Every finding on record at Chulio Hills Health and Rehab

Based on observations, staff and family interviews, record review, and review of the facility's policies titled, Notification of Changes, Change in Resident's Condition or Status, the facility's Senior Medical Systems Protocols, and New Facility Procedure, the facility failed to ensure timely assessment, monitoring, escalation, and clinical management of a resident (R) (R3) who exhibited a progressive change in condition. Harm was identified to have occurred on [DATE], when R3 was hospitalized due to a fall after a decline in condition. Findings included:Review of the facility investigation documents revealed R3 sustained a fall on [DATE] (the facility-reported incident submitted to the State Survey Agency incorrectly documented the date of the fall as [DATE]). Documentation reflected that at approximately 10:20 pm, R3 was discovered on the bathroom floor in her assigned room following an unwitnessed fall. Licensed nursing staff immediately responded and initiated assessment. Due to visible facial injuries, emergency medical services (EMS) were activated. R3 had a BIMS score of 14, indicating intact cognition. Before the incident, the resident experienced multiple episodes of nausea and emesis during the evening hours. Nursing documentation reflected that supportive interventions were provided, including ginger ale. Documentation further reflected that the resident reported worsening nausea after consuming the beverage and independently ambulated to the bathroom due to urgency to vomit. The resident stated that while attempting to turn toward the toilet, her foot became entangled in her pant leg, resulting in loss of balance and a fall to the bathroom floor. EMS arrived at approximately 10:52 pm, and the resident was transferred via stretcher to the local hospital for further evaluation.Review of the facility's Accident and Incident Reports for 2025 and 2026 revealed that R3, who required assistance with activities of daily living and was identified as being at high risk for falls, sustained multiple unwitnessed falls on [DATE], [DATE], [DATE], and [DATE].Review of hospital records for R3 revealed the resident was admitted to the local hospital on [DATE] following an unwitnessed fall at the facility while experiencing ongoing nausea and vomiting. admission documentation revealed the resident sustained significant traumatic injuries, including facial fractures and a closed odontoid cervical spine fracture. Hospital records further revealed the resident presented with severe hyponatremia (sodium level 121), Hypokalemia, acute kidney injury, weakness, and continued vomiting following several days of documented nausea, vomiting, and poor oral intake at the facility before hospitalization. Documentation revealed the resident subsequently developed vomiting with aspiration, acute hypoxemic respiratory failure requiring emergent intubation and ICU admission, aspiration pneumonia/pneumonitis, septic shock, and prolonged critical illness. Bronchoscopy revealed purulent secretions within the lung consistent with aspiration-related pulmonary injury. The resident's hospitalization was further complicated by prolonged mechanical ventilation, delirium, ileus, thrombocytopenia, and ongoing respiratory failure. Documentation revealed the resident expired on [DATE] following withdrawal of life support measures.Review of Physical Therapy Treatment Encounter Note(s) provided in hard copy dated [DATE] through [DATE] revealed repeated documentation of nausea and decline in condition, including:[DATE]: Pt not feeling well today, low energy, and indicated she is nauseated.[DATE]: Pt not doing well today, c/o nausea. nursing and SW notified.[DATE]: Pt nauseated, nurse aware.[DATE]: Pt still has abdominal pain, but nausea is better. enjoyed being outside but indicates 'I never feel good anymore'Review of R3 Medication Administration Record (MAR) revealed a one-time administration of Ondansetron HCl (Zofran) Oral Tablet 4 mg one time on [DATE] for nausea.Review of R3 Progress Notes in the EMR revealed an Order Note dated [DATE] entered by Licensed Practical Nurse (LPN) NN documenting MD AWARE. CONTINUE ORDER related to a one-time order for Ondansetron 4 mg for nausea initiated on [DATE]. Additional hard copy nursing documentation by LPN NN dated [DATE] at 0700 noted resident c/o nausea x1, requested Zofran, drinking fluids, at baseline. Review failed to reveal documented assessment, provider notification, or ongoing monitoring despite continued symptoms over several days. The surveyor attempted multiple telephone contacts with LPN NN regarding physician notification without success.Further review of Progress Notes revealed a note dated [DATE] at 10:35 pm indicating the resident sustained an unwitnessed fall from the toilet resulting in left facial swelling, left eye injury, laceration, and bruising to the neck. Nursing documentation revealed the resident had been throwing up several times prior to the fall and reported becoming entangled in her pant leg while attempting to vomit into the toilet. Documentation revealed EMS was contacted, and the resident was transferred to the local hospital at 10:52 pm. Review of nursing documentation failed to reveal evidence of comprehensive assessment of ongoing nausea/vomiting symptoms, dehydration status, provider notification timing, or documented escalation of symptoms occurring between [DATE] and [DATE].Review of R3 Task: Nutrition-Amount Eaten/ADL-Eating records provided in hard copy for the month of February 2026 revealed that [DATE] through [DATE] revealed decreased oral intake and meal refusals. Documentation revealed intake scores of 0-1 on [DATE], indicating poor intake, refusal of lunch and dinner on [DATE], and continued poor intake/incomplete meal documentation on [DATE]. Interview with Certified Nurse Aide (CNA) II revealed the resident had refused both breakfast and lunch on [DATE].Review of R3's vital signs documentation failed to identify any recorded vital signs, blood pressure measurements, or evidence of increased monitoring between [DATE] and [DATE]. This absence of monitoring occurred despite the resident exhibiting clinical symptoms including nausea, vomiting, decreased oral intake, weakness, and an overall decline in condition before the resident's fall and subsequent hospitalization. Documentation review identified only a pain assessment completed on [DATE]; however, the most recent vital signs before this period were documented on [DATE] and [DATE]. This lack of monitoring was inconsistent with facility protocol requiring assessment, monitoring, and escalation of care in response to changes in a resident's condition.Review of the facility's Communication Record-Problems or concerns regarding resident for MD and/or NP to be made aware of revealed a single entry dated [DATE] documenting fall with facial injury, sent to ER for eval & tx. MD & family notified. Review failed to reveal additional documented physician or nurse practitioner notification entries related to the resident's nausea, vomiting, decreased oral intake, weakness, or decline in condition during the period of [DATE] through [DATE]. The resident's persistent nausea, vomiting, poor oral intake, weakness, and decline in functional status constituted a significant change in condition requiring physician and responsible party notification in accordance with facility policy.Review of Senior Medical Systems, LLC progress notes revealed R3 was last evaluated by Nurse Practitioner (NP) MM on [DATE] during a monthly regulatory visit. Documentation revealed review of systems noted No weakness or fatigue, no nausea, vomiting, diarrhea, heartburn. No abdominal pain. Review of a previous monthly routine management visit dated [DATE] by the Medical Director noted, Patient offers no acute or chronic concerns or changes at this time. Nursing staff reports no acute or chronic concerns or changes at this time. This resident requires frequent monitoring and management to prevent avoidable decline. Despite the development of persistent nausea, vomiting, weakness, poor oral intake, and decline in condition beginning on or about [DATE], review failed to reveal timely physician or nurse practitioner notification, further evaluation, or reassessment by a medical provider before the resident's hospitalization on [DATE].Review of the electronic medical record (EMR) revealed that R3 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, cognitive communication deficits, generalized weakness, hypertension, myasthenia gravis, difficulty walking, impaired coordination, multiple orthopedic conditions (including prior hip and shoulder arthroplasties and a healed left humerus fracture), blindness in the left eye, and the need for assistance with personal care.A review of the R3 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating R3 was cognitively intact. Section GG, functional status, revealed R3 required partial/moderate assistance for activities of daily living (ADLs) with one-person assistance and utilized a walker and wheelchair for mobility. Section E revealed no behaviors exhibited. Section H revealed the resident was frequently incontinent of bladder and always continent of bowel.Review of R3's care plan revised [DATE] revealed the resident was identified as high risk for falls related to impaired mobility, generalized weakness, impaired coordination, dementia with reduced safety awareness, visual impairment, prior falls, polypharmacy with CNS-active medications, dizziness risk, and medical conditions including myasthenia gravis. Goals included maintaining the resident free from falls with injury requiring hospitalization. Interventions included one-person assist with gait belt for transfers and ambulation, fall-risk assessments, therapy involvement, monitoring for dizziness, sedation, confusion, and adverse medication effects, maintaining a safe, clutter-free environment with call light within reach, non-skid footwear, bed in lowest position, behavioral redirection, supervision during ADLs, and monitoring for weakness, fatigue, and impaired balance.Review of the Physician's Orders for R3 included but was not limited to:Order dated [DATE] for Ondansetron HCl (Zofran) Oral Tablet 4 mg: give 1 tablet by mouth one time only for nausea until [DATE].Order dated [DATE] for Hydrochlorothiazide 12.5 mg, give 1 tablet by mouth one time daily related to essential hypertension.Order dated [DATE] for Potassium Chloride ER Tablet 20 mEq, give 1 tablet by mouth one time a day related to essential hypertension.Order dated [DATE] for weekly vital signs every Friday night shift.Review of staffing records for the period of [DATE] through [DATE] revealed LPN DD worked the 7:00 am to 7:00 pm shift daily on the 200 Hall, where R3 resided, during the period of decline before hospitalization.Interview on [DATE] at 2:30 pm with the Assistant Director of Nursing (ADON/Acting DON) revealed that R3 was transferred to the emergency department on the date of the fall for x-rays. While at the hospital, the resident's condition declined and she required intubation. The family subsequently made the decision to withdraw life support, and the resident expired. Follow-up interview on [DATE] at 12:48 pm revealed that she is responsible for completing the fall assessments on the residents, and she completed one for R3 on [DATE], and at that time, she had received the highest score. Follow-up interview on [DATE] at 1:36 pm revealed that she did not recall R3 reporting feeling unwell during the week leading up to the fall and suggested that R3 may have been attempting to avoid participation in physical therapy. Follow-up interview on [DATE] at 10:22 am revealed that the facility utilizes standing physician orders as well as established procedures outlining conditions for changes in resident condition. The ADON stated that staff are expected to follow the facility's policies and procedures when a resident's condition changes.Interview on [DATE] at 4:20 pm with the Administrator acknowledged discrepancies in the facility report submitted to the State Survey Agency, specifically that the date of the fall was documented as [DATE] instead of [DATE]. Follow-up interview on [DATE] at 4:23 pm revealed that it is the responsibility of the Unit Managers to ensure that the floor nurses notify the physician of any changes in condition. Follow-up interview on [DATE] at 10:28 am revealed that her expectation is for staff to follow policy and procedures when it comes to a resident exhibiting a change in condition.Interview on [DATE] at 1:14 pm with LPN DD revealed that she was the nurse assigned to R3 during the day shift from the week of [DATE] through [DATE]. LPN DD recalled that in the days leading up to the incident, R3 had remained in bed more frequently, but she did not recall any other notable changes. LPN DD stated that R3 regularly participated in and enjoyed physical therapy and would independently ambulate to the therapy area located at the end of the 300 hall. LPN DD further stated that the facility's process for addressing changes in condition included monitoring and documenting the changes and notifying the provider. She stated that significant changes also required completion of a change in condition form, nursing progress notes, and other pertinent charting to ensure close monitoring, and that family members were notified of significant changes.Interview on [DATE] at 1:55 pm with Physical Therapist (PT) FF revealed that R3 had been receiving physical therapy five days per week, and the week of the fall, R3 complained of gastrointestinal symptoms, including nausea and diarrhea, with decreased appetite and intake.Dual interview on [DATE] at 10:16 am with ADON/Acting DON and the Administrator revealed that the on-call physician/NP to contact after hours and/or weekends was an NP who works for the medical director. No other backup coverage is available, and the Administrator stated that if they cannot reach the on-call NP, then they are to call 911. Additionally, the ADON stated that each physician has a binder with forms to complete, where staff enter information on residents who require follow-up. Interview on [DATE] at 10:49 am with Registered Nurse (RN), Infection Preventionist (IP), and Staff Development (SD) HH revealed that she was the Unit Manager during the week leading up to R3's fall; however, she was transitioning roles. RN HH recalled R3 had reported complaints of nausea, but she was not consistently present on the unit during that time. Further stated that the facility has standing orders and established protocols for the treatment of nausea, which staff are expected to follow when symptoms are identified.Interview on [DATE] at 11:05 am with the Medical Director revealed that he was unable to answer questions regarding R3 at that time and stated that any specific questions would need to be submitted via email. The follow-up interview further revealed that NP MM was unavailable to answer questions.Interview on [DATE] at 12:11 pm with R3's daughter revealed that although she had not seen her mother during the week leading up to the fall, she spoke with her daily by telephone and recalled R3 repeatedly complaining of not feeling well, including symptoms of nausea, vomiting, stomach discomfort, and decreased appetite. R3's daughter stated that these symptoms had been present for approximately five days before the fall and that R3 had informed her that the nursing staff was aware she was not feeling well. She further stated that the facility did not contact her regarding her mother's condition. R3's daughter reported that she was notified on [DATE] between approximately 4:00 pm and 5:00 pm that her mother had fallen and was being sent to the hospital because the situation looked bad. She stated that she was not notified at the time the fall occurred and later learned while at the hospital that the fall had reportedly occurred the previous day. R3's daughter stated she was unsure whether the resident had been transported to the hospital immediately after the fall or if the transfer occurred the following day.Interview on [DATE] at 12:33 pm with LPN JJ revealed that she was caring for R3 on the evening of the fall, [DATE]. LPN JJ stated that R3 had reported not feeling well that day and the day prior, complained of nausea, and requested medication for nausea. She stated that R3 approached her twice, at approximately 8:00 pm, reporting nausea, and again at approximately 9:30 pm, stating she did not feel well. LPN JJ recalled that R3 was carrying a basin/sick pail and reported episodes of vomiting. LPN JJ stated that she intended to contact the physician regarding the resident's condition and request anti-nausea medication; however, she did not have the opportunity to do so because she was in the process of passing medications before the fall. LPN JJ further stated that she was at the nurses' station when she was notified that R3 had fallen. Upon assessment, she observed R3 bleeding, and the resident reported that she was sitting on the toilet when she attempted to turn and vomit into the toilet and got caught in her pant leg and fell. LPN JJ stated that emergency medical services were immediately contacted and R3 was transferred to the hospital. She further stated that, during shift report, day shift nurse LPN DD had informed her that the resident had not been feeling well earlier in the day. LPN JJ stated that she did not notify R3's representative or any other individual of the fall and was unsure who had done so, as her primary concern was arranging for R3's transfer to the emergency room (ER).Interview on [DATE] at 12:48 pm with CNA II revealed that she worked the day shift on the 200 Hall, the date of the incident, [DATE], and recalled that R3 reported not feeling well and refused both breakfast and lunch that day. CNA II further stated that R3 complained of nausea and vomiting and had a basin/pail for emesis. According to CNA II, R3 informed her that she could not eat because doing so made her nauseous. CNA II stated that she notified the nurse on duty, LPN DD, that R3 was not feeling well, explaining that LPN DD routinely worked Monday through Thursday. CNA II further stated that she did not know whether LPN DD took any action regarding the resident's condition, as her responsibility was to report the information to the nurse, after which the nurse assumed responsibility for follow-up care. CNA II also stated that R3 had already been experiencing symptoms during the prior shift, as the resident had previously been provided a basin/pail for episodes of emesis.Review of the facility's Senior Medical Systems Protocols revised [DATE] revealed, ***Any medication protocol implemented should be written as a verbal order in the resident's chart, sent to pharmacy and documented in the nurse's notes and provider's communication book***. Review of section Nausea/Vomiting: abdominal assessment-notify medical provider by phone of abnormal findings. If assessment is normal (good bowel sounds in all quadrants, no blood or coffee-ground colored emesis), give Zofran 4 mg PO or IM q6h x 24-hours. Notify medical provider by phone if it continues beyond 24-hours or if coffee ground appearance or if no urine output x 8 hours. Further review on page 3 indicated Notify the medical provider immediately