Medication Administration Record (MAR), indicating the yellow bracelet was in place. These checks will be ongoing. A physician's orders [REDACTED]. Beginning on [DATE], all nursing staff was re-educated on the revised Code Status policy/procedure that included the placement of yellow wristbands to designate Full Code status, by the Director of Clinical Support Services, the DON, the SDC, and the UMs. The re-education included the necessity for immediate action by the nurse when upon assessment a resident was found to have a change of condition and also included the following: (a) If a resident is in cardiac/respiratory distress, the nurse should check for the yellow wristband, go into the hall, yell for assistance, and immediately return to the resident for further assessment and actions based upon assessment findings. (b) If the resident is without a pulse and/or breathing, the nurse will check for the yellow wristband. If a wristband is in place, the nurse will go to the hall, yell for assistance, and return to the resident and begin chest compressions. (c) If the resident is without a pulse and/or breathing, the nurse will check for the yellow wristband. If no wristband is in place, the nurse will go to the hall, yell for assistance, and return to the resident. When assistance arrives, the nurse will send someone to the medical record to confirm the resident is a no code. If the resident's medical record states the resident is a Full Code, the nurse at bedside will begin chest compressions. (d) If the resident has a non-emergency change in condition, the nurse is to conduct a thorough assessment, based on the body system(s) affected, and notify the physician for further actions. This re-education was completed in person and by telephone prior to any nursing staff caring for residents and completed on [DATE]. The staff's competency was ensured by having them verbalize the change in this policy. On [DATE], the DON, the Director of Clinical Support, the UM, and the SDC re-educated all licensed staff on assessment skills and verified competency with a return demonstration. The education included: (a) Head to toe assessments. (b) The assessments focused on the primary organs such as the heart, lungs, and pupils and how to properly assess each, along with normal findings and abnormal findings on assessment. On [DATE], the DON, the SDC, and the UMs re-educated the nurses to respond and act immediately upon an assessed change of condition in a resident's status. All new nursing staff will be educated on the Code Status policy, physical assessments (normal versus abnormal), and changes in condition prior to care for the resident. The new staff will be required to complete a posttest to ensure comprehension of the policies. All new nursing staff will be educated and tested through return demonstration on their assessment skills, Code Status, and actions to take when a resident is assessed to have change in condition prior to caring for a resident. The SDC and/or UMs will audit ten nursing staff members weekly to ensure comprehension of the Code Status policy, assessment skills, and actions to take when a resident has a change in condition. The UMs will audit the 24-hour nursing report five days a week for assessment findings as well as what immediate actions were taken, based upon assessment findings, to care for the resident with changes. The DON will review the UMs' audits and will present the findings at the quarterly Quality Assurance (QA) meetings. The UMs will audit the Medication Administration Records (MARs) of the residents that have chosen a Full Code status three times weekly to ensure the licensed nurses have completed the required yellow wristband checks. The Administrator will review the UMs' MARs audits to ensure completeness and present the findings at the quarterly QA meetings. The Admitting nurse will place a yellow wristband on the wrist of all residents admitted to the facility who choose a Full Code status. The UMs will check all newly admitted residents' admission paperwork for the selected code status, check the resident for the appropriate wristband, and check the MARs to ensure the wristband checks are documented on the MAR. --The surveyors validated the corrective actions taken by the facility as follows: A review of the chart audits conducted by the facility on [DATE], revealed the UMs and the SDC had audited all residents' charts to ensure the residents' physician's orders [REDACTED]. Record reviews of 16 residents on the Third Floor and 13 residents on the Second Floor revealed the residents had physician's orders [REDACTED]. the appropriate code status identified. Interviews on [DATE], at 4:00 PM, with UM #1, at 3:45 PM, with UM #2, and at 4:05 PM, with UM #3 revealed each resident's code status, physician's orders [REDACTED]. Interview on [DATE], at 5:15 PM, with the SDC revealed she assisted in checking all residents' physician's orders [REDACTED]. Review of the Code Status policy revealed the policy was revised to include the utilization of a yellow wristband to designate Full Code status, which was approved and signed by the Medical Director on [DATE]. Interviews on [DATE], at 4:00 PM, with the Administrator, and at 2:30 PM, with the DON, revealed the Vice President of Operations, the Nurse Consultant, the Medical Director, the Administrator, the DON, and the SDC met and discussed changes that needed to be made to the facility's Code Status policy on [DATE]. The interviews revealed after the group agreed on the changes that were required, the policy was revised, and the Medical Director reviewed and signed the revised Code Status policy on [DATE]. A review of the CPR certification audits revealed the SDC had audited all current licensed nurses providing direct care for current CPR certification on [DATE]. Interview with the SDC on [DATE], at 5:15 PM, revealed the SDC had maintained a list of all current Cardiopulmonary Resuscitation (CPR) certifications to ensure staff was appropriately trained to administer CPR. A review of the nurses' rounds audits revealed licensed nurses conducted rounds on [DATE], to ensure residents were not experiencing any acute cardiac or respiratory distress until all yellow wristbands were in place on all residents identified to be Full Code status. Interviews on [DATE], at 4:00 PM, with UM #1, at 3:45 PM, with UM #2, and at 4:05 PM, with UM #3 revealed the UMs assessed all residents' cardiac and respiratory status on the second and third floor to ensure the residents were in no distress until all yellow wristbands were applied to all residents' wrists who were Full Code status on [DATE]. A review of CNA rounds revealed CNAs conducted rounds every 30 minutes on [DATE], to ensure residents were not experiencing any distress until all yellow wristbands were in place on all residents identified to be Full Code status on [DATE]. Interviews conducted on [DATE], at 3:25 PM, with CNA #17, and at 4:35 PM, with CNA #11 revealed they monitored residents every 30 minutes for distress while the yellow wristbands were being placed on the residents identified to be Full Code status and continued the 30-minute rounds until the yellow wristbands were in place for all residents with Full Code status on [DATE]. A review of the cardio/pulmonary assessments revealed licensed nurses completed cardio/pulmonary assessments on all residents on [DATE]. Interviews on [DATE], conducted at 4:00 PM, with UM #1, at 3:45 PM, with UM #2, and at 4:05 PM, with UM #3 verified a cardio/pulmonary assessment was completed on [DATE], for all residents. A review of the yellow wristband verification audit revealed the UMs and/or the SDC verified all residents identified to be Full Code status had a yellow wristband in place on [DATE]. Interviews on [DATE], conducted at 4:00 PM, with UM #1, at 3:45 PM, with UM #2, at 4:05 PM, with UM #3, and at 5:15 PM, with the SDC revealed they verified that all residents identified to be Full Code status had a yellow wristband in place on [DATE]. Observations conducted on [DATE], from 4:30 PM till 5:00 PM, of the 16 residents on the Third Floor and from 4:00 PM till 5:00 PM, of the 13 residents on the Second Floor identified to be Full Code status revealed the residents were wearing yellow wristbands. Observations conducted during the standard survey process from ,[DATE]-,[DATE], revealed Residents #7, #13, #15, #16, #17, and #18 who were identified to be Full Code status were wearing yellow wristbands. A review of the every 4-hour checks revealed nursing staff checked all residents identified to be Full Code status, to ensure they had a yellow wristband in place beginning on [DATE], and continued the every 4-hour checks for the next 72 hours. Record review of the 29 residents identified by the facility to be a Full Code status revealed nursing staff documented on the residents' MAR each shift that the residents' yellow bracelets were in place. Interviews on [DATE], at 3:00 PM, with LPN #2, at 3:05 PM, with RN #1, at 3:10 PM, with LPN #7, at 4:00 PM, with UM #1, at 3:15 PM, with RN #7, at 3:25 PM, with LPN #3, at 3:45 PM, with UM #2, and at 4:05 PM, with UM #3 revealed all residents identified as a Full Code were checked every 4 hours for 72 hours and then each shift to ensure the yellow wristbands remained in place. Interview further revealed all Full Code residents were monitored every shift to ensure yellow bracelets were in place and this was documented on the residents' MARs. A review of staff in-services revealed all nursing staff was in-serviced on the Full Code policy revisions to include the placement of yellow wristbands to designate Full Code status which began on [DATE], and was completed on [DATE], by the Director of Clinical Support Services (DCSS), the DON, the SDC, and the UMs. Interviews on [DATE], at 2:30 PM, with the DON, at 3:45 PM, with the DCSS, at 4:00 PM, with UM #1, at 3:45 PM, with UM #2, and at 4:05 PM, with UM #3, revealed in-services regarding the Full Code policy, head to toe assessments of the residents, and actions to take when the resident was assessed to have a change in condition were conducted in person and over the phone on [DATE], prior to staff providing care to residents. Licensed staff completed a return demonstration to verify competency of the training. Interviews conducted on [DATE], at 3:00 PM, with LPN #2, at 3:05 PM, with RN #1, at 3:10 PM, with LPN #7, at 4:00 PM, with UM #1, at 3:15 PM, with RN #7, at 3:25 PM, with LPN #3, at 3:45 PM, with UM #2, at 4:05 PM, with UM #3 and with CNAs #11, #14, #15, and #16 verified staff had been in-serviced on [DATE] and [DATE], regarding the procedures for residents who experienced a change of condition and assessment skills. The interviews revealed the staff was tested and performed return demonstrations on the in-service material. The interviews further revealed staff had been in-serviced regarding the change in the facility's Code Status policy and procedures for monitoring placement of the yellow wristband every shift. A review of the in-service/competency checks revealed licensed staff was in-serviced on assessment skills (head to toe assessments, normal versus abnormal assessment findings with focus on heart, lungs, and pupils) and to respond immediately upon any assessed change in a resident's condition on [DATE] and [DATE], by the DON, the DCSS, the UMs, and the SDC. The facility verified competency by return demonstration on [DATE], for each licensed staff person. A review of audits revealed the SDC and or the UMs conducted weekly audits on [DATE], [DATE], and [DATE], of ten staff members to ensure comprehension of the Code Status policy, assessment skills, and actions to take when assessed to have a change in condition. No concerns were found with the audits. A review of the audits of the 24-hour reports revealed the UMs were conducting audits of the 24-hour nursing report five days a week. No concerns were found with the audits. A review revealed the UMs audited the MARs of residents identified to be Full Code status three times weekly on [DATE], [DATE], and [DATE], to ensure licensed staff was monitoring and documenting the yellow wristbands were in place. Interviews on [DATE], at 4:00 PM, with UM #1, at 3:45 PM, with UM #2, at 4:05 PM, with UM #3, and at 5:15 PM, with the SDC revealed they will conduct ten nursing staff audits weekly to ensure comprehension of the code status policy, assessment skills and actions to take when a resident is identified with a change in condition. Interview further revealed the 24-hour nursing report would be audited daily five days a week, along with audits of the MARs for residents with Full Code status three times a week, to ensure any resident who experienced a change in condition was assessed to ensure immediate action was taken to address the change in condition. Interview on [DATE], at 5:30 PM, with the SDC revealed there had been no new admissions to the facility since [DATE]. However, a review of an admission sheet revealed documents for the admitting nurse to complete for residents who had chosen Full Code status. Interviews on [DATE], at 4:00 PM, with UM #1, at 3:45 PM, with UM #2, and at 4:05 PM, with UM #3 revealed they will check admission paperwork for Code Status, check for the appropriate wristband, and check the MARS for the every shift yellow wristband checks.

Based on interview, record review, review of the facility policies and review of the American Heart Association Manual for Basic Life Support 2010, it was determined the facility failed to be administered in a manner that enabled resources to be used effectively and efficiently to ensure residents' highest practicable physical, mental, and psychosocial well-being was attained or maintained. The facility's Administration failed to have an effective system to ensure staff assessed residents and responded timely to residents in respiratory arrest per the American Heart Association (AHA), Basic Life Support (BLS) for Healthcare Providers, Guidelines for CPR 2010. An abbreviated standard survey conducted at the facility on ,[DATE]-,[DATE] resulted in deficient practice due to the facility's failure to administer CPR to a resident who was found to be unresponsive and was a Full Code. The facility's Plan of Correction (POC) dated [DATE], stated staff had been trained on what actions to take for residents who were a Full Code, and stated Mock Codes would be conducted to ensure staff followed the facility's policy/guidelines. The facility was conducting Mock Codes quarterly, but failed to monitor to ensure staff assessed residents and responded timely when residents were in respiratory arrest per the American Heart Association CPR Guidelines. On [DATE], Resident #1 experienced a change of condition, when family members informed LPN #1 that Resident #1 had quit breathing, while LPN #1 and family members were in the room. LPN #1 did not assess the resident, and left the room to go to the nurses' desk to obtain the resident's code status prior to the resident receiving emergency medical care by staff. A review of nursing notes revealed Resident #1 experienced "shallow" respirations at 5:35 PM, and the nursing notes stated 911 was notified and CPR was started at 5:40 PM. Based on a review of the ambulance report 911 was contacted at 5:38 PM, approximately three minutes, per nursing notes and interview, after Resident #1 experienced a change in condition and stopped breathing. Resident #1 was transported to the local emergency room where the resident was pronounced dead at 6:22 PM (refer to F309 and F520). The facility's failure to have an effective system in place to provide timely care and services for Resident #1, who experienced a change in condition, and failure to implement action plans to correct quality deficiencies, placed Resident #1 and other residents at risk for serious injury, harm, impairment, or death. An Allegation of Compliance (AOC) was received on [DATE], which alleged removal of Immediate Jeopardy on [DATE]. The State Agency determined the Immediate Jeopardy was removed on [DATE], as alleged, which lowered the scope and severity to "D" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's Plan of Correction (POC) dated [DATE], revealed nursing staff was to receive ongoing in-service training by the Staff Development Coordinator (SDC) regarding the guidelines for determining if a resident was a Full Code, how to promptly identify each resident's code status, and what actions to take if the resident was a Full Code. The POC stated the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers (UMs) would conduct mock codes on diverse shifts to ensure staff followed the facility's policy/guidelines for Full Code residents. The POC further stated the Administrator would review all audit findings and report to the QA Committee monthly, and then review the findings with the Medical Director at the quarterly QA meetings to evaluate the effectiveness of the actions taken. A review of the facility's policy, "Changes of Condition," dated [DATE], revealed it was the goal of the facility for a licensed nurse to do a thorough assessment on each resident as their condition changed and to notify the resident, responsible party, and physician. A review of the facility's "Full Code Status verses No Code-DNR" policy, not dated, revealed if a resident did not have a "no code-DNR" physician's orders [REDACTED]." Upon finding the resident with no pulse and not breathing a full code was required to be initiated with chest compression and breaths, and 911 was to be called immediately. A review of the facility's policy, "Guidelines To Take in a Full Code Situation," dated [DATE], revealed the first nurse responder was to verify code status, by checking the resident's medical record to ensure the resident was a Full Code and then was to direct the actions of other staff. A review of the American Heart Association (AHA), Basic Life Support (BLS) for Healthcare Providers, Guidelines for CPR 2010, revealed a critical concept for high quality CPR was to start compressions within ten seconds of recognition of [MEDICAL CONDITION]. According to the AHA, the first step for adults was to assess the victim for response and look for normal or abnormal breathing. If there was no response and no breathing or no normal breathing, shout for help. The healthcare provider should not delay activating the emergency response system but should check the victim simultaneously for response and breathing. The rescuer should activate the emergency response system and begin CPR if the adult victim was unresponsive and not breathing or not breathing normally and had no pulse. If within ten seconds, no pulse was found or if the rescuer was not sure of a pulse, begin chest compression. Interview with the Director of Nursing (DON) on [DATE], at 5:25 PM, revealed LPN #1 followed the facility's policy by leaving the room when the resident ceased to breathe on [DATE]. The DON further stated according to facility policy the nurse was to always look at the resident's medical record to verify the resident's code status prior to initiating resuscitative measures. Further interview with the DON on [DATE], at 4:38 PM, revealed facility staff had been performing mock codes weekly for three months, then one time a month, and facility staff was "doing good" so the mock codes were conducted quarterly. The DON stated the mock code consisted of a fake resident (staff member) placing a sign on their body that would inform staff what was wrong with them such as "no heartbeat," "no breathing." Facility staff, after finding the fake resident was then required to go to the nurses' desk where a mock code folder was placed that had the code status for the fake resident. If the fake resident was a Full Code then staff was required to page a "code" over the intercom and begin giving directions for other staff such as start CPR, get the crash cart, or hold the elevator. The DON further stated facility staff had been "doing good" during the mock codes and also felt facility staff "did good" on the night of [DATE], when Resident #1 experienced a change in condition. Further interview with the DON revealed facility staff had not identified a problem with the length of time it took to begin CPR, due to the fact the mock codes had never been timed to identify how long it took staff to find the resident, check the resident's code status, and begin emergency medical interventions if needed. The DON further stated assessments such as listening to lungs for breathing or the chest for a heartbeat were never incorporated into the mock code drills, therefore no problems had been identified. Interview with the Administrator, on [DATE], at 4:00 PM, revealed he observed the first mock code and then reviewed the audits of the mock codes conducted by the DON. The Administrator stated during the review of the audits the facility's QA Committee had not identified any issue with a time lapse in CPR initiation. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) was submitted by the facility on [DATE], which alleged removal of IJ effective [DATE]. A standard health/extended survey was conducted on ,[DATE]-,[DATE], which determined the IJ was removed on [DATE] as alleged. --A review of the AOC revealed the following: On [DATE], the Administrator and Director of Nursing (DON) reviewed and revised the facility's Code Status policy to include the utilization of yellow wristbands to designate Full Code status for residents. On [DATE], the Medical Director reviewed and approved the revised Code Status policy. The DON will review the UMs' audits and will present the findings at the quarterly Quality Assurance (QA) meetings. The Administrator will review the UMs' MARs audits to ensure completeness and present the findings at the quarterly QA meetings. --The surveyors validated the corrective actions taken by the facility as follows: Review of the Code Status policy revealed the policy was revised to include the utilization of a yellow wristband to designate Full Code status, which was approved and signed by the Medical Director on [DATE]. Interviews on [DATE], at 4:00 PM, with the Administrator and at 2:30 PM, with the DON, revealed the Vice President of Operations, the Nurse Consultant, the Medical Director, the Administrator, the DON, and the SDC met and discussed changes that needed to be made to the facility's Code Status policy on [DATE]. The interviews revealed after the group agreed on the changes that were required, the policy was revised, and the Medical Director reviewed and signed the revised Code Status policy on [DATE].