if the resident becomes unstable or conditions persist or worsen.Review of the facility's New Facility Procedure reviewed [DATE] indicated item 4. Change in Condition section A. Review the change in clinical condition requiring notification with the nurse, give recommendations or clinical guidance as needed to properly assess/observe the resident and complete the change in condition form to contact the MD. B. Change in condition form is completed with recommendations. If a clinical pathway exists and you feel it is appropriate for the resident to remain in the facility for care, please ensure that the clinical pathway is followed and requests made form physician that are consistent with the care pathway. C. Review the progress notes to ensure documentation of notification of the responsible party, MD notification, and any orders. Also if any follow-up with the responsible party is required, review to ensure it is completed. D. Review MD recommendations and documentation of the situation, and if needed, coach or review needed follow up/follow through. E. If the clinical situation is serious, it may require a follow-up phone call to subsequent shifts to review continued monitoring and follow-up. F. Ensure the resident has been added to pertinent charting and situation recorded on 24-hour report.Review of the facility policy titled Notification of Changes, revised [DATE], revealed, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Further review of section Circumstances requiring notification include: item 2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health. Item 3. Circumstances that require a need to alter treatment. This may include: New treatment.Review of the facility policy titled Change in a Resident's Condition or Status, revised [DATE], revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Further review of item 1. The nurse will notify the resident's attending physician or physician on call when there has been a(n): d. Significant change in the resident's physical/emotional/mental condition; i. specific instruction to notify the physician of changes in the resident's condition. Item 3. Before notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. Item 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury, including injuries of an unknown source; b. There is a significant change in the resident's physical, mental, or psychological status. Item 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observations, staff and family interviews, record review, and review of the facility's policies titled, Notification of Changes, Change in Resident's Condition or Status, the facility's Senior Medical Systems Protocols, and New Facility Procedure, the facility failed to ensure timely physician and responsible party notification regarding a significant change in condition of resident (R) (R3) who had a decline in condition. Harm was identified to have occurred on 2/19/2026 when R3 was hospitalized due to a fall after a decline in condition. Findings included:A review of the electronic medical record (EMR) revealed that R3 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, cognitive communication deficits, generalized weakness, hypertension, myasthenia gravis, difficulty walking, impaired coordination, multiple orthopedic conditions (including prior hip and shoulder arthroplasties and a healed left humerus fracture), blindness in the left eye, and the need for assistance with personal care.A review of R3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated R3 was cognitively intact. Section GG, functional status, revealed R3 required partial/moderate assistance for activities of daily living (ADLs) with one-person assistance and utilized a walker and wheelchair for mobility. Section E revealed no behaviors exhibited. Section H revealed the resident was frequently incontinent of bladder and always continent of bowel.A review of R3's care plan revised 2/26/2026 revealed the resident was identified as high risk for falls related to impaired mobility, generalized weakness, impaired coordination, dementia with reduced safety awareness, visual impairment, prior falls, polypharmacy with CNS-active medications, dizziness risk, and medical conditions including myasthenia gravis. Goals included maintaining the resident free from falls with injury requiring hospitalization. Interventions included one-person assist with gait belt for transfers and ambulation, fall-risk assessments, therapy involvement, monitoring for dizziness, sedation, confusion, and adverse medication effects, maintaining a safe, clutter-free environment with call light within reach, non-skid footwear, bed in lowest position, behavioral redirection, supervision during ADLs, and monitoring for weakness, fatigue, and impaired balance.A review of the Physician's Orders for R3 included, but was not limited to:Order dated 2/16/2026 for Ondansetron HCl (Zofran) Oral Tablet 4 milligrams (mg): give 1 tablet by mouth one time only for nausea until 2/16/2026.Order dated 9/30/2025 for Hydrochlorothiazide 12.5 mg: give 1 tablet by mouth one time daily related to essential hypertension.Order dated 11/06/2025 for Potassium Chloride ER Tablet 20 milliequivalent (mEq): give 1 tablet by mouth one time a day related to essential hypertension.Order dated 10/31/2025 for weekly vital signs every Friday night shift.A review of hospital records revealed that R3 was admitted to the local hospital on 2/19/2026 following an unwitnessed fall at the facility while experiencing ongoing nausea and vomiting. Documentation revealed the resident sustained facial fractures and a closed odontoid cervical spine fracture. Hospital records further revealed severe hyponatremia (sodium level 121), hypokalemia, acute kidney injury, weakness, continued vomiting, aspiration pneumonia/pneumonitis, acute hypoxemic respiratory failure requiring intubation and ICU admission, septic shock, and prolonged critical illness. A review of Physical Therapy Treatment Encounter Note(s) provided in hard copy dated 2/16/2026 through 2/18/2026 revealed repeated documentation of nausea and decline in condition, including:2/16/2026: Pt (patient) not feeling well today, low energy, and indicated she is nauseated.2/17/2026: Pt not doing well today, c/o (complaint of) nausea. nursing and SW (Social Worker) notified.2/18/2026: Pt nauseated, nurse aware.2/19/2026: Pt still c/o abdominal pain, but nausea is better. enjoyed being outside but indicates 'I never feel good anymore'A review of R3 Medication Administration Record (MAR) revealed a one-time administration of Ondansetron HCl (hydrochloride) (Zofran) Oral Tablet 4 mg one time on 2/16/2026 for nausea.A review of R3 Progress Notes in the EMR revealed an Order Note dated 2/17/2026 entered by Licensed Practical Nurse (LPN) NN documenting MD AWARE. CONTINUE ORDER related to a one-time order for Ondansetron 4 mg for nausea initiated on 2/16/2026. Additional hard copy nursing documentation by LPN NN dated 2/16/2026 at 0700 noted resident c/o nausea x1, requested Zofran, drinking fluids, at baseline. A review revealed no documented assessment, provider notification, or ongoing monitoring despite continued symptoms over several days. The surveyor attempted multiple telephone contacts with Licensed Practical Nurse (LPN) NN regarding physician notification without success.Further review of Progress Notes revealed a note dated 2/19/2026 at 10:35 pm indicating the resident sustained an unwitnessed fall from the toilet, resulting in left facial swelling, left eye injury, laceration, and bruising to the neck. Nursing documentation revealed the resident had been throwing up several times before the fall and reported becoming entangled in her pant leg while attempting to vomit into the toilet. Documentation revealed Emergency Medical Services (EMS) was contacted, and the resident was transferred to the local hospital at 10:52 pm.A review of R3 Task: Nutrition-Amount Eaten/ADL-Eating records provided in hard copy for February 2026 revealed that 2/16/2026 through 2/19/2026 revealed decreased oral intake and meal refusals. Documentation revealed intake scores of 0-1 on 2/16/2026, indicating poor intake, refusal of lunch and dinner on 2/18/2026, and continued poor intake/incomplete meal documentation on 2/19/2026. An interview with Certified Nurse Aide (CNA) II revealed the resident had refused both breakfast and lunch on 2/19/2026.A review of R3's vital signs documentation failed to identify any recorded vital signs, blood pressure measurements, or evidence of increased monitoring between 2/16/2026 and 2/19/2026. This absence of monitoring occurred despite the resident exhibiting clinical symptoms including nausea, vomiting, decreased oral intake, weakness, and an overall decline in condition before the resident's fall and subsequent hospitalization. Documentation review identified only a pain assessment completed on 2/19/2026; however, the most recent vital signs before this period were documented on 2/14/2026 and 2/13/2026. This lack of monitoring was inconsistent with facility protocol requiring assessment, monitoring, and escalation of care in response to changes in a resident's condition.A review of the facility's Communication Record-Problems or concerns regarding resident for MD and/or NP to be made aware of revealed a single entry dated 2/19/2026 documenting fall with facial injury, sent to ER for eval & tx. MD & family notified. Review failed to reveal additional documented physician or nurse practitioner notification entries related to the resident's nausea, vomiting, decreased oral intake, weakness, or decline in condition during the period of 2/16/2026 through 2/19/2026. The resident's persistent nausea, vomiting, poor oral intake, weakness, and decline in functional status constituted a significant change in condition requiring physician and responsible party notification in accordance with facility policy.A review of progress notes revealed R3 was last evaluated by Nurse Practitioner (NP) MM on 1/28/2026 during a monthly regulatory visit. Documentation revealed review of systems noted No weakness or fatigue, no nausea, vomiting, diarrhea, heartburn. No abdominal pain. Review of a previous monthly routine management visit dated 12/29/2025 by the Medical Director noted, Patient offers no acute or chronic concerns or changes at this time. Nursing staff reports no acute or chronic concerns or changes at this time. This resident requires frequent monitoring and management to prevent avoidable decline. Despite the development of persistent nausea, vomiting, weakness, poor oral intake, and decline in condition beginning on or about 2/16/2026, review failed to reveal timely physician or nurse practitioner notification, further evaluation, or reassessment by a medical provider before the resident's hospitalization on 2/19/2026.A review of staffing records for the period of 2/16/2026 through 2/19/2026 revealed LPN DD worked the 7:00 am to 7:00 pm shift daily on the 200 Hall, where R3 resided, during the period of decline before hospitalization.An interview on 5/21/2026 at 1:14 pm with LPN DD revealed that she was the nurse assigned to R3 during the day shift from the week of 2/16/2026 through 2/19/2026. LPN DD recalled that in the days leading up to the incident, R3 had remained in bed more frequently, but she did not recall any other notable changes. LPN DD stated that R3 regularly participated in and enjoyed physical therapy and would independently ambulate to the therapy area located at the end of the 300 hall. LPN DD further stated that the facility's process for addressing changes in condition included monitoring and documenting the changes and notifying the provider. She stated that significant changes also required completion of a change in condition form, nursing progress notes, and other pertinent charting to ensure close monitoring, and that family members were notified of significant changes.An interview on 5/21/2026 at 1:55 pm with Physical Therapist (PT) FF revealed that R3 had been receiving physical therapy five days per week, and the week of the fall, R3 complained of gastrointestinal symptoms including nausea and diarrhea, with decreased appetite and intake.An interview on 5/22/2026 at 11:05 am with the Medical Director revealed that he was unable to answer questions regarding R3 at that time and stated that any specific questions would need to be submitted via email. The follow-up interview further revealed that NP MM was unavailable to answer questions.An interview on 5/22/2026 at 12:11 pm with R3's daughter revealed that although she had not seen her mother during the week leading up to the fall, she spoke with her daily by telephone and recalled R3 repeatedly complaining of not feeling well, including symptoms of nausea, vomiting, stomach discomfort, and decreased appetite. R3's daughter stated that these symptoms had been present for approximately five days before the fall and that R3 had informed her that the nursing staff was aware she was not feeling well. She further stated that the facility did not contact her regarding her mother's condition. R3's daughter reported that she was notified on 2/20/2026 between approximately 4:00 pm and 5:00 pm that her mother had fallen and was being sent to the hospital because the situation looked bad. She stated that she was not notified at the time the fall occurred and later learned while at the hospital that the fall had reportedly occurred the previous day. R3's daughter stated she was unsure whether the resident had been transported to the hospital immediately after the fall or if the transfer occurred the following day.An interview on 5/22/2026 at 12:33 pm with LPN JJ revealed that she was caring for R3 on the evening of the fall, 2/19/2026. LPN JJ stated that R3 had reported not feeling well that day and the day prior, complained of nausea, and requested medication for nausea. She stated that R3 approached her twice, at approximately 8:00 pm, reporting nausea, and again at approximately 9:30 pm, stating she did not feel well. LPN JJ recalled that R3 was carrying a basin/sick pail and reported episodes of vomiting. LPN JJ stated that she intended to contact the physician regarding the resident's condition and request anti-nausea medication; however, she did not have the opportunity to do so because she was in the process of passing medications before the fall. LPN JJ further stated that she was at the nurses' station when she was notified that R3 had fallen. Upon assessment, she observed R3 bleeding, and the resident reported that she was sitting on the toilet when she attempted to turn and vomit into the toilet and got caught in her pant leg and fell. LPN JJ stated that emergency medical services were immediately contacted and R3 was transferred to the hospital. She further stated that, during shift report, day shift nurse LPN DD had informed her that the resident had not been feeling well earlier in the day. LPN JJ stated that she did not notify R3's representative or any other individual of the fall and was unsure who had done so, as her primary concern was arranging for R3's transfer to the emergency room (ER).An interview on 5/22/2026 at 10:22 am with the Assistant Director of Nursing (ADON)/Acting DON revealed that the facility utilizes standing physician orders as well as established procedures outlining conditions for changes in resident condition. The ADON stated that staff are expected to follow the facility's policies and procedures when a resident's condition changes.An interview on 5/20/2026 at 4:20 pm with the Administrator acknowledged discrepancies in the facility report submitted to the State Survey Agency, specifically that the date of the fall was documented as 2/20/2026 instead of 2/19/2026. Follow-up interview on 5/22/2026 at 10:28 am with the Administrator revealed that her expectation is for staff to follow policy and procedures when it comes to a resident exhibiting a change in condition.An interview on 5/22/2026 at 12:48 pm with CNA II revealed that she worked the day shift on the 200 Hall, the date of the incident, 2/19/2026, and recalled that R3 reported not feeling well and refused both breakfast and lunch that day. CNA II further stated that R3 complained of nausea and vomiting and had a basin/pail for emesis. According to CNA II, R3 informed her that she could not eat because doing so made her nauseous. CNA II stated that she notified the nurse on duty, LPN DD, that R3 was not feeling well, explaining that LPN DD routinely worked Monday through Thursday. CNA II further stated that she did not know whether LPN DD took any action regarding the resident's condition, as her responsibility was to report the information to the nurse, after which the nurse assumed responsibility for follow-up care. CNA II also stated that R3 had already been experiencing symptoms during the prior shift, as the resident had previously been provided a basin/pail for episodes of emesis.A review of the facility's Senior Medical Systems Protocols revised 2/14/2025 revealed, ***Any medication protocol implemented should be written as a verbal order in the resident's chart, sent to pharmacy and documented in the nurses' notes and provider's communication book***. Review of section Nausea/Vomiting: abdominal assessment-notify medical provider by phone of abnormal findings. If assessment is normal (good bowel sounds in all quadrants, no blood or coffee-ground colored emesis), give Zofran 4 mg PO or IM q6h x 24 hours. Notify medical provider by phone if it continues beyond 24-hours or if coffee ground appearance or if no urine output x 8 hours. Further review on page 3 indicated Notify the medical provider immediately if the resident becomes unstable or conditions persist or worsen.A review of the facility's New Facility Procedure reviewed 5/4/2022 indicated item 4. Change in Condition section A. Review the change in clinical condition requiring notification with the nurse, give recommendations or clinical guidance as needed to properly assess/observe the resident and complete the change in condition form to contact the MD (physician). C. Review the progress notes to ensure documentation of notification of the responsible party, MD notification, and any orders. Also, if any follow-up with the responsible party is required, review to ensure it is completed.A review of the facility policy titled Notification of Changes, revised 1/1/2021, revealed, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Further review of section Circumstances requiring notification include: item 2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health. Item 3. Circumstances that require a need to alter treatment. This may include: New treatment.A review of the facility policy titled Change in a Resident's Condition or Status, revised October 2020, revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Further review of item 1. The nurse will notify the resident's attending physician or physician on call when there has been a(n): d. Significant change in the resident's physical/emotional/mental condition; i. specific instruction to notify the physician of changes in the resident's condition. Item 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury, including injuries of an unknown source; b. There is a significant change in the resident's physical, mental, or psychological status.