Based on interview, record review, policy review, review of a Statement of Deficiencies (SOD) dated [DATE], and review of the facility's Plan of Correction (POC) dated [DATE], it was determined the facility failed to have an effective system to identify issues for which quality assessment and assurance activities were necessary, and failed to develop and implement appropriate plans of action to correct quality deficiencies. This was evidenced by repeated deficiencies related to the facility's failure to provide care/services and the facility's failure to implement its Abuse Reporting & Prevention policy. The facility failed to ensure staff assessed one of twenty-one residents (Resident #1) when the resident experienced a change of condition and failed to ensure staff immediately initiated emergency medical care when the resident stopped breathing. On [DATE], family members noted a change in Resident #1's condition and summoned Licensed Practical Nurse (LPN) #1 to the resident's room. At 5:35 PM, while LPN #1 was in the resident's room, the family reported to the nurse Resident #1 had stopped breathing. LPN #1 left Resident #1's room to check the resident's code status without first assessing the resident's condition and initiating emergency care as needed. According to documentation from the ambulance service, 911 was called at 5:38 PM on [DATE], three minutes after Resident #1 experienced the change of condition. Nursing notes revealed staff did not start Cardiopulmonary Resuscitation (CPR) until 5:40 PM, approximately five minutes after Resident #1 experienced a change of condition. Resident #1 was pronounced dead upon arrival to the emergency room at 6:22 PM. The facility also failed to ensure two abuse allegations reported by Resident #2 and Resident #20 were reported to the appropriate state agencies as per the facility Abuse Reporting & Prevention policy. The facility's failure to have an effective system to ensure the Quality Assurance Program identified and implemented appropriate plans of action to correct identified quality deficiencies placed Resident #1 and other residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. Immediate Jeopardy was verified to be removed on [DATE], as alleged prior to exiting with the facility on [DATE], which lowered the scope and severity to "D" while the facility develops and implements a Plan of Correction, and monitors the effectiveness of the systemic changes and Quality Assurance activities. The findings include: 1. A review of an SOD dated [DATE], revealed an abbreviated standard survey was conducted on ,[DATE]-,[DATE], which resulted in deficient practice due to the facility's failure to administer Cardiopulmonary Resuscitation (CPR) to a resident who was found to be unresponsive and was a Full Code. A review of the facility's Plan of Correction (POC) dated [DATE], revealed nursing staff would receive ongoing in-services by the Staff Development Coordinator (SDC) regarding the guidelines for determining if a resident was a Full Code, how to promptly identify each resident's code status, and what actions to take if the resident was a Full Code. The POC stated the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers (UMs) would conduct mock codes on diverse shifts to ensure staff followed the facility's policy/guidelines for Full Code residents. The POC further stated the Administrator would review all audit findings and report to the Quality Assurance (QA) Committee monthly, and then review the findings with the Medical Director at the quarterly QA meetings to evaluate the effectiveness of the actions taken. A review of the facility's "Full Code Status verses No Code-DNR" policy, not dated, revealed if a resident did not have a "no code-DNR" physician's orders [REDACTED]." The policy stated upon finding the resident with no pulse and not breathing, a Full Code was required to be initiated with chest compression and breaths, and 911 was to be called immediately. A review of the facility's policy, "Guidelines To Take in a Full Code Situation," dated [DATE], revealed the first nurse responder was to verify code status, by checking the resident's medical record to ensure the resident was a Full Code and then was to direct the actions of other staff. A review of the American Heart Association (AHA), Basic Life Support (BLS) for Healthcare Providers, Guidelines for CPR 2010, revealed a critical concept for high quality CPR was to start compressions within ten seconds of recognition of [MEDICAL CONDITION]. According to the AHA, the first step for adults was to assess the victim for response and look for normal or abnormal breathing. If there was no response and no breathing or no normal breathing, shout for help. The healthcare provider should not delay activating the emergency response system but should check the victim simultaneously for response and breathing. The rescuer should activate the emergency response system and begin CPR if the adult victim was unresponsive and not breathing or not breathing normally and had no pulse. If within ten seconds no pulse was found or if the rescuer was not sure of a pulse, begin chest compressions. On [DATE], family members were visiting Resident #1, and when they noticed a change in the resident's condition they summoned the nurse. At 5:35 PM, while Licensed Practical Nurse (LPN) #1 was in the resident's room, family members stated Resident #1 stopped breathing. LPN #1 proceeded to leave the resident's room, to obtain the resident's medical record to verify code status, without assessing the resident's condition and/or initiating any immediate emergency care. According to the ambulance transfer report, facility staff contacted 911 at 5:38 PM, three minutes after the resident experienced a change in condition. Interview with LPN #1 and review of nursing notes revealed facility staff initiated CPR on the resident at 5:40 PM. Resident #1 was transported to the hospital by the ambulance service where the resident was pronounced dead on arrival at 6:22 PM. Interview with the DON on [DATE], at 2:30 PM, revealed the mock codes were not timed by the staff conducting the mock code, the staff responding to the code did not document the time the person was identified not to be breathing, the time the Emergency Medical System was activated, or the time the code was initiated or ended. The DON stated she had not identified a lapse in timely CPR initiation while conducting the mock codes; therefore, the facility had not identified or revised their plan of action. Interview with the Medical Director on [DATE], at 2:50 PM, revealed the facility's Immediate Jeopardy that was identified on [DATE], was discussed at the first QA meeting after the Jeopardy was identified. However, the Immediate Jeopardy had not been discussed at a QA meeting he had been involved in since the first meeting. The Medical Director stated facility staff informed him that "everything" "is being done" in relation to the Jeopardy identified on [DATE]. Interview with the Administrator on [DATE], at 4:00 PM, revealed he observed the first mock code and then reviewed the audits of the mock codes conducted by the DON. The Administrator stated during the review of the audits the facility's QA Committee had not identified any issue with a time lapse in CPR initiation (refer to F309). 2. A review of an SOD dated [DATE], revealed an abbreviated survey conducted on ,[DATE]-,[DATE], identified deficient practice related to the facility's failure to report possible neglect. Review of the facility's POC dated [DATE], revealed nursing staff would receive ongoing in-services by the SDC regarding abuse/neglect prevention and reporting. The POC stated the Administrator and DON were re-in-serviced on identification/investigation of abuse/neglect as well as their duty to report suspected abuse/neglect to the appropriate agencies timely. The POC revealed the DON, ADON, and UM would conduct visual audits of nine residents to ensure there were no indicators of abuse/neglect. The POC further stated the Administrator would review all audit findings and report to the QA Committee monthly, and then review the findings with the Medical Director at the quarterly QA meetings to evaluate the effectiveness of the actions taken. Review of the facility's Abuse Reporting & Prevention policy, updated [DATE], revealed the Administrator, or designee, will immediately report any incident of abuse/neglect to the appropriate state agencies. Review of the facility's investigation dated [DATE], revealed Resident #2 reported that Resident #15 raped Resident #21 during the night of [DATE]. The investigation stated "Administrator and Director of Nursing (DON) discussed the concern via telephone and it was decided that the information obtained thus far was not criminal in nature and did not need to be reported in two hours." Review of the facility's investigation dated [DATE], revealed Resident #20 reported a staff person put their finger in the resident's rectum and the resident started bleeding. Interview with the DON on [DATE], at 2:30 PM, revealed after investigating Resident #2's and Resident #20's allegations, there was nothing to report to the State Agencies. The DON stated the facility monitored for resident abuse/neglect but had not monitored for the reporting of allegations of abuse/neglect as part of the QA program. Interview with the Administrator on [DATE], at 4:00 PM, revealed he made the decision not to report Resident #2's and Resident #20's allegations to the appropriate state agencies. The Administrator stated the facility monitored for resident abuse/neglect but had not monitored to ensure allegations of abuse/neglect were reported to state agencies (refer to F226). **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) was submitted by the facility on [DATE], which alleged removal of IJ effective [DATE]. A standard health/extended survey was conducted on ,[DATE]-,[DATE], which determined the IJ was removed on [DATE], as alleged. --A review of the AOC revealed the following: Beginning on [DATE], nursing staff checked all residents with yellow wristbands every four hours to ensure the wristband remained in place. The 4-hour checks continued for the next 72 hours. Then a licensed nurse checked all residents with yellow wristbands every shift to ensure the wristband remained in place, and documented on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. These checks will be ongoing. The SDC and/or UMs will audit ten nursing staff members weekly to ensure comprehension of the Code Status policy, assessment skills, and actions to take when a resident has a change in condition. The UMs will audit the 24-hour nursing report five days a week for assessment findings as well as what immediate actions were taken, based upon assessment findings to care for the resident with changes. The DON will review the UMs' audits and will present the findings at the quarterly Quality Assurance (QA) meetings. The UMs will audit the Medication Administration Records (MARs) of the residents that have chosen a Full Code status three times weekly to ensure the licensed nurses have completed the required yellow wristband checks. The Administrator will review the UMs' MARs audits to ensure completeness and present the findings at the quarterly QA meetings. --The surveyors validated the corrective actions taken by the facility as follows: Interviews on [DATE], at 3:00 PM, with Licensed Practical Nurse (LPN) #2, at 3:05 PM, with Registered Nurse (RN) #1, at 3:10 PM, with LPN #7, at 4:00 PM, with UM #1, at 3:15 PM, with RN #7, at 3:25 PM, with LPN #3, at 3:45 PM, with UM #2, and at 4:05 PM, with UM #3 revealed all residents identified as a Full Code were checked every 4 hours for 72 hours and then each shift to ensure the yellow wristbands remained in place. Interview further revealed all Full Code residents were monitored every shift to ensure yellow bracelets were in place and this was documented on the residents' MARs. A review of audits revealed the SDC and or the UMs conducted weekly audits on [DATE], [DATE], and [DATE], of ten staff members to ensure comprehension of the Code Status policy, assessment skills, and actions to take when assessed to have a change in condition. No concerns were found with the audits. A review of the audits of the 24-hour reports revealed the UMs were conducting audits of the 24-hour nursing report five days a week. No concerns were found with the audits. A review revealed the UMs audited the MARs of residents identified to be Full Code status three times weekly on [DATE], [DATE], and [DATE], to ensure licensed staff was monitoring and documenting the yellow wristbands were in place. Interviews on [DATE], at 4:00 PM, with UM #1, at 3:45 PM, with UM #2, at 4:05 PM, with UM #3, and at 5:15 PM, with the SDC revealed they will conduct ten nursing staff audits weekly to ensure comprehension of the code status policy, assessment skills, and actions to take when a resident is identified with a change in condition. Interview further revealed the 24-hour nursing report would be audited daily five days a week, along with audits of the MARs for residents with Full Code status, three times a week, to ensure any resident who experienced a change in condition was assessed to ensure immediate action was taken to address the change in condition.