Based on staff interviews, record review, and review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to ensure a resident (R) (R2) remained free from sexual abuse. Findings included:A review of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with pertinent diagnoses including but not limited to left-sided hemiplegia/hemiparesis following cerebral infarction, seizure disorder, dysphagia, cognitive communication deficit, and generalized muscle weakness and wasting.A review of R2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11, which indicated moderate cognitive impairment. Section GG, functional status, revealed R2 had upper and lower impairment on one side and required substantial maximum assistance with Activities of Daily Living (ADLs). Section E revealed that no behaviors were exhibited.A review of R2's care plan dated 4/14/2026 identified the resident as high risk for abuse and non-consensual interactions due to impaired communication following a Cerebrovascular Accident (a stroke) (CVA) with mixed receptive-expressive language disorder, cognitive deficits, and dependence on staff for activities of daily living. The care plan noted the resident may have difficulty understanding questions and may be unable to effectively report or describe abuse. Goals included maintaining resident safety and ensuring the resident can report unwanted interactions. Interventions included use and reinforcement of a designated safety word ( PISTACHIO), routine safety checks, use of simple yes/no questions to assess safety, monitoring for behavioral or emotional changes, prompt reporting of concerns to nursing leadership, maintaining consistent caregivers when possible, and ensuring calm, supportive communication to promote dignity and emotional safety during care.A review of the facility investigation documents revealed that on 4/10/2026, Certified Nurse Aide (CNA) LL observed R4 inside R2's room while R2 was lying in bed and observed R4 kissing R2 on the mouth. CNA LL immediately instructed R4 to leave the room and reported the incident to the Assistant Director of Nursing (ADON/Acting DON). The ADON notified the Social Services Director (SSD) and the Administrator, and the facility immediately initiated an abuse investigation. Review revealed that R2 was interviewed by the SSD, ADON, and later law enforcement regarding the incident. Documentation reflected that R2 reported the kiss occurred on her lips, described it as a wet kiss, and stated that the interaction was unwanted and non-consensual. Documentation further revealed R2 reported feeling uncomfortable with R4 being in her room. Staff provided reassurance and emotional support to R2 during the investigation process. Review further revealed that R2 was referred for and received mental health/behavioral health services following the incident. Further review revealed that R4 was interviewed by facility administration and admitted to kissing R2. Documentation reflected that R4 demonstrated limited insight into the inappropriate nature of the interaction and acknowledged awareness that the conduct was wrong due to R2's cognitive impairment. Local law enforcement responded to the facility, interviewed both residents, and subsequently placed R4 under arrest. Review revealed that the physician, responsible parties, local law enforcement, corporate leadership, and the State Survey Agency (SSA) were notified of the incident. Facility documentation reflected that the allegation was reported in a timely manner in accordance with facility policy and regulatory requirements. Additional review revealed that witness statements were obtained, interviewable residents and staff were interviewed, abuse observations were conducted throughout the facility, and abuse education/in-services were provided to facility staff following the incident. Review further revealed R4 was discharged from the facility due to concerns related to resident safety and being identified as an immediate risk to other residents.An observation and interview on 5/20/2026 at 4:14 pm of R2 in her room revealed that R2 was sitting upright in bed, appeared appropriately groomed, and was only able to answer simple yes and no questions. When asked if she felt safe at the facility, R2 stated yes. When asked about the incident involving another resident kissing her the previous month, R2 stated no when asked if she wanted to be kissed. When asked if staff came to help her when the incident occurred, R2 answered yes. When asked if she had spoken with a counselor regarding the incident, R2 stated yes and confirmed it had only occurred one time when asked. When asked if staff treated her with respect and did not abuse her, R2 answered yes. Follow-up observation and interview on 5/21/2026 at 2:30 pm in R2's room revealed R2 was lying in bed and appeared calm. When asked how she was doing, R2 responded, ok. When asked if she would like to continue speaking with someone regarding the incident, such as a counselor on an ongoing basis, R2 answered yes.A review of R2 Progress Notes in the EMR revealed a note dated 4/10/2026 that documented that a CNA reported a male resident was observed in R2's room leaning over her and kissing her. Staff immediately removed the resident from the room and notified nursing leadership. The SSD and ADON interviewed R2, who reported the kiss occurred on her lips, described it as a wet kiss, and stated she did not consent to the interaction. R2 further indicated she felt uncomfortable and reported she did not know how to express no. Staff provided reassurance, reviewed safety measures with the resident, and encouraged her to alert staff if she felt unsafe. Law enforcement was contacted, and the officer interviewed R2 and completed a report consistent with her statements.A review of R2's Behavioral Health Progress Note dated 4/14/2026 in the EMR revealed the resident participated in an onsite individual psychotherapy session following a reported sexual abuse incident involving another resident. The resident was diagnosed with an unspecified anxiety disorder related to adjustment difficulties associated with facility placement and loss of independence. The resident presented alert and fully oriented, with appropriate behavior, calm psychomotor activity, and euthymic mood. The session focused on emotional support, reassurance, and coping related to the recent incident. The resident reported anxiety regarding what may occur following the event but stated she currently felt safe in the facility since the involved resident had been removed. The clinician documented that no visible post-traumatic stress symptoms were observed or reported at the time of the visit. Treatment goals included stabilization of anxiety and emotional adjustment following the incident, with recommendations for continued supportive counseling and psychotherapy services on an ongoing basis.A review of the EMR revealed R4 was admitted to the facility on [DATE] with pertinent diagnoses including but not limited to chronic cardiopulmonary disease, major depressive disorder, dysphagia, and generalized weakness with impaired mobility.A review of R4's quarterly MDS assessment dated [DATE] revealed a BIMS of 15, which indicated R4 was cognitively intact. Section GG, functional status, revealed R4 utilized a walker for ambulation and required supervision to independent assistance with ADLs.A review of R4's care plan revised 4/20/2026 revealed that multiple prior goals related to consensual intimacy, sexual expression, and provision of a private environment for sexual activity were initiated on 2/14/2024. Interventions included honoring the resident's stated wish to engage in consensual intimacy with another consenting resident, providing a private space for sexual activity, treating the resident and partner with respect, protecting dignity related to sexual expression, and providing education regarding safe sex practices and risk reduction, including sexually transmitted infections. The care plan also included interventions for ongoing assessment of the resident's cognitive capacity and ability to consent to sexual activity, with periodic reassessment of consent capacity per facility policy.A review of R4's Progress Notes in the EMR revealed a note dated 4/10/2026 that documented that R4 was observed in the room of R2 during an inappropriate interaction in which R4 admitted to kissing R2. The resident was interviewed by facility leadership and law enforcement and acknowledged the interaction. The resident was informed that the behavior was inappropriate given the cognitive status and inability of the other resident to consent. R4 was noted to be non-receptive to redirection or counseling regarding the incident and stated he believed his actions were acceptable. Law enforcement subsequently arrested R4, and he was removed from the facility due to being considered an imminent risk to other residents. The resident was discharged from the facility and is no longer residing in the building.A review of R4's Physician Discharge Note dated 4/13/2026 in the EMR revealed that R4 was discharged from the facility effective immediately and transferred into the custody of local law enforcement. The physician concurred with the facility's determination that the resident presented an imminent threat of harm to other residents based on recent unwanted sexual contact toward another resident. An interview on 5/20/2026 at 2:30 pm with the Administrator and ADON revealed that R4 was no longer in the facility, as he was arrested on the date of the incident, and subsequently indicted by the grand jury and remains in custody of law enforcement.An interview on 5/21/2026 at 12:52 pm with SSD revealed she responded immediately following the incident and interviewed R2 and R4. The SSD stated R2 reported that R4 had kissed her. R4 acknowledged the interaction but was described as non-receptive to redirection, stating he believed his actions were appropriate and that he was helping the resident. The SSD reported that law enforcement was notified, and R4 was subsequently arrested after admitting to the interaction. The SSD further stated R2 declined to press charges at that time and was provided follow-up mental health services, including a psychological evaluation with ongoing counseling offered as needed. The SSD also confirmed that staff initiated immediate protective measures and supervision during the investigation.An interview on 5/21/2026 at 1:36 pm with the ADON revealed the incident occurred during the evening shift when staff observed R4 in R2's room engaging in inappropriate physical contact. The ADON stated that staff immediately intervened, removed R4 from the room, and initiated notification to administration and social services. R4 was interviewed and confirmed the contact but minimized the behavior, stating he was giving her some loving. The ADON reported that law enforcement was contacted, and R2 confirmed she did not want the contact. R4 was subsequently arrested following law enforcement's determination. The ADON further stated that facility-wide interviews were conducted with residents, all of whom denied abuse or inappropriate contact. Staff were re-educated on abuse prevention and reporting procedures. The ADON also noted R4 had a history of expressing interest in a consensual relationship with another resident; however, that relationship discontinued due to changes in the cognitive status of the other resident involved.Interview attempts were made on 5/21/2026 and 5/22/2026 to make contact with CNA LL, who was involved in the initial discovery of the incident; however, contact was unsuccessful.An interview on 5/22/2026 at 10:35 am with the Administrator revealed she was present at the facility at the time of the incident and was immediately notified by staff. The Administrator stated she initiated law enforcement contact and the internal investigation process without delay. She further stated she spoke with R4, who acknowledged the interaction but minimized the behavior. The Administrator confirmed R4 was restricted from contact with R2 pending law enforcement arrival. Law enforcement responded to the facility, interviewed both residents, and determined R4 would be arrested due to the nature of the incident and the inability of R2 to consent.A review of the facility's policy titled Abuse, Neglect, and Exploitation, revised 9/17/2025, indicated It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Further review of section Definitions included Sexual Abuse in non-consensual sexual contact of any type with a resident.

Based on observations, staff interviews, and review of the facility's policy titled, Cleaning and Disinfection of Environmental Surface, the facility failed to provide a safe, functional, sanitary, and comfortable environment throughout the facility on the 100, 200, and 300 Halls, the common area near the nurse station, and lobby, related to delay in repairing damaged ceilings tiles and dust-like vents.Findings include:The policy titled Cleaning and Disinfection of Environmental Surface revised date October 2018, revealed under number 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis, when spills occur, and when these surfaces are visibly soiled. 14. Horizontal surfaces will be wet dusted regularly using clean cloths moistened with EPA (Environmental Protection Agency)-registered hospital disinfectant.An observation conducted on 12/16/2025, at 9:33 am, during the initial tour, indicated the presence of dust-like accumulation on the ceiling vents and a broken sheetrock ceiling tile.On 12/18/2025, at 1:05 pm, an interview and observation were conducted with the Administrator, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed the presence of a dust-like accumulation on the vents situated near the nurse station along the pathway to the common areas of the dining room and front entrance. Each individual acknowledged that this buildup could potentially provoke allergic reactions, shortness of breath, coughing, itching, and respiratory distress in residents with pre-existing respiratory conditions. Observations revealed buildup on each vent across all three halls and common areas.An interview conducted on 12/18/2025, at 2:38 pm, with the Maintenance Director indicated that cleaning was monitored through TELS (maintenance on line reporting system) and was scheduled to occur every three months. The Maintenance Director affirmed that he performed daily rounds; however, he had not observed any accumulation of dust resembling a ventilation issue.

Based on observations, staff interviews, a review of the facility policy titled, Specific Medication Administration Procedures, and a review of the manufacturer's instructions for steroid inhalers, the facility failed to maintain a medication error rate below five percent. An observed medication error rate of 5.71% was identified during 35 medication administration opportunities. Specifically, medication administration errors were observed during two of five medication passes, in which nursing staff failed to instruct residents to rinse and spit after administration of corticosteroid inhalers. This deficient practice has the potential to increase the risk of medication-related side effects.Findings include:Review of the facility's policy titled Specific Medication Administration Procedures, last reviewed on 4/1/2016, revealed the Policy section Q: For steroid inhalers, provide the resident with a cup of water and instruct him/her to rinse the mouth and spit the water back into the cup.Review of the manufacturer's instructions How to use your ELLIPTA inhaler it reads .Rinse your mouth with water after use. Be sure not to swallow the water.Review of the manufacturer's instructions for use for Arnuity Ellipta revealed the following directive: . Step 6: Rinse your mouth. Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water.On 12/17/2025 at 8:15 am, Licensed Practical Nurse (LPN) AA was observed performing a medication pass for Resident R74. During the medication pass, LPN AA administered Breo Ellipta Inhaler, (a medication used to treat chronic obstructive pulmonary disease (COPD) that contains a corticosteroid.) However, the nurse did not offer the resident water to rinse their mouth and spit after use.In an interview with LPN AA following the observation, the surveyor asked whether any additional action should have been taken after administering the inhaler. LPN AA appeared uncertain. The surveyor asked whether the inhaler was a steroid and whether the resident should have been offered water and instructed to rinse the mouth after use. LPN AA responded, I should have, but I only placed a cup of water on the bedside table. A bright green note on the inhaler box stated, Rinse mouth thoroughly after each use.On 12/17/2025 at 8:45 am, LPN BB was observed performing a medication pass for R47. During the medication pass, LPN BB administered Arnuity Ellipta Inhaler, (a medication used to treat asthma that contains a corticosteroid.) However, the nurse did not offer the resident water to rinse their mouth and spit after use.In an interview with LPN BB following the observation, the surveyor asked whether the inhaler was a steroid and whether the resident should have been instructed to rinse the mouth after use. LPN BB acknowledged that mouth rinsing should have been offered and stated that she forgot to do so. The inhaler box was observed to have a bright green note stating, Rinse mouth thoroughly after each use.In an interview with the Pharmacist (C) on 12/17/2025 at 11:34 am, the Pharmacist stated that rinsing the mouth after use is needed for inhaled corticosteroids to prevent oral candidiasis. The pharmacist further stated that nursing staff were alerted to this requirement through a bright label placed on the medication box indicating rinse mouth after use. In a joint interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 12/17/2025 at 2:45 pm, they stated that mouth rinsing after use was recommended for steroid inhalers to prevent thrush. They further stated that nursing staff were aware of this requirement because it was indicated on the medication packaging. The ADON stated that she expect nursing staff to encourage residents to rinse and spit after inhaler use by providing a cup of water.

Based on record review, staff interviews, review of the Resident Assessment Instrument (RAI) Manual, and review of the facility policy titled Maintaining Minimum Data Set (MDS) Assessments, the facility failed to accurately complete the Quarterly MDS assessment by not including hospice services for one of twelve residents (R) (R7) on hospice.Findings include:Review of the policy titled, Maintaining Minimum Data Set (MDS) Assessments revised November 2019, revealed the policy addressed maintenance and retention of MDS records but did not include guidance to ensure accurate coding of services, including hospice services, on Quarterly MDS assessments.Review of the electronic medical record (EMR) revealed R7 was admitted into hospice services on 6/11/2025.Review of R7 quarterly MDS assessment dated [DATE] revealed that section O, Special Treatments, Procedures, and Programs, did not indicate hospice services.Interview on 12/16/2025 at 12:53 pm with MDS Registered Nurse (RN) LL revealed that hospice services for resident R7 were not coded on the Quarterly MDS. She stated that she had since opened a modification and corrected the assessment. She further stated that accurate MDS coding was important because it affected the resident's care plan, and if the MDS was not accurate, the care plan was also not accurate.Interview on 12/18/2025 at 1:50 pm with the Director of Nursing (DON) revealed that the MDS must be accurate, as it reflected the resident's care plan and directs care tasks, and that the care plan was the foundation for all aspects of resident care.

Based on observations, staff and resident interviews, record review, and review of the facility policies titled Infection Prevention and Control Program, and Handwashing/Hand Hygiene, the facility failed to maintain appropriate infection control practices. Specifically, a nurse was observed using a box of gloves during wound care and removing it from the resident's room for use with other residents, a staff member failed to adhere to Transmission-Based Precautions by not wearing appropriate PPE (Personal Protective Equipment) and did not perform hand hygiene when entering/exiting an isolation room, and the facility failed to ensure the Infection Prevention and Control Program policy was reviewed and updated annually. These failures had the potential to contribute to the transmission of infectious organisms among residents, staff, and visitors Findings include:Review of the facility's policy titled, Infection Prevention and Control Program, revised October 2018, section 11, Prevention of Infection, subsection a. (3) revealed educating staff and ensuring that they adhere to proper techniques and procedures. Further review of section 6, Policies and Procedures subsection c. revealed, The infection prevention and control committee, Medical Director, Director of Nursing Services, and other key clinical and administrative staff review the infection control policies at least annually.Review of the facility's policy titled, Handwashing/Hand Hygiene, revised February 2021, section 7, Use an alcohol-based hand rub containing at least 62% (percent) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: n. Before and after entering isolation precaution settings.Review of the facility policy titled Infection Prevention and Control Program, last revised October 2018, revealed that it has not been reviewed or revised since that date, indicating noncompliance with the facility's policy requirement for annual review as outlined in section (6.c).Observation made on 12/17/2025 at 9:57 am, revealed Wound/Treatment Licensed Practical Nurse (LPN) EE performing wound care. The nurse brought a full box of gloves into the resident's room and placed it on the overbed table. Gloves were removed from the box during the procedure, and upon completion, the nurse carried the same box out of the room.Observation made on 12/17/2025 at 4:25 pm, revealed Maintenance Assistant HH exiting room [ROOM NUMBER]-P, which had signage posted with Contact Precautions for candida auris. The door was wide open, and he was observed coming out of the resident's bathroom without wearing PPE (gown or gloves) and without performing hand hygiene after exiting the isolation room.Interview on 12/17/2025 at 9:57 am with Wound/Treatment LPN EE revealed that when asked about the box of gloves, the nurse stated she intended to use it for wound care on another resident. When asked about infection control concerns, the nurse acknowledged that the box should have remained in the resident's room, as removing it could create a contamination risk for other residents.Interview on 12/17/2025 at 4:25 pm with Maintenance Assistance HH when questioned about the Contact Isolation Precautions and posted signs, he initially stated, I don't know anything about that, and began to walk away. After being asked to review the signs, he stated, I guess I was supposed to wear a gown and gloves, probably because of some infection, and acknowledged he had not received Infection Prevention training. When questioned about hand hygiene, he stated he intended to perform it.Interview on 12/18/2025 at 1:23 pm with Infection Preventionist/Unit Manager revealed that everyone entering a Contact Precautions room should wear full PPE, as the resident is in isolation and could potentially transmit infection to others. She further stated that all staff must receive proper training and perform hand hygiene at all times, regardless of isolation status. Regarding wound care, she explained that if a box of gloves was taken into a resident's room and used, it must remain in that room, as removing it would be considered contaminated.Interview on 12/18/2025 at 1:50 pm with Director of Nursing (DON) revealed that all staff, regardless of position, required to observe and follow Contact Precautions and use appropriate PPE to protect themselves and residents and prevent transmission to other residents. She further stated that staff must perform hand hygiene and that a box of gloves used during wound care should not be removed from the resident's room.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Adaptive Equipment the facility failed to ensure one of eight residents (R) (R88) received a feeding adaptive equipment device at each meal. This failure had the potential to affect the nutritional independence of R88.Findings include:Review of facility policy, Adaptive Equipment last revised March 2024 documented in Procedures: . 3. The resident will be assessed as needed for appropriateness of the adaptive equipment and make changes as needed to help facilitate independence. Interview on 12/16/2025 at 10:28 am with R88 revealed that her feeding adaptive equipment was usually not on her tray, and that, due to her health/stroke, she has great difficulty eating without it.Observation on 12/16/2025 at 12:30 pm revealed no feeding adaptive equipment served on R88's tray. The menu card revealed in bold letters, Built-Up Utensil (1 Each) under Preferences. R88 indicated that she had to ask the CNA (Certified Nursing Assistant) to get it for her. She indicated the CNA did get it from the kitchen, but by that time the food was cold. Observation on 12/17/2025 at 12:10 pm revealed tray being delivered to R88's room with no assistive device. R88 displayed her regular utensils only and the meal card that indicated a feeding adaptive equipment preference.Review of the Order Listing Report dated 12/18/2025 revealed this report listed R88 with an order summary of Built up handled utensils for all meals. Interview on 12/18/2025 at 9:43 am with the Dietary Manager regarding feeding adaptive equipment revealed that residents with orders were to be getting their devices at every meal, and that they had enough of the devices. The physician did make orders for these devices. We can't put the devices on the plate without the order. Interview on 12/18/2025 at 10:51am with the Administrator revealed he expected the residents to get their utensils. If there's a physician's order, then they needed to have the feeding devices.

Based on observations, staff interview, record review, and a review of facility policy titled, Oxygen Concentrator, the facility failed to ensure that one resident (R) R89 was administered oxygen therapy in accordance with the physician's orders. Findings include:Review of facility policy titled Oxygen Administration, revised date 3/5/2024, revealed in section 4. Use of the Concentrator a. When oxygen is ordered for a resident, the nurse will be responsible for initiating use, labeling tubing to include initials and date, and ensure all orders for filter cleaning and humidification into the Computer Order Entry System (CPOE). m. Check the resident's oxygen saturations as ordered by physician. Troubleshoot the concentrator if saturation do not correlate with the resident's clinical presentation.A review of the clinical record for R19 revealed she was admitted to the facility with diagnoses including but not limited to multiple encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV), respiratory failure, unspecified with hypoxia, and pneumonia, Unspecified Organism.The resident's most recent Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was coded as 15, which indicated cognitive impairment.A review of the care plan initiated on 11/19/2025 and revised on 09/3/2025 revealed The resident has altered respiratory status r/t respiratory failure. Further interventions indicate OXYGEN SETTINGS: O2 via nasal cannula at 2 Liters per Minute (LPM) continuously.An observation conducted on 12/16/2025, at 11:23 am, indicated that the oxygen levels were recorded between 1.5 and 2, yet remained below the 2 liters (L) being administered through the Nasal Cannula (NC).An observation made on 12/17/ 2025 at 4:47 pm indicated that the oxygen (O2) levels were consistent with the previous readings while administering less than 2 liters through the NC.Interview and Observation on 12/17/2025 at 5:10 pm, Licensed Practical Nurse (LPN) MM accompanied the surveyor to the residents' room and verified that the O2 concentrator's flow rate was set below 2 LPM, as delivered through the NC, which was slightly lower than the physician's orders. LPN MM also confirmed that while conducting her rounds this morning, she observed the concentrator.Interview with Assistant Director of Nursing (ADON) 12/18/2025 at 10:42 am, confirmed R89's order was for O2 at 2 LPM and the concentrator was between 1.5 and 2 LPM, but the marker should be placed on the line. Given that the resident has congestive heart failure (CHF), her inaccurate saturation levels may induce anxiety, leading to shortness of breath. The ADON clarified that if she were to establish the saturation levels, she would make certain that the concentrator was set at eye level, although she could not confirm whether this was in accordance with policy.An interview conducted on 12/18/2025 at 2:10 pm with the Director of Nursing (DON) indicated that nurses should monitor concentrators and make adjustments or corrections according to physician orders. The DON noted that inaccurate reading could exacerbate symptoms and extend the duration of R89' pneumonia.