Based on interview, record review, and facility policy review, it was determined the facility failed to identify issues for which quality assessment and assurance activities were necessary, and failed to develop and implement appropriate plans of action to correct identified quality deficiencies. There was no evidence the facility Quality Assurance Committee identified that CMT #1 was not knowledgeable and competent regarding the facility policy to disinfect blood glucose monitoring devices between each resident use. The facility Quality Assurance Committee failed to identify and correct quality deficiencies related to disinfecting blood glucose monitors according to manufacturer's guidelines. In addition, the facility's failure to monitor the effectiveness of the training regarding the blood glucose monitoring policy and failure to monitor to ensure staff competency placed residents at risk for serious injury, harm, impairment, or death. (Refer to F441 and F490.) The findings include: A review of the facility infection control policies for transmission based precautions with a revised date of June 2010 revealed the policy had no guidance for quality assurance to monitor staff usage of equipment to prevent the risk for transmission of infectious bloodborne pathogens. On May 31, 2011, CMT #1 was observed to obtain residents #3, #16, and #17's blood sugar and clean the machine between each resident use with an alcohol wipe instead of the Super Sani-Cloth Germicidal Wipe as required by facility policy. An interview conducted with the Infection Control Nurse (ICN) on June 2, 2011, at 3:16 p.m., revealed the infection control nurse was required to monitor staff for competency regarding the use of equipment; however, there was no guidance from the quality assurance committee regarding the procedure for the monitoring of staff to ensure that all staff was competent after the facility staff received training on the change of the cleaning policy for the blood glucose monitor (BGM). According to the ICN, in-services were conducted for all staff who utilized the BGM on February 15, 2011 and March 1, 2011. A review of the in-service minutes revealed 13 staff members were trained on February 15, 2011, and 10 staff members were trained on March 1, 2011. Further interview revealed the in-services were often conducted on the spot with each staff member and the staff would often be distracted during the in-service. Review of the ICN audits for competency of use and disinfecting of the BGMs revealed competency was reviewed for three staff members; however, an audit was not completed for CMT #1 to ensure competency of the policy for disinfecting the BGMs between resident use. Quality Assurance (QA) interviews conducted with the Administrator and Director of Nursing (DON) on June 2, 2011, from 6:15 p.m. to 6:45 p.m., revealed the facility conducted a monthly QA meeting to identify concerns. The interview revealed infection control was a part of QA and the role of infection control in QA was defined by the Centers for Disease Control (CDC) Guidelines. Further interview with the Administrator and the DON revealed the QA Committee was not aware of any concerns regarding staff competency of cleaning BGMs according to the new policy. In addition the QA Committee was not aware that monitoring of staff competency after a policy change was not being completed systematically to ensure that all staff was competent in the cleaning/disinfecting of the BGMs between resident use. **An acceptable Allegation of Compliance was received on June 3, 2011, which alleged removal of Immediate Jeopardy on June 4, 2011. An extended survey was conducted on June 7, 2011, which determined the Immediate Jeopardy was removed on June 4, 2011. A review of the Allegation of Compliance and verification revealed the following: A review of the facility policy for Quality Assurance revealed the policy was revised on June 3, 2011, with provisions for monitoring staff competency related to in-service training and the cleaning/disinfecting of BGMs. Observations and interviews conducted on June 7, 2011, from 12:30 to 4:00 p.m., with CMTs, LPNs, and RNs who performed blood glucose monitoring for residents revealed the staff had been trained by the facility and competency established by return demonstration on the facility's blood glucose monitoring policy. Observations conducted on June 7, 2011, from 12:30 to 4:00 p.m., revealed LPN and RN staff demonstrated proper technique for blood glucose monitoring according to the facility's policy and procedure and CDC guidelines when obtaining the resident's blood glucose. A review of in-service documentation revealed an in-service was conducted with the QA committee on June 3, 2011, by the Clinical Nurse Consultant regarding identification of problems/issues, development of actions plans, monitoring the action plan, review of the monitoring results, and revision of the action plans if noncompliance issues were still present. A review of QA Committee meeting minutes revealed that the QA Committee had met on June 3, 6, and 7, 2011, to review and monitor the facility ongoing interventions for appropriate use of BGMs between residents and for signs and symptoms of infection for all residents who could have been affected by the inappropriate disinfection of the BGMs between resident use by CMT #1. Interviews conducted with the Administrator and the Director of Nursing on June 7, 2011, from 5:15 to 6:30 p.m., revealed the CNC had in-serviced the facility QA Committee to monitor the infection control program for quality deficiencies and develop plans of action to address the quality deficiencies. Further interview revealed the plans of action would be evaluated for effectiveness. Further interview revealed the in-services for QA would be extended to all staff. Based on the above findings, it was determined the Immediate Jeopardy was removed on June 4, 2011. Noncompliance continued with scope and severity lowered to "D" based on the facility's need to evaluate the effectiveness of CQI activities related to the implementation of Policies and Procedures for the Infection Control Program and the QA Committee's oversight and monitoring of the Infection Control Program for quality deficiencies.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure it was administered in a manner that enabled the facility to use resources effectively and efficiently to attain or maintain the highest practicable physical well-being of residents. Certified Medication Technician (CMT) #1 failed to disinfect a blood glucose monitor (BGM) between resident use for three of twenty-four sampled residents. The facility's failure to not have an effective infection control program to ensure staff followed facility policy and current CDC guidelines related to BGM disinfecting guidelines for multiple resident use and to prevent the potential development and transmission of infections placed residents at risk for serious injury, harm, impairment, or death. (Refer to F441 and F520.) The findings include: A review of the facility policy Titled Glucometer Cleaning Guidelines (dated February 2011) revealed the BGM should be cleaned between each resident test with a Super Sani-Cloth Germicidal Disposable Wipe. On May 31, 2011, CMT #1 was observed to perform fingerstick blood tests on residents #3, #16, and #17 without disinfecting the BGM using the required disinfectant according to the facility policy between each resident use. An interview conducted with the facility's Administrator on June 2, 2011, at 6:45 p.m., revealed the Administrator was made aware of the Centers for Disease Control (CDC) Guidelines and Regulatory Changes regarding the Use of Blood Glucose Monitoring Machines by the facility's Corporate Representative in February 2011. According to the Administrator, the facility policy was revised to include the recommendations to clean and disinfect the BGMs between residents. In addition, in-services were conducted and staff trained on the new policy. The Administrator was not aware of any monitoring regarding staff competency or regarding the cleaning and sanitizing of the BGM. In addition, the Administrator stated blood glucose monitoring machines had been purchased for each resident that required the machine, but were not being utilized due to lack of storage space for the machines. Further interview revealed the facility had looked into purchasing carts for the machines, but had not decided on a particular cart. Additional interview with the Administrator revealed that infection control was reviewed monthly during the Quality Assurance Meeting related to the number of infections and for an increase of infections, but infection control was not reviewed regarding staff knowledge of practices and procedures related to infection control. **An acceptable Allegation of Compliance (AOC) was received on June 3, 2011, which alleged removal of Immediate Jeopardy on June 4, 2011. An extended survey was conducted on June 7, 2011, which determined the Immediate Jeopardy was removed on June 4, 2011. A review of the Allegation of Compliance and verification revealed the following: A review of the AOC revealed that residents who had received blood glucose monitoring checks by CMT #1 were assessed on June 3, 2011, and monitored daily each shift for signs and symptoms of infections with no concerns identified. The facility policy for the cleaning/disinfecting of BGMs was reviewed and revised on June 2, 2011, by the Director of Nursing (DON) and all staff that utilizes the BGMs was retrained and competency was verified by return demonstration with monitoring and reeducation bi-weekly for two months ongoing. A review of in-service documents dated June 3, 2011, revealed the Administrator was in-serviced by the Clinical Nurse Consultant (CNC) regarding the QA process to identify quality deficiencies and staff competency on June 3, 2011. A review of QA meeting minutes revealed the Administrator had conducted QA meetings to identify concerns on June 3, 6, and 7, 2011, with no concerns identified according to the meeting minutes. Observations and interviews on June 7, 2011, from 12:30 to 4:00 p.m., of staff completing blood glucose monitoring checks on residents revealed the staff had been in-serviced related to blood glucose monitoring and observations of blood glucose monitoring checks conducted by the staff revealed no concerns. An interview conducted with the Administrator on June 7, 2011, at 6:30 p.m., revealed the blood glucose monitoring policy had been revised on June 2, 2011. All staff had been trained regarding disinfecting the BGM with competency determined by repeat demonstration on June 3, 2011, and daily monitoring was ongoing of diabetic residents for signs and symptoms of infection. Based on the above findings, it was determined the Immediate Jeopardy was removed on June 4, 2011. Noncompliance continued with scope and severity lowered to "D" based on the facility's need to evaluate the effectiveness of CQI activities related to the implementation of Policies and Procedures for the Infection Control Program and the Administrator's oversight and monitoring of the Infection Control Program.