Based on observations, staff interviews, record review, and review of the facility policy titled, Wound Management Program Pressure Ulcers, the facility failed to ensure that appropriate pressure ulcer prevention interventions were initiated, implemented, monitored, and documented for one of 15 residents (R) (R96) who were identified as being at risk for pressure injuries and who developed a pressure ulcer during the facility stay. This deficient practice had the potential to cause actual harm, including the development and worsening of pressure ulcers, delayed wound healing, increased risk for infection, pain, and decline in skin integrity.Findings include:Review of the policy titled, Wound Management Program Pressure Ulcers revised October 2023 states that: A resident that enters our facility without pressure ulcers will not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. Review of section 4 states: Every resident will be assessed upon admission or re-admission using the Braden weekly x 4 weeks. This assessment will be updated if a resident who does not have pressure ulcers develops a pressure ulcer. Review of section 9 states: All residents will have a head to toe skin observation done with showers by the C.N.A. (Certified Nursing Assistant) and Weekly Skin Assessments/Observations will be done by the licensed nurses in the electronic medical record. Further review of section 12. A. states: All bed bound/chair bound residents will be positioned every 1-2 hours as determined by the interdisciplinary team.Review of the electronic medical record (EMR) revealed R96 was admitted to the facility on [DATE] for five days of Respite care via Hearth Hospice and pertinent diagnoses including but was not limited to morbid obesity (370 pounds), acute respiratory failure with hypercapnia, chronic diastolic heart failure, obstructive sleep apnea, atherosclerotic heart disease, peripheral vascular disease (PVD), hereditary spastic paraplegia, polyneuropathy, ataxia, lymphedema, and autism.R96 did not have a formal Minimum Data Set (MDS) completed during the respite stay; however, relevant information including cognitive status, functional status, and care needs, were obtained from progress notes and nursing documentation. Brief Interview for Mental Status (BIMS) could not be completed, as R96 was unable to respond to the interview, indicating severe cognitive impairment (score 0.0). Section GG, functional status, revealed R96 required extensive/maximal assistance for all activities of daily living (ADLs). R96 had impairments in both upper and lower extremities. Bed mobility required assistance for rolling left and right. Sit-to-lying and lying-to-sitting on the side of the bed were not attempted due to medical condition or safety concerns. Sit-to-stand, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers were not attempted. R96 did not use a wheelchair or scooter, and ambulation, including walking on flat or uneven surfaces or climbing steps, was not attempted. Review of R96 care plan dated 12/6/2024 indicated the resident was bed-bound, and transfers or mechanical lifts were not utilized during the 5-day respite stay per family request due to fear of mechanical lifts related to Autism. Staff provided total assistance with all self-care activities, including eating, oral hygiene, toileting, bathing (partial or sponge bath), dressing (upper and lower body), and putting on or taking off footwear, while encouraging the use of the call light for assistance. The resident was fully dependent for all bed mobility, with transfers avoided in accordance with the care plan. Staff were instructed to perform skin observations during ADL care and bathing, monitoring for redness, open areas, cuts, bruises, or other changes, and to report any findings to licensed nursing staff. Care plan interventions also addressed peripheral vascular disease, instructing staff to monitor for edema, injury, infection, or ulcers and provide medications or elevation as ordered. Incontinence care included frequent checks, prompt cleansing after episodes, and maintaining dignity while keeping the skin clean and dry. Staff were directed to follow facility protocols for skin care, encourage nutrition and hydration to promote skin health, use caution during repositioning to prevent injury, explain procedures before care, and respect the resident's right to refuse care.Review of the Physician's Orders for R96 included but was not limited to:Order dated 12/11/2024, Cleanse (UNSTAGEABLE) Pressure Ulcer to Left Heel with Normal Saline, Pat Dry, Apply Skin Prep. Cover with Foam dressing every day shift Monday, Wednesday, Friday and PRN for soiling and displacement.Order dated 12/11/2024, Discharge skin assessment to be completed on day of discharge.Order dated 12/6/2024, admission skin assessment to be completed on admission. Review of R96 Braden Scale evaluation (wound evaluation) completed on admission [DATE], with a score of 15, indicated R96 was at risk for pressure injuries.Review of R96 skin assessment on 12/6/2024, admission, noted skin is dry and intact. On 12/10/2024, the skin assessment revealed right heel-blister; sacrum-redness; other-bottom redness; RLE (right lower extremity) and LLE (left lower extremity) redness, swollen, painful to touch and weeping. On 12/11/2024, day of discharge, the skin assessment revealed left heel-blister covering most of heel; other-lower extremities slightly swollen and discolored. These were the only documented skin assessments during the resident's stay; no other skin assessments were completed.Review of R96 skilled nursing observations under skin/wound documentation revealed that on 12/10/2024, R96 skin was noted as skin very dry, blister on left heel. On 12/11/2024, documentation indicated blister on left heel, lower extremities slightly discolored. These were the only documented skilled nursing observations during the resident's stay; no other observations were completed.Review of R96's EMR revealed no documentation or evidence of treatment provided for the pressure ulcer. Although an order was written on 12/11/2024 for treatment of the pressure ulcer on the left heel, no corresponding treatment notes or interventions were recorded.Interview on 12/17/2025 at 9:57 am with Wound/Treatment Licensed Practical Nurse (LPN) EE revealed that she was not employed as the wound care nurse during R96's stay. She stated that any wounds identified should be reported immediately to the wound nurse, as facility protocols were in place to initiate treatment promptly. Upon review of the EMR, she confirmed she was unable to locate any documentation indicating that R96 received wound care during his stay.Interview on 12/17/2025 at 11:27 am with Office Manager at Hearth Hospice revealed that R96 was admitted by the Hospice RN Case Manager on 12/6/2024, and her notes indicated that R96 was dependent in 5 of 6 ADLs (activities of daily living), receiving all medications at the facility, incontinent, nervous/shaky, and not using his arms normally. On 12/11/2025 the Social Worker observed R96 at the facility and had a large blister on the left heel. Social Worker notified management and the Hearth RN Case Manager. Unit Manager at the facility provided a bandage. On 12/12/2024 the Skilled Nurse observed R96 at home, and noted a large blister/pressure wound to the left heel.Interview on 12/17/2025 at 1:18 pm with Licensed Practical Nurse (LPN) GG revealed that nurses conduct weekly skin checks. CNAs Certified Nursing Assistants) completed shower sheets documenting skin issues, reviewed and signed by nurses. Concerns were reported immediately to the wound care nurse.Interview on 12/17/2025 at 1:23 pm with CNA II revealed that any changes were reported to the nurses. Baths were scheduled based on resident rotation. Skin issues such as tears, rashes, or open sores are verbally reported to nurses.Interview on 12/18/2024 at 1:23 pm with Infection Preventionist/Unit Manager revealed that she did not recall R96 specifically, noted that many respite residents were admitted at that time. Unable to locate documentation such as bath sheets or skin assessments in the system.Interview on 12/18/2025 at 3:00 pm with Administrator revealed that she recalled R96 and confirmed that the admission skin assessment documented no wounds. She further stated that the discharge skin assessment identified multiple wounds, including an unstageable pressure ulcer to the heel and other seeping wounds to the lower extremities. The Administrator reported that staff had informed her of difficulty turning the resident; however, she was unable to provide supporting documentation or evidence of care plan updates reflecting refusal of care or difficulty with repositioning.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Comprehensive Care Plan, the facility failed to develop and implement comprehensive, person-centered care plan for one of 42 sampled residents (R) (R47). Specifically, the facility failed to develop and implement care plan interventions related to oxygen (O2) administration. This deficient practice had the potential to place the resident at risk for inadequate monitoring and improper oxygen administration, which could compromise the resident's health and safety.Findings include:Review of the facility's policy titled Comprehensive Care Plan, revised January 2021, revealed under the section 2, .All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care.Record review of the Electronic Medical Record (EMR) revealed R47 was admitted with pertinent diagnoses including but not limited to Alzheimer's Disease, chronic obstructive pulmonary disease (COPD), respiratory failure, asthma, acute respiratory failure with hypoxia, hypertensive heart disease with heart failure, and iron deficiency anemia.Review of R47 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated R47 was severely cognitively impaired. Section I listed the following respiratory diagnoses: respiratory failure, asthma/chronic obstructive pulmonary disease (COPD) or chronic lung disease, and acute respiratory failure with hypoxia. Section O revealed oxygen therapy.Review of R47's care plan dated 11/10/2025 revealed no problems or interventions related to respiratory conditions or oxygen use, despite the MDS indicating both respiratory diagnoses and oxygen administration.Review of the Physician's Orders for R47 included but was not limited to: Order dated 11/10/2025 for administer oxygen at 2 L/min per nasal cannula (NC) as needed.Order dated 11/15/2025 for change O2 tubing weekly when oxygen is in use.Order dated 11/15/2025 for clean oxygen concentrator filter weekly when oxygen is in use.Order dated 11/10/2025 for elevate head of bed related to shortness of breath when lying flat.Observation and interview on 12/16/2025 at 11:08 am revealed that R47 had an oxygen concentrator next to the head of the bed but was unsure how frequently she is supposed to receive oxygen.Observation and interview on 12/17/2025 at 10:42 am revealed R47 was wearing her O2 via NC and the O2 concentrator was running at the setting of 2 Liters Per Minute (LPM).Observation and interview on 12/18/2025 at 12:29 pm revealed R47 was wearing her O2 via NC and the O2 concentrator was running at the setting of 2 LPM.Interview on 12/16/2025 at 12:53 pm with MDS Registered Nurse (RN) LL confirmed that R47 care plan was missing information regarding oxygen use and respiratory diagnoses. Stated that she reviewed care plans daily and this one was missed. She further stated that accurate MDS coding was important because it affected the resident's care plan, and if the MDS was not accurate, the care plan was also not accurate.Interview on 12/18/2025 at 1:50 pm with the Director of Nursing (DON) revealed that the MDS must be accurate, as it reflected the resident's care plan and directed care tasks, and that the care plan was the foundation for all aspects of resident care.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Notification of Changes and Change in a Resident's Condition or Status, the facility failed to notify the responsible party and the Registered Dietician for one of 42 sampled residents (R)(R70) of significant changes in the resident's condition. This deficient practice had the potential to compromise the resident's nutritional management, overall care, and the responsible party's ability to participate in care planning and decision-making.Findings include:Review of the facility policy titled, Notification of Changes revised 1/1/2021, states The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Further review under the heading Circumstances requiring notification include: section 2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status. Section 3. Circumstances that require a need to alter treatment. This may include: a. New treatment.Review of the facility policy titled, Change in a Resident's Condition or Status revised October 2020, states under Policy Statement, that Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Review of section 2. revealed A 'significant change' of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan. Further review of section 6 revealed Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments.Review of the electronic medical record (EMR) revealed resident R70 was admitted to the facility with pertinent diagnoses including but not limited to hypertension, unspecified symptoms and signs involving cognitive functions and awareness, dysphagia, pharyngoesophageal phase, hypotension, unspecified complication of kidney transplant, immunodeficiency, unspecified atrial fibrillation, chronic kidney disease stage 3, insomnia, cognitive communication deficit, and diagnosed with abnormal weight loss on 12/15/2025.Review of R70 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated that R70 had moderate cognitive impairment. Section GG, functional abilities and goals, revealed no impairments, independent to supervision/touching assistance.Review of R70's care plan dated 7/31/2025 indicated a problem of therapeutic diet to maintain optimal health and nutrition. Diet order: regular diet. Goals included but not limited to adequate nutritional intake while complying with diet restrictions. Intervention included but not limited to arrange dental consult if needed; monitor for tolerance and acceptance of ordered diet; monitor meal intake; obtain and monitor pertinent labs; obtain and monitor weights as ordered or per protocol; ST (Speech Therapy) consult as needed. Review of the Physician's Orders for R70 included but was not limited to:Order dated 8/4/2025 for Regular diet, Regular texture, Thin consistency.Order dated 11/18/2025 for ReadyCare 2.0 or equivalent 2.0 calorie product: two times a day for recent weight loss, RD (Registered Dietician) consult. 90 mL (milliliters) per serving. May substitute equivalent 2.0 Cal product.Order dated 12/15/2025 for Remeron Tablet 15 mg (milligrams) (Mirtazapine): Give 0.5 tablet by mouth at bedtime related to Abnormal Weight Loss. Dosage is 7.5 mg. Review of R70's nutrition intake log revealed that R70 either refused meals or consumed less than 25% (percent) of meals on 12/17/2025, 12/16/2025, 12/15/2025, 12/13/2025, 12/11/2025, and 12/10/2025.Review of R70's medication administration record for December 2025 revealed multiple medication refusals. Refusals occurred at the 0800 (8:00 am) medication administration time on 12/16/2025, 12/15/2025, 12/10/2025, 12/9/2025, 12/8/2025, and 12/7/2025. Additional refusals occurred at the 1700 (5:00 pm) medication administration time on 12/16/2025, 12/15/2025, 12/10/2025, 12/9/2025, and 12/7/2025.Review of R70's progress notes revealed no documentation indicating that R70's representative or Registered Dietician (RD) were informed of the significant change in status related to R70's refusal of meals and medications.Interview and observation on 12/16/2025 at 10:41 am with R70 revealed that he had lost weight. Follow-up interview and observation at 1:20 pm revealed R70 had not touched his lunch tray, did not consume any portion of the lunch.Interview and observation on 12/17/2025 at 10:40 am with R70 revealed resident had not consumed any breakfast that morning but did consume a Boost (nutritional supplement), per Licensed Practical Nurse (LPN) GG. Follow-up interview and observation at 1:23 pm revealed resident had not consumed his lunch, per Certified Nursing Assistant (CNA) II.Interview on 12/17/2025 at 1:57 pm with R70 representative, via telephone, revealed that he had not been made aware that R70 had been refusing his meals and his medications. Stated that he had not been in to see R70 in over a week because he has been dealing with some legal matters pertaining to R70, but that no one had reached out to him about this change. He stated that he would be coming in to see him today or tomorrow. Interview and observation on 12/18/2025 at 12:23 pm with R70 revealed that resident only consumed 10% of his breakfast meal that morning and refused his Boost, per CNA II.Interview on 12/17/2025 at 1:23 PM with CNA II revealed that R70 began exhibiting this behavior of refusing meals or consuming very little food mid-week, last week. CNA II stated this behavior was new for R70 and confirmed he did not consume any of his lunch this day.Interview on 12/17/2025 at 1:18 pm with LPN GG revealed that R70 had been refusing meals and medications. LPN GG stated that R70 did not consume any of his breakfast that morning but did consume his Boost supplement. LPN GG further stated that R70 did not take any of his medications on Monday, Tuesday, and Wednesday of that week. She stated that she documented refusals and notified the Unit Manager, who then informed the physician. LPN GG also stated that R70 previously had a strong appetite; however, due to weight loss, Remeron (medication for appetite) and Boost High-Calorie were prescribed. LPN GG indicated that the ongoing refusals represented a significant change for R70.Interview on 12/18/2025 at 11:53 am with the RD revealed that ReadyCare 2.0, 90 milliliters twice daily, was added on 11/14/2025 due to significant weight loss identified the previous month, with R70 experiencing greater than 9% weight loss within a one-month period. The RD stated she was not notified that R70 had been refusing meals and indicated she would reassess R70 later that week. She further stated she planned to increase the ReadyCare supplementation now that she was made aware that R70 was refusing meals. The RD stated she did not coordinate directly with the physician but did communicate with nursing and dietary staff.Interview on 12/16/2025 at 12:53 pm with MDS Registered Nurse (RN) LL when asked why R70's significant weight loss did not trigger a significant change, RN LL stated that a significant change required two or more issues, and since R70 only had one issue, she did not consider it a significant change.Interview on 12/18/2025 at 1:23 pm with the Infection Preventionist/Unit Manager revealed that R70 was added to the Weight PAR (Patients At Risk) list, and the physician had added Remeron on Monday. She stated that R70 previously ate all meals but has recently stopped eating and refused staff assistance with feeding. R70 did have cognitive decline, and his condition had worsened over the past couple of weeks. She indicated that the next steps would include contacting the family to discuss options such as a G-tube, code status, and aligning care with the family's wishes. She recalled informing the resident's nephew about R70's intake but did not document it. She emphasized that the family has the right to be informed of changes in the resident's condition and that she plans to reach out to the family to determine next steps.Interview on 12/18/2025 at 1:50 pm with the Director of Nursing (DON) revealed that when a resident experiences a change in condition, all relevant parties, including the family, needed to be notified. She emphasized that it was important to inform the family of all changes affecting the resident's care, as they may become involved and provide support.Interview on 12/18/2025 at 3:00 pm with the Administrator revealed that it was her expectation that everyone was notified of any changes in a resident's condition. She stated that a note should always be made with any contact that has been made or attempted.

Based on observations, staff interviews, and review of facility policies titled, Food Brought by Visitors and Food Storage Guidelines, the facility failed to ensure dietary staff labeled and dated open food items in the dry storage area; failed to prevent/remove ice build-up on top of opened food to prevent contamination in the walk-in freezer; failed to label and date resident foods items the resident nourishment room and; failed to demonstrate the proper procedure to sanitize dishware in the three compartment sink to prevent food borne illness. The facility census was 77 with 71 residents receiving an oral diet. Findings include: Review of the facility policy titled Food Brought by Visitors revealed: Food items are covered, dated with the date the food was brought to the facility and a discard date if applicable, and labeled with the resident's name. Review of the facility policy titled Food Storage Guidelines revealed: non-perishable food will have the following dates available: Delivery date and once opened, will have the open date. 1. Observation on 8/2/2024 at 8:55 am of the dry storage area revealed an opened five-pound bag of grits in a clear, resealable plastic bag. There was no open date. Interview on 8/2/2024 at 8:55 am, the Dietary Manager (DM) confirmed that the bag of grits did not have an open date. The DM revealed that dietary staff should have placed an open date on the open bag before placing inside the resealable plastic bag and putting in dry storage area. 2. Observation on 8/2/2024 at 9:00 am and 8/4/2024 at 9:45 am of the walk-in freezer revealed an open case of frozen strawberries on the food storage shelf located under the air condenser with ice build-up on top. The ice build-up covered half of the top of the case and was over the open seam. Interview on 8/2/2024 at 9:00 am, the DM confirmed that there was ice build-up on the top of the open case of frozen strawberries. The DM revealed that the air condenser in the walk-freezer had been producing some ice due to high temperature outside and mechanics for the freezer were located on the roof of the building. The DM revealed that dietary staff had been removing the ice build-up as needed. 3. Observation on 8/3/2024 at 8:40 am of the resident nourishment room revealed the bottom shelf had a large white Styrofoam container with no resident name or date. On the top shelf was a small white Styrofoam container with no resident name. The top shelf also had a plastic restaurant bag with several containers of food inside, this bag did not have a resident name or date. Further observation revealed the top freezer had three individual sized frozen pizzas with no resident name or date. Interview on 8/3/2024 at 8:40 am, the DM revealed that dietary was only responsible for stocking food items in the nourishment room. The DM revealed that nursing staff were responsible for label and dating resident foods when placed in resident refrigerator and freezer. The DM confirmed that both white Styrofoam containers had no resident name or date, the DM confirmed that the plastic restaurant bag had no resident name or date and confirmed that the pizzas in the resident freezer had no name or date. The DM stated that when she was stocking food items in the resident nourishment room and noticed resident's foods with no name or date, she will let the nursing staff know so they can label and date. Interview on 8/3/2024 at 8:50 am, the Administrator confirmed that the Styrofoam containers and plastic restaurant bag did not have a resident name or date. The Administrator revealed that nursing staff have been educated on labeling and dating resident food items and expected nursing staff to label and date resident foods before placing in the resident refrigerator. 4. Observation on 8/3/2024 at 9:20 am of the three-compartment sink revealed the facility was using a quaternary (a solution that uses four compounds) sanitizing solution to sanitize dishware. Two posters were located on the wall over the sink, one poster stated dishware immersion time one minute. The second poster indicated step four was to submerge in sanitizer sink for one to two minutes. Continued observation of Dietary [NAME] BB sanitize the lid to the food processor revealed he removed it from sanitizing solution and placed it on the drying rack. Interview on 8/3/2024 at 9:20 am with dietary cook BB revealed that he normally submerges dish items in the sanitizing solution for 20-30 seconds which is what the DM and the Department of Health told him. The dietary cook confirmed that the posters over the sink did state to submerge for at least one minute in the sanitizing solution. Dietary cook BB stated that he should have kept the dishware in the sanitizing solution for a longer time to sanitize. Interview on 8/3/2024 at 9:40 am, the DM confirmed that the facility was using a quaternary sanitizing solution in the three-compartment sink. The DM confirmed that the posters on the wall above the sink indicated to submerge/immerse dishware in the sanitizing solution for at least one minute. The DM revealed she excepted dietary staff to have placed dishware in the sanitizing solution for at least one minute.

Based on staff interviews and review of the facility policy titled, Management/Dietary Services Manager, the facility failed to ensure that the staff designated as Dietary Manager (DM) was certified in dietary or food service management or had a similar food service management certification or degree. The facility census was 77 with 71 residents receiving an oral diet. Findings include: Review of the facility policy titled Management/Dietary Services Manager dated March 2024 revealed under Procedure: The Dietary Service Manager is responsible for obtaining and maintaining current Serve Safe Food Handler certification and CEU's (continuing education unit) required for the Certified Dietary Managers (CDM) certification once obtained. The Dietary Services Manager will follow the CMS (Centers for Medicare/Medicaid Services) guidelines for obtaining CDM certification per the CMS regulations. Review of the DM's employee file revealed she was hired as a dietary cook on 9/28/2012 and promoted to Dietary Manager on 7/13/2023. Interview on 8/2/2024 at 9:25 am with the DM revealed that she did not have any dietary certifications. The DM revealed that she was in the process of becoming certified and only needed to complete the test. Interview on 8/3/2024 at 2:15 pm with the Administrator revealed that when the DM was promoted to current position there was an expectation that the DM would at least obtain the Serve Safe Food Manager certification and then eventually become a Certified Dietary Manager. The Administrator revealed that she was Serve Safe certified and provides dietary oversite when needed. The Administrator revealed the facility was not utilizing a DM from any sister facilities to assist with dietary oversite. Continued interview revealed that the Registered Dietitian visits the facility once a month and provides dietary guidance when needed.

Based on staff interviews, record review, and a review of the facility policy titled, Resident Trust Fund Accounting Policies and Procedures, the facility failed to maintain a Surety Bond in an adequate amount to cover the resident trust fund account balance for three of six months reviewed. This deficient practice had the potential to adversely affect the finances of 62 of 62 residents with trust fund accounts managed by the facility. Findings include: A review of the undated facility policy titled Resident Trust Fund Accounting Policies and Procedures revealed, .Policy: The facility must purchase a Surety Bond to assure the security of all personal funds of residents deposited with the facility. A review of the facility's Surety Bond revealed that the [NAME] Term Effective was April 1, 2022, to April 1, 2025, in the amount of $80,000.00. A review of the last six months of bank statements for the Resident Trust Account for Chulio Hills revealed that three of the six months' statements documented an ending balance in excess of $80,000.00. The ending balance for February 2024 was $92,715.87, the ending balance for May 2024 was $93,849.05, and the ending balance for July 2024 was $95,520.15. A review of the facility-provided list of residents with resident trust fund accounts, dated 8/4/2024, revealed that 62 of 77 residents had an active resident trust fund account. In an interview on 8/3/2024 at 2:00 pm, the Administrator verified the facility's Surety Bond was for the amount of $80,000.00. She further verified the resident trust fund end-of-the-month bank statement for February 2024 was $92,715.87, May 2024 was $93,849.05, and July 2024 was $95,520.15. She stated she was unsure why the Surety Bond amount was not more than the highest resident trust fund monthly balance. She further stated the facility's Corporate Human Resources stated the bond company had recommended the amount of $80,000.00 based on the resident trust fund end-of-the-month balance of August 2021 to January 2022.