Based on observation, interview, policy and procedure review, and review of manufacturer's recommendations, it was determined the facility failed to have an effective Infection Control Program in place to provide a safe environment to prevent the development and transmission of disease and infection. The facility failed to ensure resident multi-use Blood Glucose Monitors (BGMs) were disinfected between each resident use according to the facility's policy and manufacturer's recommendations. CMT #1 was observed performing blood glucose monitoring via fingerstick without disinfecting the BGM before and after use for three of twenty-four sampled residents (residents #3, #16, and #17). It was further determined the facility failed to provide evidence the facility's infection control program was effective in ensuring the competency of CMT #1 in the proper technique to disinfect resident glucometer devices as recommended by the facility's policy, CDC guidelines, and the glucometer manufacturer's recommendation. In addition the facility staff failed to pass ice to residents under sanitary conditions on May 31, 2011, at 3:50 p.m., and the facility wound/treatment nurse was observed to not wash hands when indicated during wound care for resident #5 on June 1, 2011. (Refer to F490 and F520.) The facility's failure to have an effective infection control program placed residents at risk for serious injury, harm, impairment, and death. The findings include: 1. According to the Centers for Disease Control (CDC) Guidelines, updated March 23, 2011, "Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared." The facility's policy "Glucometer Cleaning Guidelines" (dated February 2011) revealed the glucometer was required to be cleaned between each patient/resident test according to the facility's policy. The RN, LPN, and/or CMT should use super sani-cloth germicidal wipes to disinfect the glucometer. The meter should be visibly cleaned/wet for two minutes and allowed to dry for 15 seconds. If the meter was visibly soiled, it should be cleaned with one wipe and a second wipe should be used to disinfect the meter. According to the manufacturer's recommended guidelines for disinfection of the Assure 4 glucometer used by the facility, a dilute of 1 milliliter of household bleach (5%-6% sodium hypochlorite solution) in 9 milliliters of water to achieve a 1:10 dilution (final concentration of 0.5% - 0.6% sodium hypochlorite) should be used. The solution should be used to dampen a paper towel (do not saturate the towel); then use the dampened paper towel to thoroughly wipe down the meter. There were commercially available 1:10 bleach wipes from a variety of manufacturers. Super Sani-Cloth Germicidal Disposable Wipe was included as an effective disinfectant for use on the Assure 4 glucometer. A record review revealed resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3 had physician's orders for blood glucose monitoring two times a day and received hypoglycemics as therapeutic treatment. A review of resident #16's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #16 had physician's orders for blood glucose monitoring two times a day. During observation of a medication pass conducted on May 31, 2011, at 3:10 p.m., Certified Medication Technician (CMT) #1 was observed to obtain resident #3's blood glucose via fingerstick. CMT #1 was observed to clean the blood glucose monitor with an alcohol pad, and then obtain resident #16's blood glucose via fingerstick. The CMT then used an alcohol pad to clean the blood glucose monitor after obtaining the blood sample and placed the glucometer back into a medication cart drawer. CMT #1 failed to ensure the glucometer was disinfected per manufacturer's guidelines and facility policy. An interview conducted with CMT #1 on May 31, 2011, at 3:10 p.m., revealed CMT #1 had been trained to sanitize the BGM with alcohol after use to check blood sugar and to also use alcohol as a cleaning/sanitizing agent between residents. A record review revealed resident #17 was admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. Resident #17 had a physician's order dated May 2011 for glucose monitoring via fingerstick four times a day and as needed. During observation of a medication pass conducted on May 31, 2011, at 3:30 p.m., Certified Medication Technician (CMT) #1 performed a blood glucose check for resident #17 and failed to disinfect the glucometer prior to use or after use. Observations revealed CMT #1 cleaned the BGM with an alcohol pad prior to obtaining resident #17's blood glucose via fingerstick, used an alcohol pad to clean the BGM after obtaining the blood sample, and placed the meter back in a drawer on the medication cart. An interview conducted on May 31, 2011, at 3:35 p.m., with CMT #1 revealed she had been trained to disinfect the glucometer used for resident #17 with an alcohol prep pad. An additional interview conducted on June 1, 2011, at 3:25 p.m., with CMT #1 revealed she had been in-serviced a couple of months ago (unable to recall exact date) on the facility's policy and procedure to clean and disinfect the resident's BGM by the Infection Control Nurse (ICN) and Licensed Practical Nurse (LPN) #1, the Third Flood Supervisor. CMT #1 was unable to recall specifics of the in-service but believed she was supposed to use an alcohol prep pad to disinfect the resident glucometers before and after performing a blood glucose test. An interview conducted on June 1, 2011, with LPN #1, the Third Floor Supervisor, revealed she was responsible to do immediate one-on-one retraining with the individual staff member in the event of failure to follow policy and procedure. LPN #1 revealed the facility's policy for BGM disinfecting had changed several months ago (unable to recall date) and all Registered Nurses (RNs), LPNs, and CMTs had been in-serviced on the facility's updated policy and procedure. The staff confirmed BGMs were required to be disinfected with a Super Sani-Cloth Germicidal Disposable Cloth before and after a resident blood glucose test was performed. An interview conducted on June 2, 2011, at 3:15 p.m., with the Infection Control Nurse (ICN), revealed she was responsible for providing in-service education for CMTs, LPNs, and RNs on the facility's updated policies and procedures and to perform audits/reviews of staff to evaluate and assure competency of the training provided. The ICN stated an in-service training on "Glucometer Cleaning Guidelines" for CMTs, LPNs, and RNs was conducted on February 15, 2011, and again on March 1, 2011. The ICN did not recall an audit of CMT #1's competency regarding the facility's policy/procedure on BGM Cleaning Guidelines and was unable to provide evidence of an evaluation of CMT #1's competency. An interview conducted on June 2, 2011, at 6:10 p.m., with the Director of Nursing (DON) revealed the facility had updated the BGM disinfectant policy in February 2011, and the ICN was responsible for providing training and monitoring CMTs, LPNs, and RNs on this new policy update. The DON further stated the facility had not identified any staff problems with failure to follow the facility's policy and procedure of disinfecting a resident's BGM. The DON confirmed the facility's policy was to disinfect the BGM before and after resident testing with a Super Sani-Cloth Germicidal Disposable Wipe. The DON stated according to the facility's policy and procedure and CDC guidelines, the use of an alcohol prep pad to disinfect the resident's glucometers had a potential for the transmission of bloodborne pathogens/infections to the staff using the glucometer and residents. 2. The facility policy titled Ice Machines and Ice Storage Chests (revised December 2009) directed staff that to prevent contamination of ice machines, ice storage chests/containers of ice, staff should keep the ice scoop/bin in a covered container when not in use. Observation on May 31, 2011, at 3:50 p.m., revealed CNA #3 passed ice to resident rooms on the second floor. Observation revealed CNA #3 filled an ice pitcher for an unsampled resident in room [ROOM NUMBER]; however, CNA #3 left the ice scoop in the ice chest with the handle touching the ice that remained in the ice cooler. Further observation revealed CNA #3 entered resident room [ROOM NUMBER] and obtained an ice pitcher for an unsampled resident. CNA #3 was observed to handle/touch the resident's bedside table and bathroom door knob, empty the water from the ice pitcher in the resident's bathroom, open the ice cooler, grasp the ice scoop that was lying on the ice in the cooler, and fill the resident's pitcher with ice. CNA #3 then left the ice scoop in the ice chest with the handle touching the ice that remained in the ice cooler. Further observation on May 31, 2011, at 4:10 p.m., revealed CNA #3 stored the ice cooler in the second floor utility room and the ice scoop remained inside the cooler with the handle in contact with the ice. Interview on June 1, 2011, at 4:00 p.m., with CNA #3 revealed the CNA was knowledgeable of the requirement to store the ice scoop in the covered container that was positioned on the shelf below the ice cooler. CNA #3 stated he just failed to use the storage container and left the ice scoop in the ice chest by mistake. CNA #3 stated the handle of the ice scoop should not come in contact with the ice that was to be served to residents. 3. A review of the facility policy for hand washing and the use of gloves dated December 1998 revealed staff was required to wash their hands after removing gloves with a specific note which indicated gloves do not replace hand washing. Observation of wound care for resident #5 on June 1, 2011, at 3:35 p.m., revealed the facility's wound treatment nurse removed a soiled dressing from the coccyx area of resident #5, removed the soiled gloves from her hands, donned clean gloves, and cleaned the wound area. The wound treatment nurse removed her soiled gloves after cleaning the wound area, donned clean gloves, and applied a dressing to the wound on the coccyx area of resident #5. The wound care nurse failed to wash her hands after removing her soiled gloves and donning clean gloves. An interview conducted with the wound treatment nurse on June 1, 2011, at 3:35 p.m., revealed the wound treatment nurse washed her hands prior to starting the treatment and after the treatment was complete. Further interview revealed the wound treatment nurse was not aware that handwashing was required after removing gloves. **An acceptable Allegation of Compliance was received on June 3, 2011, which alleged removal of Immediate Jeopardy on June 4, 2011. An extended survey was conducted on June 7, 2011, which determined the Immediate Jeopardy was removed on June 4, 2011. A review of the Allegation of Compliance and verification revealed the following: The residents that received glucose checks by CMT #1 had a visual inspection of their fingers and temperatures taken on June 3, 2011, by a Licensed Nurse; no signs of infection or elevated temperatures were noted. All residents receiving blood glucose monitoring had visual inspection of their fingers and temperatures taken on June 3, 2011, by a Licensed Nurse. No signs of infection were noted nor any elevated temperatures. The Manufacturer Guidelines for the Assure 4 glucometer on disinfection of the glucometers were reviewed by the Director of Nursing, Clinical Nurse Consultant (CNC), and the Administrator on June 3, 2011. The guidelines reflected the Assure 4 meter was adequately disinfected with the Super Sani-Cloth Germicidal Disposable Wipes that the facility utilized. The Central Supply clerk was educated by the DON to only order Super Sani-Cloth Germicidal. The Glucometer Disinfecting Guidelines were reviewed and revised by the DON on June 2, 2011. A check-off/competency form following the manufacturer's guidelines for cleaning and disinfecting the Assure 4 meter was developed by the DON and CNC on June 2, 2011. The CNC reeducated the Staff Development Coordinator (SDC) and the MDS Coordinator related to the revised guidelines for appropriate disinfecting of the glucometers. Competency was established by return demonstration on June 2, 2011. A staff RN was educated and competency tested by the MDS Coordinator on June 3, 2011. She assisted with the staff training on June 3, 2011. Reeducation for all RN, LPN, and CMT staff with return demonstration of disinfection on the glucometers by the Staff Development Coordinator, the MDS Coordinator, and a staff RN began on June 3, 2011, and was completed on June 3, 2011. The SDC, MDS Coordinator, and the staff RN will reeducate with return demonstration to ensure competency of all the RN, LPN, and CMT staff bi-weekly for two months, monthly for two months, and then as recommended by the Quality Assurance Committee. Review of residents #3, #16, and #17's records revealed staff had documented on June 6, 2011, that the residents had no signs or symptoms of infection, elevated temperature, or identified blood infections. The monitoring sheet was added to the residents' Medication Administration Record (MAR). The facility updated the Glucometer Disinfecting Guideline (dated June 2, 2011) to reflect CDC guidelines to prevent the spread of actual and/or potential infections between patients/residents. A review of Glucometer Check-off Competency Forms dated June 3, 2011, revealed all nurses and CMTs demonstrated competency with Manufacturer's Guidelines for disinfecting the glucometer. Observations and interviews conducted June 7, 2011, from 12:30 to 4:00 p.m., with CMTs, LPNs, and RNs who performed blood glucose monitoring for residents revealed staff had been trained by the facility and competency established by return demonstration on the facility's blood glucose monitoring policy. Observations conducted on June 7, 2011, from 12:30 to 4:00 p.m., revealed LPN and RN staff demonstrated proper technique for blood glucose monitoring according to the facility's policy and procedure and CDC guidelines when performing resident blood glucose monitoring. An interview conducted with CMT #1 (via telephone) on June 7, 2011, at 2:40 p.m., revealed she had been trained on blood glucose monitoring with return demonstration of competency on June 3, 2011. Interview with the DON conducted on June 7, 2011, at 5:15 p.m., revealed the facility had reviewed and updated the blood glucose monitoring policy and procedure to follow the manufacturer's recommended disinfectant guidelines and CDC Guidelines. The facility had developed a competency check-off sheet to assure staff competency of training. The DON confirmed all CMTs, LPNs, and RNs who worked at the facility had been in-serviced by the facility on the updated policy and procedure for blood glucose monitoring. Return demonstrations were performed to assure competency. Based on the above findings, it was determined the Immediate Jeopardy was removed on June 4, 2011. Noncompliance continued with scope and severity lowered to "D" based on the facility's need to evaluate the effectiveness of CQI activities related to the implementation of Policies and Procedures for the Infection Control Program.