Based on record review, staff interviews, and review of the facility policy titled, Medication Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for four of nine residents (R) (R31, R56, R59, and R40) reviewed for unnecessary medications. Findings include: A review of the facility policy titled Medication Orders effective date November 28, 2017, revealed under Procedures: .E. PRN [as needed] orders for psychotropic drugs are limited to 14 days. If the attending prescribing practitioner believes it was appropriate for a PRN order to be extended beyond 14 days, he or she should document the rationale in the resident's medical record and indicate the duration of the PRN order. 1. A review of the Medical Doctor's (MD) orders for R31 dated 6/22/2024 revealed an order for 1 mg (milligram) of lorazepam by mouth every four hours as needed for anxiety. The order had an indefinite end date. A review of the Medication Administration Record (MAR) revealed that R31 was administered 1 mg of lorazepam by mouth on 6/30/2024 at 7:33 am, 7/19/2024 at 2:33 pm, 7/23/2024 at 10:19 am, 7/25/2024 at 8:42 pm, 7/29/2024 at 9:07 am and 9:06 pm, and 7/30/2024 at 7:19 pm. During an interview on 8/3/2024 at 4:40 pm with the Director of Nursing (DON), she stated that Licensed Practical Nurse (LPN) Unit Manager (UM) CC reviewed all new medications to ensure all stop dates were entered if required. The DON explained she went behind the UM to verify stop dates were entered. The DON acknowledged staff did not enter a stop for R11's lorazepam and said the medication should have had one as it was a psychotropic medication. 46691 2. A review of R56's Physician's Orders revealed an order dated 6/19/2024 for lorazepam 1mg oral tablet, one by mouth every 4 hours as needed for agitation. The order had an indefinite end date. A review of R56's MARs revealed he was administered lorazepam 1 mg by mouth on 6/22/2024 at 7:46 am, 6/23/2024 at 11:38 am, 6/25/2024 at 12:11 am, 7/3/2024 at 1:58 am, 7/6/2024 at 8:50 pm, 7/7/2024 at 2:44 am and 12:52 pm, 7/17/2024 at 2:14 am, and 7/20/2024 at 8:16 pm. In an interview on 8/3/2024 at 10:55 am, LPN/UM CC and LPN/UM DD stated they reviewed new physician orders daily. They stated the physician normally indicates a stop date for psychotropic medications, and they were unsure how the order for PRN lorazepam 1 mg was missed. In an interview on 8/3/2024 at 1:20 pm with the Administrator and DON, the DON stated that the nurses transcribe the physician orders, and PRN medication orders should not be transcribed without a stop date. The Administrator stated her expectation was that if a physician's order for antipsychotic medications was received without a stop date, the nurse should put a 14-day stop date on the order and call the physician for clarification of the stop date. In an interview on 8/3/2024 at 5:00 pm, the DON verified R56's physician's order dated 6/19/2024 for lorazepam oral tablet 1 mg, give 1 mg by mouth every 4 hours as needed for agitation did not have a stop date. She stated there should be a stop date and the resident should be assessed before re-ordering the medication to determine if the medication order was still indicated based on the resident's needs. 47146 3. Review of the electronic medical record (EMR) revealed medication orders for R59 included but was not limited to Ativan solution 2 milligrams (mg)/milliliters (ml), inject 1 ml intramuscularly every four hours as needed for anxiety/agitation related to seizures. Interview on 8/3/2024 at 10:55 am with LPN Unit Manager CC and LPN Unit Manager DD, they verified and confirmed R59 had an physician order for Ativan, as needed with no stop date documented in the EMR. They revealed that they reviewed all new orders on each resident each day. Interview with the DON and the Administrator on 8/3/2024 at 1:20 pm, the DON revealed that PRN orders are entered into the system by the nurse who transcribes the order from a written physician order. She stated she was not sure how or why a PRN Ativan order was entered without a stop date. She stated that she and the Assistant Director of Nursing (ADON) review new orders daily to catch these type errors. She stated she was not sure of what adverse effect this type error could have on a resident. The Administrator stated her expectation was that orders be entered into the EMR correctly and if the physician order for an antipsychotic medication was received without a stop date, the nurse should automatically put a 14 day stop date on the order and call the physician to clarify the stop date. 33548 4. Review of R40's EMR revealed they were admitted to the facility with a diagnosis of, but not limited to epilepsy. Review of the physician orders revealed R40 was ordered to receive lorazepam injection solution 2 ml, inject 1 ml every four hours as needed for seizures. The lorazepam was ordered 4/3/2024 with no stop date indicated. Review of the care plan revealed a focus area indicating R40 uses anti-anxiety medication (Xanax and lorazepam, as needed) due to adjustment disorder with anxiety and seizures. Interview on 8/3/2024 at 5:00 pm, the DON confirmed that R40 had an order for as needed lorazepam. The DON revealed that R40 has seizure activity about every other day and was given the lorazepam at those times. The DON revealed that the as needed lorazepam should have had a 14 day stop date.

Based on observations, staff interviews, and review of the facility policy titled, Medication Storage In The Facility, the facility failed to ensure one of three medication carts was locked and secured when left unattended by the nurse. This deficient practice created the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored on the medication cart. The facility census was 77 residents. Findings include: A review of the facility policy titled Medication Storage In The Facility, dated 4/1/2016, revealed the Policy stated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The Procedures section included, . B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. An observation on 8/2/2024 at 7:37 am, during the initial tour of the facility, revealed one unlocked and unattended medication cart positioned with the drawers facing the hallway, located on the 300 Hall between rooms [ROOM NUMBERS]. At 7:38 am, Registered Nurse (RN) EE walked by the cart without looking at the cart. At 7:39 am, a resident self-propelled himself from room [ROOM NUMBER] and by the cart. At 7:40 am, RN EE walked by the cart without looking at the cart. In an interview at 7:41 am, RN EE stated he was responsible for the medication cart and verified the cart was unlocked. unattended, and located in an area easily accessible to residents. He locked the medication cart and walked away, declining further interview. In an interview on 8/2/2024 at 8:30 am, the Administrator stated the medication carts should be locked and secured when left unattended by the nurse. She stated the nurses knew to lock the carts when walking away from them, and she had no explanation for the cart being left unlocked and unattended. In an interview on 8/4/2024 at 8:05 am, the Director of Nursing (DON) stated she expected the medication carts to be locked and secured when left unattended by the nurse to prevent residents, unauthorized staff, or visitors from obtaining medications from the cart. She stated a pharmacy consultant conducted random audits of the medication carts and provided monthly education to licensed nursing staff. She further stated she was unsure whether the night shift nurses received the education provided by the pharmacy consultant since the education was provided during the day shift. She stated leaving the medication carts unlocked and unattended increased the chance for a resident or unauthorized staff to have access to medications that could cause harm to the resident.

Based on observations, staff interviews, record review, and review of the facility policy titled, Resident Assessment - Coordination with PASARR Program, the facility failed to refer one of 35 sampled residents (R) (R33) for a preadmission screening and resident review (PASARR) level two. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled Resident Assessment - Coordination with PASARR Program copyright date 2021, revealed the Policy was The facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to insure that individual with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The sub-section titled Policy Explanation and Compliance Guidelines revealed under number nine any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Subsection nine (b) revealed a resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. Review of the electronic medical record (EMR) revealed Resident (R)33 was admitted to the facility with pertinent diagnoses including but not limited to general anxiety disorder and major depressive disorder diagnosed on [DATE]. Review of R33's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/14/2024 revealed a Brief Interview for Mental Status (BIMS) of 15, which indicates R33 was cognitively intact. Section D (Mood) revealed that R33 had a total severity score of 2 which indicated no depression. Section E (Behaviors) revealed no potential indicators for psychosis. Review of R33's care plan with focus on use of anti-anxiety medications related to mood disorder, anxiety, and depression (initiated 4/20/2018) and use of antidepressant medication related to mood disorder and insomnia (initiated 4/20/2018). Her goals included but not limited to R33 will be free from discomfort or adverse reactions related to anti-anxiety therapy or medications (initiated 4/20/2018). Interventions included but not limited to administer anti-anxiety and antidepressant medications as ordered by the physician (initiated 4/20/2018), monitor/record occurrence of target behaviors, monitor for worsening signs of depression, monitor for adverse reactions to anti-anxiety therapy (initiated 4/20/2018). Review of the EMR revealed physician's orders for R33 included but were not limited to: buspirone 10 milligrams (mg) by mouth, twice a day (BID); Seroquel 25 mg by mouth at bedtime; and trazodone 75 mg at bedtime. Observations made on 8/2/2024 at 11:39 am of R33 revealed she was sitting up in bed, noted to be clean and well groomed, and there were no objectionable odors noted in the room. She was conversational and no behaviors were noted. Observations made on 8/3/2024 at 8:44 am of R33 revealed she was sitting up in bed eating breakfast, she was conversational, and no behaviors were observed. An interview with the Social Service Director on 8/3/2024 at 11:10 am revealed that R33 was not currently receiving psychiatric services because the facility was changing mental health service providers. She stated she would soon be under the care of the new service provider. She stated she did not resubmit a PASARR for R33 to obtain a level two PASARR because she did not think R33 needed a level two because her primary diagnosis was not a mental health diagnosis. An interview with the Administrator on 8/3/2024 at 1:35 pm revealed that her expectation related to the submission of PASARR for level two PASARR was that each resident's diagnosis be reviewed and if the resident had a major mental health diagnosis, then it was expected that the Social Service Director resubmit the PASARR and obtain a level two PASARR. She stated not obtaining a level two PASARR for residents with a major mental health diagnosis places the resident at risk for improper placement and not receiving the correct mental health care needed.

Based on observations, staff interviews, and review of the facility policies titled, Enhanced Barrier Precautions and Bed Baths, the facility failed to utilize proper infection control techniques while providing care to one of 35 sampled residents (R) (R75) on Enhanced Barrier Precautions (EBP). The deficient practice had the potential for staff to spread infection to other residents in the facility. Findings included: A review of the undated facility policy titled Bed Baths under Policy Explanation and Compliance Guidelines revealed: staff should change the basin water, obtain a clean washcloth, perform hand hygiene and don (put on) new gloves after washing and before rinsing the resident. Additionally, cleaning would begin at the face and work over the body, with the groin and buttocks cleaned last. A review of the facility policy titled Enhanced Barrier Precautions dated 4/1/2024 revealed under Policy Explnation and Compliance Guidelines: .3. b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities . 4. High-contact resident activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes h. Wound care: any skin opening requiring a dressing. A review of the Medical Doctor's (MD) orders dated 6/18/2024 revealed that Enhanced Barrier Precautions (EBP) were ordered for R75. Staff were to don gloves and a gown before contact with the resident for high-contact resident care activities, which included bathing/showering, changing linens, providing hygiene, changing briefs, or providing indwelling Foley catheter care. A review of R75's care plan revealed that the resident was care planned for EBP related to a Foley catheter. The care plan indicated that staff would be compliant with the enhanced barrier precautions as ordered. Interventions included having staff wear gowns and gloves for the following High-Contact resident care activities: bathing/shower, brief changing, incontinent care, and linen changes. An observation of R75's room on 8/2/2024 at 10:05 am revealed a sign outside the door indicating the resident was on EBP. The signage included instructions for all staff to don gowns and gloves when providing direct care. During an observation of catheter care on 8/2/2024 at 10:19 am, CNA AA cleaned R75's catheter site and groin area with a washcloth, soap, and water. CNA AA then used the same washcloth to clean R75's entire front body. CNA AA then rinsed the soap from R75 with the same water used to wash R75. During the same observation, CNA AA did not don a gown while providing the resident with a bed bath, incontinent care, linen change, and dressing. R75 was on Enhanced Barrier Precautions due to an indwelling catheter. During an interview with the Infection Control Preventionist (ICP) on 8/2/2024 at 3:45 pm, she stated it was her expectation for any staff providing care to a resident on EBP to wear the proper PPE. The ICP indicated that staff should wear gowns and gloves when caring for residents on EBP. The ICP stated that all staff had received EBP training, signs were posted on any resident's rooms that were on EBP, and the signage indicated the proper PPE required. The ICP said that staff were trained to use separate water basins for washing and rinsing a resident when providing bed baths or incontinent care. The staff was also trained to use a clean washcloth after utilizing a washcloth on any peri areas. During an interview with Certified Nursing Assistant (CNA) AA on 8/2/2024 at 4:00 pm, CNA AA confirmed she had not donned a gown when providing R75 with direct care. She stated she did not know she was supposed to use PPE when caring for residents with Foley catheters, feeding tubes, PICC (peripherally inserted central catheter) lines, or IVs (intravenous). Per CNA AA, she did not see the sign on R75's door, and she had never read it. Additionally, CNA AA confirmed she used the same washcloth she cleaned R75's Foley and groin area to bathe the rest of his body. CNA AA stated she thought it was okay to use the same washcloth, provided she used another washcloth to rinse the resident. The CNA AA confirmed she used the same basin of water for washing and rinsing R75 and added she did not know she needed to use a clean basin of water to rinse the soap from R75.

Based on record review, observations, interviews, and review of the facility policy titled, Catheter Management - Indwelling Urinary Catheters, the facility failed to ensure an indwelling urinary catheter had a privacy cover for one resident (R)(R#22), of eight residents who had an indwelling urinary catheter. Findings include: A review of the facility policy, titled, Catheter Management-Indwelling Urinary Catheters, dated 10/1/20, revealed, Procedure: 13. Staff will be trained to report urinary leakage, kinks, issues with leg strap placement, correct placement of the drainage bag (below bladder) and any dignity issues related to foley catheter use. A review of the Transfer/Discharge Report revealed the facility admitted R#22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the annual Minimum Data Set (MDS) for R#22, dated 4/7/22, revealed a Brief Interview for Mental Status (BIMS) could not be completed as the resident was rarely/never understood. According to the Staff Assessment for Mental Status, R#22's cognitive skills for daily decision making were severely impaired. The resident had an indwelling urinary catheter. A review of R#22's care plan revised 4/13/22 , revealed R#22 had an indwelling catheter. Interventions included positioning the catheter bag and tubing below the level of the bladder and away from the room door entrance, checking the tubing for kinks, monitoring for pain and discomfort due to the catheter, monitoring, and reporting to the physician any signs or symptoms of a urinary tract infection ([CONDITION(S)]). Observation on 5/24/22 at 9:07 a.m., R#22 was observed in his room. R#22 was observed to have a catheter bag hanging on the left side of the bed, facing the doorway to the room, without a privacy cover. Observation on 5/24/22 at 11:40 a.m., R#22's catheter bag was observed from the hallway. There was no privacy cover on the bag. Observation on 5/25/22 at 9:58 a.m., R#22's catheter bag was observed, and the bag did not have a privacy cover. Urine could be observed inside the bag. During an interview on 5/25/22 at 10:30 a.m., Certified Nursing Assistant (CNA) KK stated the facility had blue covers to cover up the catheter bags. She stated all catheter bags should have dignity (privacy) covers. During an interview on 5/25/22 at 10:33 a.m., Licensed Practical Nurse (LPN) LL stated the facility had privacy bags to cover the catheter bag. She indicated the staff did not put privacy covers over the catheter bag unless the residents came out of their rooms. She stated the bags were to protect the privacy and dignity of the resident. During an interview on 5/25/22 at 11:48 a.m., the Director of Nursing (DON) stated catheter bags should be covered. During an interview on 5/25/22 at 11:49 a.m., the Administrator stated she would expect the catheter bags to be covered.