Based on interview and record review, it was determined the facility failed to provide care and services to maintain physical wellbeing for one (1) of six (6) sampled residents (resident #1). Resident #1 was found unresponsive and not breathing on February 6, 2011. The facility failed to ensure Cardiopulmonary Resuscitation (CPR) was administered to resident #1 who had a Full Code Status. Resident #1 expired at the facility on February 6, 2011. The failure of the facility to ensure care and services to maintain physical wellbeing was provided for residents placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy and Substandard Quality of Care were determined to exist on February 6, 2011. The findings include: Review of the facility's Cardiopulmonary Resuscitation (CPR) Policy and Procedure, dated February 1999, revealed the document addressed the correct clinical steps to be performed when administering CPR, but failed to address actions expected to be taken when a resident was found unresponsive and not breathing to ensure the correct code status was followed by facility staff. Review of resident #1's medical record revealed the facility admitted resident #1 on [DATE], with [DIAGNOSES REDACTED]. The resident had been adjudicated incompetent, appointed a State Guardian, and had physician's orders [REDACTED]. Review of the facility's investigation dated February 7, 2011, revealed on February 6, 2011, RN #1 was summoned to resident #1's room by a Certified Nursing Assistant who found resident #1 unresponsive and not breathing. RN #1 confirmed the resident to be without blood pressure, pulse, or respirations; however, CPR was not administered to resident #1. Review of a signed statement by RN #1 dated February 7, 2011, and interview with RN #1 on [DATE], at 10:50 a.m., revealed RN #1 "thought" resident #1 was a DNR, although the resident's chart was clearly labeled the resident was a full code. Interview with the Director of Nursing (DON) on [DATE], at 1:45 p.m. and 3:00 p.m., revealed the facility had conducted no training or monitoring to ensure staff was checking residents' charts to identify residents' code status prior to making a decision if CPR would be initiated when a resident was found unresponsive and not breathing. Interview with the DON on [DATE], at 1:45 p.m. and 3:00 p.m., revealed the facility did not have a policy/procedure in place prior to February 6, 2011, that instructed staff on appropriate actions to take to ensure the proper code status was followed when a resident was found unresponsive and not breathing. According to the DON and a review of facility's in-services revealed the facility staff had participated in CPR certification classes in [DATE] and [DATE]; however, the facility had not conducted training or elicited staff competency regarding correctly determining code status of an individual resident. **An acceptable allegation of compliance related to the Immediate Jeopardy was submitted by the facility on [DATE], which alleged removal of Immediate Jeopardy effective [DATE]. A partial extended survey was conducted on [DATE]-8, 2011, which determined the Immediate Jeopardy was removed on [DATE]. A review of the allegation of compliance revealed the following: Resident #1 expired at the facility on February 6, 2011. On February 7, 2011, all current residents' charts were audited by the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Coordinators (UC) for code status, physician's orders [REDACTED]. All charts were verified to contain the correct code status for the resident. The Code Status Policy was reviewed and revised by the Administrator and DON on February 7, 2011. Current CPR Certification was validated for all licensed nurses on February 7, 2011, and subsequent renewal classes were held on February 16 and 17, 2011. RN #1 received individual in-servicing on February 7, 2011, on the revised code policy and procedure. All Nursing staff was educated on February 7, 2011, by the Staff Development Coordinator (SDC) on the revised Code Policy. New employees will be in-serviced while in orientation related to the guidelines for determining if a resident is a full code and how to promptly identify each resident's code status and what actions to take if the resident is a full code or DNR. Ongoing in-servicing related to guidelines for determining if a resident is a full code and how to promptly identify each resident's code status and what actions to take if the resident is a full code or DNR will be conducted by the SDC monthly for three months and then as directed by the Quality Assurance (QA) Committee. The Medical Director was consulted and reviewed the Revised Code Status Policy and Procedure on [DATE]. The DON will interview five staff members weekly for one month to ensure the employees are aware of how to determine if a resident is a full code or a DNR and what action should be taken dependent upon the resident's code status. Additionally, the DON, ADON, and UC will conduct a mock code weekly for one month on diverse shifts to ensure that staff follows the facility's Revised Code Status policy and procedure. Thereafter, the mock codes will be conducted every two weeks for one month, and then conducted quarterly. The DON will audit all new admissions and four additional charts weekly to determine the resident's appropriate code status is clearly documented and all forms are contained in the resident's medical record. The Medical records clerk will audit all charts monthly for three months to determine if the medical record contains physician's orders [REDACTED]. The surveyor validated the corrective action taken by the facility as follows: Review of Code Status Review forms dated February 7, 2011, and interviews conducted on [DATE], with the DON, ADON, and UC revealed all resident charts were audited for correct code status, appropriate physician's orders [REDACTED]. Additionally, a review of five resident charts on [DATE], revealed the charts were designated with the appropriate code status, contained physician's orders [REDACTED]. Review of the revised Code policy and procedure including the Full Code Status versus No Code-DNR revision dated February 7, 2011, revealed the policy and procedure contained specifics regarding decisions of code status by the resident/family, what must be documented in the medical record, what designation of a "full code" entailed, and specific instructions for staff to utilize when a resident was found unresponsive to ensure the resident's correct code status was initiated. Additionally, a review of Current and Expiration of CPR Certification and interview with the DON on [DATE], revealed that a review of all licensed staff 's CPR certification was conducted and as of February 17, 2011, all licensed staff was certified in CPR. Review of a Counseling/Discipline Record for RN #1 dated February 25, 2011, and interview with RN #1 on [DATE], revealed RN #1 was educated regarding the revised code status policy/procedure on February 7, 2011. Review of Upstairs Solutions DNR/No Code Policy and Procedure training dated February 7, 2011, and interview with the SDC on [DATE], revealed nursing staff had been in-serviced regarding the revised Code Policy. Additionally, interviews on [DATE]-8, 2011, with RN #2, Licensed Practical Nurse (LPN) #2, LPN #3, Certified Nursing Assistants (CNAs) #1, #2, and #3, and a Certified Medication Technician (CMT) revealed staff had received training regarding the Revised Code Policy on February 7, 2011. Review of a facility Orientation Checklist and interview with the DON on [DATE], revealed new employees would be trained regarding the facility's revised CPR policy and CPR Certification during facility orientation. Interview with the DON on [DATE], revealed the facility had scheduled training regarding the facility's revised CPR policy and procedure for March, April, and [DATE]. Review of the Revised Code Status Policy and Procedure revealed the Medical Director's signature verifying review and approval of the document on [DATE]. Review of QA Mock Full Code Status forms and interview with the DON on [DATE], revealed staff was able to answer the mock code questions appropriately on [DATE], and appropriately performed a Mock code simulation on [DATE]. Additionally, interviews conducted on [DATE]-8, 2011, with RN #1, RN #2, LPN #2, LPN #3, LPN #4, LPN #6, CNA #1, CNA #2, CNA #3, CMT #1, and LPN #5 revealed staff was knowledgeable and able to verbalize all parts/steps in the facility's Revised Code Status in regards to acting appropriately in a code situation. Review of a QA Code Status dated [DATE], and interview with the DON on [DATE], revealed ten resident charts were reviewed with no concerns identified related to appropriate physician's orders [REDACTED]. Additionally, a review of five resident charts on [DATE], revealed the charts were designated with the appropriate code status, and contained physician's orders [REDACTED]. Based on the above findings, it was determined the Immediate Jeopardy was removed on [DATE]. Noncompliance continued with scope and severity lowered to "D" based on the facility's need to evaluate the effectiveness of Quality Assurance activities related to the implementation of policies and procedures for ensuring residents were free from abuse/neglect and ensuring the facility provided the necessary care and services to maintain each resident's physical wellbeing.

Based on interview and record review, it was determined the facility failed to implement policies and procedures for reporting an incident of possible neglect for one (1) of six (6) sampled residents (resident #1). Although the facility conducted an investigation regarding the failure of staff to administer Cardiopulmonary Resuscitation (CPR) to resident #1 who was to receive all life sustaining/resuscitative measures possible, the facility failed to report the incident as an act of possible negligence to appropriate agencies as required. The facility's failure to ensure all possible instances of neglect were reported to appropriate agencies as required placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy and Substandard Quality of Care were determined to exist on February 6, 2011. The findings include: Review of a facility investigation dated February 7, 2011, revealed resident #1 was discovered to be unresponsive and not breathing on February 6, 2011. Resident #1 had physician's orders [REDACTED]. However, Registered Nurse (RN) #1 who was summoned to the resident's room "thought" resident #1 had a DNR order, and failed to initiate resuscitative measures to the resident. Review of the facility's Abuse Reporting and Prevention policy/procedure, updated [DATE], revealed that neglect was failure to provide goods and services necessary to avoid physical harm, and was required to be reported immediately to appropriate state agencies. Interview with the Director of Nursing on [DATE], at 1:45 p.m. and 3:00 p.m., revealed he/she became aware that resuscitative measures had not been administered to resident #1, despite the resident being a "full code" on February 6, 2011, when he/she was contacted at home regarding the incident. The DON stated it was immediately recognized that CPR should have been initiated to resident #1, and a facility investigation was initiated to determine why RN #1 failed to initiate resuscitative measures to resident #1. However, the facility failed to report the incident to any outside agencies as a possible act of negligence to resident #1. The DON further revealed in the interview on [DATE], at 1:45 p.m. and 3:00 p.m., that the facility's investigation determined resident #1 would not have wanted life sustaining/resuscitative measures initiated, and was only a "full code" due to having been appointed a State Guardian which required the resident to be a "full code." Therefore, according to the DON the facility did not feel the failure to initiate Cardiopulmonary Resuscitation to resident #1 was neglectful despite the resident having physician's orders [REDACTED]. **An acceptable allegation of compliance related to the Immediate Jeopardy was submitted by the facility on [DATE], which alleged removal of Immediate Jeopardy effective [DATE]. A partial extended survey was conducted on [DATE]-8, 2011, which determined the Immediate Jeopardy was removed on [DATE]. A review of the allegation of compliance revealed the following: Resident #1 expired at the facility on February 6, 2011. On February 7, 2011, all current residents' charts were audited by the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Coordinators (UC) for code status, physician's orders [REDACTED]. All charts were verified to contain the correct code status for the resident. The Abuse and Neglect Policy and Procedure was reviewed by the Administrator and DON on [DATE]. RN #1 received individual in-servicing on February 7, 2011, on the revised code policy and procedure. Education/training related to abuse/neglect prevention and reporting was conducted for all employees on [DATE]-4, 2011, by the Staff Development Coordinator (SDC), DON, ADON, UCs, and Administrator. The Administrator and DON were re-educated regarding their responsibilities to report suspected abuse/neglect when identified by the SDC on [DATE]. New employees will be in-serviced related to abuse/neglect prevention and reporting while in orientation. Ongoing in-servicing related to abuse and neglect prevention/reporting will be provided to nursing staff by the SDC monthly for three months then as directed by the Quality Assurance (QA) Committee. The Administrator will interview five residents and five staff members weekly to determine if any perceived instances of abuse/neglect have occurred. The DON, ADON, and/or UC will visually audit nine residents weekly for three months to ensure there are no indications of abuse/neglect. The Administrator will review the audits with the QA committee, who will direct continued visual audits. The surveyor validated the corrective action taken by the facility as follows: Review of Code Status Review forms dated February 7, 2011, and interviews conducted on [DATE], with the DON, ADON, and UC revealed all resident charts were audited for correct code status, appropriate physician's orders [REDACTED]. Additionally, a review of five resident charts on [DATE], revealed the charts were designated with the appropriate code status, contained physician's orders [REDACTED]. Interviews with the Administrator and DON on [DATE], revealed the review of the abuse and neglect policy and procedure conducted on [DATE], revealed no identified concerns. Additionally, a copy of the Abuse Reporting and Prevention policy/procedure signed and dated [DATE], by the Administrator and DON was reviewed. Review of a Counseling/Discipline Record for RN #1 dated February 25, 2011, and an interview with RN #1 on [DATE], revealed RN #1 was educated regarding the revised code status policy/procedure on February 7, 2011. A review of the Abuse/Neglect policy in-service revealed RN #1 received training on the Abuse/Neglect policy/procedure on [DATE]. Review of On the Spot Education/Re-education forms dated [DATE], and 4, 2011, and interviews with the SDC, DON, ADON, UCs, and Administrator on [DATE], revealed staff had been in-serviced, including RN #1, regarding the abuse/neglect policy and procedure. Additionally, interviews on [DATE]-8, 2011, with RN #2, Licensed Practical Nurse (LPN) #3, Certified Nursing Assistants (CNAs) #1, #2, and #3, and the Certified Medication Technician (CMT) on [DATE], revealed all the staff interviewed had attended training on the abuse neglect policy/procedure on either [DATE], or 4, 2011. Review of an On the Spot Education/Re-education dated [DATE], and interviews with the Administrator and DON on [DATE], revealed the SDC had re-educated the Administrator and DON of their ultimate responsibility to report allegations of abuse and neglect to the appropriate agencies timely. Review of a facility's Orientation Checklist and interview with the DON on [DATE], revealed new employees would be trained regarding the facility's abuse/neglect policy/procedure including prevention and reporting during the facility orientation. Review of a Monthly Education form and interview with the DON on [DATE], revealed the facility had scheduled abuse/neglect training for March, April, and [DATE]. Review of QA Audits: Perceived Neglect or Abuse Allegations dated [DATE], and signed by the Administrator, and interview with the Administrator on [DATE], revealed five residents and five staff persons were interviewed regarding any perceived abuse or neglect incidents with no concerns identified. Additionally, a review of Quality Assurance: Round Audit Tools dated [DATE], and interviews with the DON, ADON, and UC on [DATE], revealed nine residents were reviewed on [DATE], for any signs/symptoms of neglect with no concerns identified. Based on the above findings, it was determined the Immediate Jeopardy was removed on [DATE]. Noncompliance continued with the scope and severity lowered to "D" based on the facility's need to evaluate the effectiveness of Quality Assurance activities related to the implementation of policies and procedures for ensuring residents were free from abuse/neglect and ensuring the facility provided the necessary care and services to maintain each resident's physical wellbeing.

Based on interview and record review, it was determined the facility failed to provide goods and services necessary to avoid physical harm for one (1) of six (6) sampled residents (resident #1). On February 6, 2011, resident #1 was found unresponsive and not breathing. The facility failed to administer Cardiopulmonary Resuscitation (CPR) to resident #1 who had a physician's orders [REDACTED]. Resident #1 expired at the facility on February 6, 2011. The facility's failure to ensure that necessary services to avoid physical harm were administered placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy and Substandard Quality of Care were determined to exist on February 6, 2011. The findings include: Review of the facility's Abuse Reporting and Prevention policy/procedure, updated [DATE], revealed that neglect was failure to provide goods and services necessary to avoid physical harm. Review of resident #1's medical record and the facility's investigation, dated February 7, 2011, revealed resident #1 was discovered by staff to be unresponsive and not breathing on February 6, 2011. Registered Nurse (RN) #1 was summoned to resident #1's room, and confirmed resident #1 was without blood pressure, pulse, or respirations; however, RN #1 failed to administer CPR to resident #1. Review of RN #1's signed statement, dated February 7, 2011, and interview with RN #1 on [DATE], at 10:50 a.m., revealed RN #1 "remembered thinking (resident #1) was in such a better place and wasn't suffering anymore. I was thinking (he/she) was a DNR (do not resuscitate)." Further review of the written statement and interview with RN #1 revealed no action was taken to confirm resident #1's code status in the medical record, stating "in my mind (he/she) was a DNR." Per interview, RN #1 did not know resident #1 required administration of all life sustaining/resuscitative measures possible to maintain life, until at least 15 minutes after the resident had been assessed to have no signs of life. RN #1 stated, "By that time it had been too long to do CPR." Interview with the Director of Nursing on [DATE], at 1:45 p.m. and 3:00 p.m., revealed he/she became aware that RN #1 failed to perform resuscitative measures to resident #1 on February 6, 2011, when he/she was contacted at home regarding the incident. The DON stated it was immediately recognized that CPR should have been initiated to resident #1, however, the DON stated he/she failed to consider RN #1's actions as being neglectful, and considered the incident a "mistake" made by RN #1. Review of resident #1's medical record revealed on February 6, 2011, resident #1 had a current signed physician's orders [REDACTED]. Interview with resident #1's state appointed Guardian on [DATE], at 2:20 p.m., confirmed resident #1 was a "full code" and all measures necessary to revive/sustain the life of resident #1 should have been taken (refer to F309). **An acceptable allegation of compliance related to the Immediate Jeopardy was submitted by the facility on [DATE], which alleged removal of Immediate Jeopardy effective [DATE]. A partial extended survey was conducted on [DATE]-8, 2011, which determined the Immediate Jeopardy was removed on [DATE]. A review of the allegation of compliance revealed the following: Resident #1 expired at the facility on February 6, 2011. On February 7, 2011, all current residents' charts were audited by the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Coordinators (UC) for code status, physician's orders [REDACTED]. All charts were verified to contain the correct code status for the resident. The Abuse and Neglect Policy and Procedure was reviewed by the Administrator and DON on [DATE]. RN #1 received individual in-servicing on February 7, 2011, on the revised code policy and procedure. Education/training related to abuse/neglect prevention and reporting was conducted for all employees on [DATE]-4, 2011, by the Staff Development Coordinator (SDC), DON, ADON, UCs, and Administrator. The Administrator and DON were re-educated regarding their responsibilities to report suspected abuse/neglect when identified by the SDC on [DATE]. New employees will be in-serviced related to abuse/neglect prevention and reporting while in orientation. Ongoing in-servicing related to abuse and neglect prevention/reporting will be provided to nursing staff by the SDC monthly for three months then as directed by the Quality Assurance (QA) Committee. The Administrator will interview five residents and five staff members weekly to determine if any perceived instances of abuse/neglect have occurred. The DON, ADON, and/or UC will visually audit nine residents weekly for three months to ensure there are no indications of abuse/neglect. The Administrator will review the audits with the QA committee, who will direct continued visual audits. The surveyor validated the corrective action taken by the facility as follows: Review of Code Status Review forms dated February 7, 2011, and interviews conducted on [DATE], with the DON, ADON, and UC revealed all resident charts were audited for correct code status, appropriate physician's orders [REDACTED]. Additionally, a review of five resident charts on [DATE], revealed the charts were designated with the appropriate code status, contained physician's orders [REDACTED]. Interviews with the Administrator and DON on [DATE], revealed the review of the abuse and neglect policy and procedure conducted on [DATE], revealed no identified concerns. Additionally, a copy of the Abuse Reporting and Prevention policy/procedure signed and dated [DATE], by the Administrator and DON was reviewed. Review of a Counseling/Discipline Record for RN #1 dated February 25, 2011, and an interview with RN #1 on [DATE], revealed RN #1 was educated regarding the revised code status policy/procedure on February 7, 2011. A review of the Abuse/Neglect policy in-service revealed RN #1 received training on the Abuse/Neglect policy/procedure on [DATE]. Review of On the Spot Education/Re-education forms dated [DATE], and 4, 2011, and interviews with the SDC, DON, ADON, UCs, and Administrator on [DATE], revealed staff had been in-serviced, including RN #1, regarding the abuse/neglect policy and procedure. Additionally, interviews on [DATE]-8, 2011, with RN #2, Licensed Practical Nurse (LPN) #3, Certified Nursing Assistants (CNAs) #1, #2, and #3, and the Certified Medication Technician (CMT) on [DATE], revealed all the staff interviewed had attended training on the abuse neglect policy/procedure on either [DATE], or 4, 2011. Review of an On the Spot Education/Re-education dated [DATE], and interviews with the Administrator and DON on [DATE], revealed the SDC had re-educated the Administrator and DON of their ultimate responsibility to report allegations of abuse and neglect to the appropriate agencies timely. Review of a facility's Orientation Checklist and interview with the DON on [DATE], revealed new employees would be trained regarding the facility's abuse/neglect policy/procedure including prevention and reporting during the facility orientation. Review of a Monthly Education form and interview with the DON on [DATE], revealed the facility had scheduled abuse/neglect training for March, April, and [DATE]. Review of QA Audits: Perceived Neglect or Abuse Allegations dated [DATE], and signed by the Administrator, and interview with the Administrator on [DATE], revealed five residents and five staff persons were interviewed regarding any perceived abuse or neglect incidents with no concerns identified. Additionally, a review of Quality Assurance: Round Audit Tools dated [DATE], and interviews with the DON, ADON, and UC on [DATE], revealed nine residents were reviewed on [DATE], for any signs/symptoms of neglect with no concerns identified. Based on the above findings, it was determined the Immediate Jeopardy was removed on [DATE]. Noncompliance continued with the scope and severity lowered to "D" based on the facility's need to evaluate the effectiveness of Quality Assurance activities related to the implementation of policies and procedures for ensuring residents were free from abuse/neglect and ensuring the facility provided the necessary care and services to maintain each resident's physical wellbeing.

Based on interview and record review, it was determined the Administrator failed to effectively administer the facility in a manner that promoted the highest physical wellbeing of each resident. The facility's administration failed to ensure the Cardiopulmonary Resuscitation (CPR) Policy and Procedure detailed actions staff would take to ensure correct code status was followed in the event a resident was found unresponsive and not breathing. Furthermore, this failure resulted in the facility's failure to ensure staff was knowledgeable regarding the procedures. On February 6, 2011, facility staff found resident #1 unresponsive and not breathing. Registered Nurse (RN) #1 "thought" the resident was a "do not resuscitate" (DNR), failed to confirm the resident's code status, and neglected to administer the resident cardiopulmonary resuscitation (CPR). Resident #1 expired at the facility on February 6, 2011 (refer to F224, F226, and F309). Although the facility conducted an investigation regarding the failure of staff to administer Cardiopulmonary Resuscitation (CPR) to resident #1 who was to receive all life sustaining/resuscitative measures possible, the facility failed to identify neglect and failed to report the incident as an act of possible negligence to appropriate state agencies as required. These facility failures placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy and Substandard Quality of Care were determined to exist on February 6, 2011, at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care, and Immediate Jeopardy at 483.75 Administration. The findings include: A review of the facility's Cardiopulmonary Resuscitation (CPR) Policy and Procedure, dated February 1999, revealed the document addressed the correct clinical steps to be performed when administering CPR, but failed to address actions expected to be taken when a resident was found unresponsive and not breathing to ensure the correct code status was followed by facility staff. Review of the facility's investigation dated February 7, 2011, revealed on February 6, 2011, RN #1 was summoned to resident #1's room by a Certified Nursing Assistant who found resident #1 unresponsive and not breathing. RN #1 confirmed the resident to be without blood pressure, pulse, or respirations; however, CPR was not administered to resident #1. Review of a signed statement by RN #1 dated February 7, 2011, and interview with RN #1 on [DATE], at 10:50 a.m., revealed RN #1 "thought" resident #1 was a DNR, although the resident's chart was clearly labeled the resident was a full code. Interviews conducted on [DATE], at 1:45 p.m. and 3:00 p.m., with the DON revealed he/she was notified of the incident on February 6, 2011, and immediately recognized that CPR should have been initiated to resident #1. However, the DON stated he/she failed to consider RN #1's actions as being neglectful, viewing the incident as a "mistake," and did not report the failure to initiate CPR to resident #1 as an act of possible neglect as required. The DON stated at the conclusion of the investigation it was determined resident #1 would not have wanted life sustaining/resuscitative measures initiated, and was only a "full code" due to having been appointed a State Guardian which required the resident to be a "full code." Therefore, according to the DON the facility "actually did the right thing" despite the resident having physician's orders [REDACTED]. The DON stated the facility did not conduct training or elicit staff competency for determining code status of an individual resident prior to February 6, 2011. Additionally, the DON stated he/she did not realize the policy/procedure had not been reviewed/revised since 1999, and did not address confirming a resident's code status until February 7, 2011, when the incident involving resident #1 was being investigated. An interview was conducted on [DATE], at 11:00 a.m., with the Administrator, who stated although he/she was made aware on February 6, 2011, that resident #1 had expired at the facility without being administered CPR despite the resident being a "full code," all clinical issues in the facility were handled by the facility's Director of Nursing (DON). The Administrator explained that after ensuring the DON was made aware of the situation, the incident was primarily investigated and addressed by the DON. **An acceptable allegation of compliance related to the Immediate Jeopardy was submitted by the facility on [DATE], which alleged removal of Immediate Jeopardy effective [DATE]. A partial extended survey was conducted on [DATE]-8, 2011, which determined the Immediate Jeopardy was removed on [DATE]. A review of the allegation of compliance revealed the following: Resident #1 expired at the facility on February 6, 2011. On February 7, 2011, all current residents' charts were audited by the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Coordinators (UC) for code status, physician's orders [REDACTED]. All charts were verified to contain the correct code status for the resident. The Code Status Policy was reviewed and revised by the Administrator and DON on February 7, 2011. Current CPR Certification was validated for all licensed nurses on February 7, 2011, and subsequent renewal classes were held on February 16 and 17, 2011. RN #1 received individual in-servicing on February 7, 2011, on the revised code policy and procedure. All Nursing staff was educated on February 7, 2011, by the Staff Development Coordinator (SDC) on the revised Code Policy. New employees will be in-serviced while in orientation related to the guidelines for determining if a resident is a full code and how to promptly identify each resident's code status and what actions to take if the resident is a full code or DNR. Ongoing in-servicing related to guidelines for determining if a resident is a full code and how to promptly identify each resident's code status and what actions to take if the resident is a full code or DNR will be conducted by the SDC monthly for three months and then as directed by the Quality Assurance (QA) Committee. The Medical Director was consulted and reviewed the Revised Code Status Policy and Procedure on [DATE]. The DON will interview five staff members weekly for one month to ensure the employees are aware of how to determine if a resident is a full code or a DNR and what action should be taken dependent upon the resident's code status. Additionally, the DON, ADON, and UC will conduct a mock code weekly for one month on diverse shifts to ensure that staff follows the facility's Revised Code Status policy and procedure. Thereafter, the mock codes will be conducted every two weeks for one month, and then conducted quarterly. The DON will audit all new admissions and four additional charts weekly to determine the resident's appropriate code status is clearly documented and all forms are contained in the resident's medical record. The medical records clerk will audit all charts monthly for three months to determine if the medical record contains physician's orders [REDACTED]. The Abuse and Neglect Policy and Procedure was reviewed by the Administrator and DON on [DATE]. Education/training related to abuse/neglect prevention and reporting was conducted for all employees on [DATE]-4, 2011, by the Staff Development Coordinator (SDC), DON, ADON, UCs, and Administrator. The Administrator and DON were re-educated regarding their responsibilities to report suspected abuse/neglect when identified by the SDC on [DATE]. New employees will be in-serviced related to abuse/neglect prevention and reporting while in orientation. Ongoing in-servicing related to abuse and neglect prevention/reporting will be provided to nursing staff by the SDC monthly for three months then as directed by the Quality Assurance (QA) Committee. The Administrator will interview five residents and five staff members weekly to determine if any perceived instances of abuse/neglect have occurred. The DON, ADON, and/or UC will visually audit nine residents weekly for three months to ensure there are no indications of abuse/neglect. The Administrator will review the audits with the QA committee, who will direct continued visual audits. The surveyor validated the corrective action taken by the facility as follows: Review of Code Status Review forms dated February 7, 2011, and interviews conducted on [DATE], with the DON, ADON, and UC revealed all resident charts were audited for correct code status, appropriate physician's orders [REDACTED]. Additionally, a review of five resident charts on [DATE], revealed the charts were designated with the appropriate code status, contained physician's orders [REDACTED]. Review of the revised Code policy and procedure including the Full Code Status versus No Code-DNR revision dated February 7, 2011, revealed the policy and procedure contained specifics regarding decisions of code status by the resident/family, what must be documented in the medical record, what designation of a "full code" entailed, and specific instructions for staff to utilize when a resident was found unresponsive to ensure the resident's correct code status was initiated. Additionally, a review of Current and Expiration of CPR Certification and interview with the DON on [DATE], revealed that a review of all licensed staff's CPR certification was conducted and as of February 17, 2011, all licensed staff was certified in CPR. Review of a Counseling/Discipline Record for RN #1 dated February 25, 2011, and interview with RN #1 on [DATE], revealed RN #1 was educated regarding the revised code status policy/procedure on February 7, 2011. Review of Upstairs Solutions DNR/No Code Policy and Procedure training dated February 7, 2011, and interview with the SDC on [DATE], revealed nursing staff had been in-serviced regarding the revised Code Policy. Additionally, interviews on [DATE]-8, 2011, with RN #2, Licensed Practical Nurse (LPN) #2, LPN #3, Certified Nursing Assistants (CNAs) #1, #2, and #3, and a Certified Medication Technician (CMT) revealed staff had received training regarding the Revised Code Policy on February 7, 2011. Review of a facility Orientation Checklist and interview with the DON on [DATE], revealed new employees would be trained regarding the facility's revised CPR policy and CPR Certification during facility orientation. Interview with the DON on [DATE], revealed the facility had scheduled training regarding the facility's revised CPR policy and procedure for March, April, and [DATE]. Review of the Revised Code Status Policy and Procedure revealed the Medical Director's signature verifying review and approval of the document on [DATE]. Review of QA Mock Full Code Status forms and interview with the DON on [DATE], revealed staff was able to answer the mock code questions appropriately on [DATE], and appropriately performed a Mock code simulation on [DATE]. Additionally, interviews conducted on [DATE]-8, 2011, with RN #1, RN #2, LPN #2, LPN #3, LPN #4, LPN #6, CNA #1, CNA #2, CNA #3, CMT #1, and LPN #5 revealed staff was knowledgeable and able to verbalize all parts/steps in the facility's Revised Code Status in regards to acting appropriately in a code situation. Review of a QA Code Status dated [DATE], and interview with the DON on [DATE], revealed ten resident charts were reviewed with no concerns identified related to appropriate physician's orders [REDACTED]. Additionally, a review of five resident charts on [DATE], revealed the charts were designated with the appropriate code status, and contained physician's orders [REDACTED]. Interviews with the Administrator and DON on [DATE], revealed the review of the abuse and neglect policy and procedure conducted on [DATE], revealed no identified concerns. Additionally, a copy of the Abuse Reporting and Prevention policy/procedure signed and dated [DATE], by the Administrator and DON was reviewed. Review of On the Spot Education/Re-education forms dated [DATE], and 4, 2011, and interviews with the SDC, DON, ADON, UCs, and Administrator on [DATE], revealed staff had been in-serviced, including RN #1, regarding the abuse/neglect policy and procedure. Additionally, interviews on [DATE]-8, 2011, with RN #2, LPN #3, CNAs #1, #2, and #3, and the CMT on [DATE], revealed all the staff interviewed had attended training on the abuse neglect policy/procedure on either [DATE], or 4, 2011. Review of an On the Spot Education/Re-education dated [DATE], and interviews with the Administrator and DON on [DATE], revealed the SDC had re-educated the Administrator and DON of their ultimate responsibility to report allegations of abuse and neglect to the appropriate agencies timely. Review of a facility's Orientation Checklist and interview with the DON on [DATE], revealed new employees would be trained regarding the facility's abuse/neglect policy/procedure including prevention and reporting during the facility orientation. Review of a Monthly Education form and interview with the DON on [DATE], revealed the facility had scheduled abuse/neglect training for March, April, and [DATE]. Review of QA Audits: Perceived Neglect or Abuse Allegations dated [DATE], and signed by the Administrator, and interview with the Administrator on [DATE], revealed five residents and five staff persons were interviewed regarding any perceived abuse or neglect incidents with no concerns identified. Additionally, a review of Quality Assurance: Round Audit Tools dated [DATE], and interviews with the DON, ADON, and UC on [DATE], revealed nine residents were reviewed on [DATE], for any signs/symptoms of neglect with no concerns identified. Based on the above findings, it was determined the Immediate Jeopardy was removed on [DATE]. Noncompliance continued with scope and severity lowered to "D" based on the facility's need to evaluate the effectiveness of Quality Assurance activities related to the implementation of policies and procedures for ensuring residents were free from abuse/neglect and ensuring the facility provided the necessary care and services to maintain each resident's physical wellbeing.