Based on reviews of the facility's job description titled: Infection Control Preventionist, the facility failed to designate a Certified Infection Preventionist serving in this role, which completed specialized training in infection prevention and control. The lack of a Certified Infection Preventionist to provide oversight and monitoring of the facility's Infection Control and Prevention Program resulted in the facility's failure to implement the Center for Medicare, Medicaid Services (CMS), Centers for Disease Control (CDC), and Georgia Department of Public Health's (GDPH) recommended practices for control and mitigation of Covid-19. This failure affected the entire facility census. The census was 53. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator, Assistant Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were notified on [DATE], at 12:00 p.m. of the Immediate Jeopardy. The Immediate Jeopardy is outlined as follows: 1. The facility failed to ensure an effective Infection Prevention Control Program (IPCP) was implemented and maintained that would investigate and identify an infection outbreak to prevent or reduce the spread of Covid-19 to residents and staff. 2. The facility failed to implement outbreak testing of residents and staff when a resident (R#27) tested positive for Covid-19 on [DATE]. 3. The facility failed to implement outbreak guidance of the Centers for Disease Control (CDC), Centers for Medicare/Medicaid Services (CMS) and the Georgia Department of Public Health (GDPH) for isolation, appropriate cohorting of residents, baseline testing of all staff and residents on [DATE] when a resident tested positive for Covid-19, failed to consistently test staff, and failed to provide evidence that unvaccinated staff were being tested per the community positivity/transmission rate since [DATE] to prevent or reduce the spread of Covid-19 to residents and staff. 4. The facility failed to have a Certified Infection Control Preventionist on staff, who was responsible for the Infection Control Program. 5. The facility failed to educate staff on the use of Personal Protective Equipment (PPE). 6. The facility failed to ensure that staff were trained and utilized the appropriate PPE throughout the facility once the Covid-19 outbreak was identified. 7. The facility was unable to provide documentation of ongoing facility-wide surveillance which included data collection, root-cause analysis, interpretation, and dissemination of surveillance information utilizing the tools identified in the facility's policy and procedure. 8. The facility failed to have an effective Quality Assurance Performance Improvement Plan (QA/PI) to address a Covid-19 outbreak. 9. The facility failed to ensure the Governing Body provided effective oversight to prevent or reduce the spread of Covid-19 infection. As a result of these failures 21 residents and 29 staff have tested positive for Covid-19. In addition, six Covid-19 positive residents (R#11, R#12, R#17, R#18, R#19, and R#21) were hospitalized due to Covid-19 as of [DATE], and two residents (Resident (R)#10 and R#12) died as a result of Covid-19. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2) Governing Body, F837; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867; 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control, F880; 42 CFR 483.80(b)(1)-(4)(c) Infection Preventionist Qualifications/role, F882; 42 CFR 483.80 (h)(1)-(6) -- Covid-19 Testing-Residents & Staff, F886. All IJ deficiencies were cited at a Scope and Severity (S/S) of L. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include: A review of the facility's revised [DATE] Infection Preventionist (IP) job description indicated the IP the primary purpose of your job is to plan, organize, develop, coordinate, and direct our infection prevention and control program and its activities in accordance with current federal, state, and local standards, guidelines, and regulations that govern such programs, and as may be directed by the Administrator (ADM) and the IP and Control Committee to ensure that an effective infection prevention and control program is maintained at all times. Administrative Functions: 1. Plan, develop, organize, implement, evaluate, coordinate, and direct our infection prevention and control program in accordance with current rules, regulation, and guidelines that govern such requirements in nursing care facilities. 2. Ensure that the facility is in compliance with current CDC, OSHA, and local regulations concerning infection prevention and control. 3. Develop, maintain, and periodically update infection prevention and control processes and techniques in accordance with current best practices. 4. Review, modify and interpret infection prevention and control policies and procedures as necessary. 9. Make rounds to nursing units for the purpose of case findings, review of environmental sanitation procedures, and supervision of standard and transmission-based precautions. 10. Visit residents as necessary to ensure that established standard and transmission-based precautions and aseptic technique are followed. 17. Prepare monthly summaries of all residents/personnel infections, corrective action taken, and the results of the corrective action. Submit a copy to the Administrator and Director of Nursing Services. 22. Monitor and address possible sources of infection within the facility, including personnel, visitors, residents, and the environment. 24. Assist in developing infection prevention and control procedures for the routine and terminal cleaning of rooms, common areas, equipment cleaning, etc. Nursing Care and Consultation Functions: 1. Ensure that residents with known communicable or infectious diseases are placed on appropriate transmission -based precautions. Working Conditions: 1. Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents needs in relation to prevention and control of infections. Staff Development: 1. Develop, implement, and maintain an effective orientation program that orients the new employee to our infection prevention and control and employee health programs. 2. Provide leadership training that includes the administrative and supervisory principles essential for Nurse Supervisors/Charge Nurses. Experience: 1. Must have, as a minimum, two years clinical experience in a hospital, nursing care facility, or other related healthcare facility. 3. Association of Professional in Infection Control and Epidemiology (APIC) Certification in infection prevention and control is preferred, but not necessary. An interview with the ADM on [DATE] at 9:30 a.m. confirmed the facility did not have a Certified Infection Control Preventionist (ICP) serving in that role since the previous ICP left on [DATE]. An interview with the ICP AA, who is servicing in the role, on [DATE] at 10:00 a.m. revealed that she assumed the role of ICP nurse in [DATE] after the previous ICP left the faciity on [DATE]. ICP AA revealed that many aspects of the ICP program were a challenge due to reporting back to the previous DON. She further revealed that she reported to the previous DON and then awaited ongoing instructions for the ICP program, but she would not hear back with a plan for education or infection control. She stated that she thought the previous DON was taking care of those areas in the facility. ICP AA confirmed that she has not completed training as an ICP. She revealed that education for the staff was not provided once the outbreak began in [DATE]. Cross refer F880.

Based on a review of the facility policy titled, COVID-19 Testing Plan/Policy revised [DATE] and interviews, the facility failed to ensure consistent testing throughout the facility for staff and residents and to develop and implement corrective actions to address concerns with the facilities Infection Control program specifically with the current outbreak of COVID-19 in the facility. The census was 53. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator, Assistant Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were notified on [DATE], at 12:00 p.m. of the Immediate Jeopardy. The Immediate Jeopardy is outlined as follows: 1. The facility failed to ensure an effective Infection Prevention Control Program (IPCP) was implemented and maintained that would investigate and identify an infection outbreak to prevent or reduce the spread of Covid-19 to residents and staff. 2. The facility failed to implement outbreak testing of residents and staff when a resident (R#27) tested positive for Covid-19 on [DATE]. 3. The facility failed to implement outbreak guidance of the Centers for Disease Control (CDC), Centers for Medicare/Medicaid Services (CMS) and the Georgia Department of Public Health (GDPH) for isolation, appropriate cohorting of residents, baseline testing of all staff and residents on [DATE] when a resident tested positive for Covid-19, failed to consistently test staff, and failed to provide evidence that unvaccinated staff were being tested per the community positivity/transmission rate since [DATE] to prevent or reduce the spread of Covid-19 to residents and staff. 4. The facility failed to have a Certified Infection Control Preventionist on staff, who was responsible for the Infection Control Program. 5. The facility failed to educate staff on the use of Personal Protective Equipment (PPE). 6. The facility failed to ensure that staff were trained and utilized the appropriate PPE throughout the facility once the Covid-19 outbreak was identified. 7. The facility was unable to provide documentation of ongoing facility-wide surveillance which included data collection, root-cause analysis, interpretation, and dissemination of surveillance information utilizing the tools identified in the facility's policy and procedure. 8. The facility failed to have an effective Quality Assurance Performance Improvement Plan (QA/PI) to address a Covid-19 outbreak. 9. The facility failed to ensure the Governing Body provided effective oversight to prevent or reduce the spread of Covid-19 infection. As a result of these failures 21 residents and 29 staff have tested positive for Covid-19. In addition, six Covid-19 positive residents (R#11, R#12, R#17, R#18, R#19, and R#21) were hospitalized due to Covid-19 as of [DATE], and two residents (Resident (R)#10 and R#12) died as a result of Covid-19. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2) Governing Body, F837; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867; 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control, F880; 42 CFR 483.80(b)(1)-(4)(c) Infection Preventionist Qualifications/role, F882; 42 CFR 483.80 (h)(1)-(6) -- Covid-19 Testing-Residents & Staff, F886. All IJ deficiencies were cited at a Scope and Severity (S/S) of L. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings Include: A review of the facility policy titled COVID-19 Testing Plan/Policy, it is the policy of this facility to conduct [MEDICATION(S)] testing on symptomatic residents and facility employees, asymptomatic residents and facility employees as part of a COVID-19 outbreak response or testing of asymptomatic residents or facility staff who are known close contacts of persons with COVID-19, and asymptomatic facility staff as part of expanded screening testing according to the policy explanation and compliance guidelines. Testing may be provided by this facility (Point of Care testing) or offsite through an approved laboratory that has rapid testing capabilities (the ability to process large numbers of test and report results within 48 hours) Test must be able to detect the [CONDITION(S)]-CoV-2 virus (e.g., polymerase chain reaction/PCR) with greater than 95% sensitivity, greater than 90% specificity and with results obtained within 48 hours. Antibody tests are not used to diagnose active infection, or to inform the infection prevention and control strategy for COVID-19 Testing of Symptomatic Staff or Residents: 1. Staff and residents vaccinated and unvaccinated with signs and symptoms must be tested . 2. If the resident or staff is the first positive test for COVID-19 within the facility, an outbreak response should be initiated immediately. 3. For residents or staff who test positive and are fully vaccinated, the public health authorities should be informed, and the facility will follow the guidance provided by the public health department. 4. If an [MEDICATION(S)] test is presumptive negative, perform RT-PCR immediately (e.g., within 2 days) a. symptomatic residents should be kept on Transmission-Based Precautions and symptomatic staff should be excluded from work until RT-PCR results return. b. Clinical discretion should be utilized to determine who test negative on such platforms and should be retested with RT-PCR. Some [MEDICATION(S)] platforms have higher sensitivity when testing people within 5 days of symptom onset. In some instances, confirmatory testing may not be necessary if the individual has a low likelihood of COVID-19 infection (e.g., non-respiratory systemic symptoms soon after COVID-19 vaccine administration in a staff or resident with no known exposures in a non-outbreak facility or has had a [CONDITION(S)]-CoV-2 infection in the last 3 months. c. If [MEDICATION(S)] and confirmatory test are negative and the individual resides or works in an outbreak facility, the confirmatory negative test does not affect implementation of appropriate precaution for the facility with an outbreak. Additionally, both residents and staff should be serially tested every ,d+[DATE] days until no new cases are identified for 14 days. Testing of staff and residents in response to or as part of an outbreak or those who are known close contacts of a person with COVID-19 includes: 1. All staff and residents vaccinated and unvaccinated will be tested upon identification of a single new case of COVID-19 infection in any staff or residents. 2. All staff and residents that are a known close contact of a person with COVID-19 vaccinated and unvaccinated will be tested . 3. All staff and residents that test negative will be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. The facility will monitor their county's positivity rate every other week and adjust the frequency of performing testing according to the testing intervals as outlined. 1. If the county positivity rate increases to a higher level of activity, the facility will begin testing staff at the frequency of the outlined. 2. If the county positivity rate decreases to a lower level of activity, the facility will continue testing staff at the higher activity level until the positivity rate has remained at the lower activity for at least two weeks before reducing the testing frequency. a. Green (Counties with test percent positivity <5.0% or with <20 tests in 14 days)-once a month b. Yellow (Counties with test percent positivity 5.0%-10% or with <500 tests and <,d+[DATE]kand >10%positivity over 14 days- once a week c. Red (Counties >10% and not the criteria for Green or Yellow)- Twice a week Review of the Community Positivity Rates, published by the Georgia Department of Public Health (GDPH) revealed that beginning on [DATE] the County was designated as Red, requiring twice weekly testing for all unvaccinated staff. The facility was unable to provide evidence that all unvaccinated staff were tested for COVID-19 from [DATE] through [DATE]. Review of the Community Transmission rate for the week of [DATE] revealed the rate was High requiring twice weekly testing was required. Review of the HR sheets used to check off for testing revealed that testing was conducted only tested on e time that week on [DATE] with 13% of staff not tested . The testing revealed five COVID-19 positive residents and six COVID-19 staff members. Review of the Community Transmission rate for the week of [DATE] revealed the rate was High requiring twice weekly testing. Review of the HR sheets used to check off for testing revealed that testing was conducted only one time that week on [DATE] with 4.5% of staff not tested . The testing revealed 14 COVID-19 positive residents and four COVID-19 staff members. Review of the Community Transmission rate for the week of [DATE] revealed the rate was Substantial requiring twice weekly testing. Review of the HR sheets used to check off for testing revealed that testing was conducted one time that week on [DATE] with 9.1% of staff not tested . The testing revealed two COVID-19 positive residents and three positive staff members. Review of the Community Transmission rate for the week of [DATE] revealed the rate was Substantial requiring twice weekly testing. Review of the HR sheets used to check off for testing revealed that testing was conducted twice once on [DATE] with 4.5% of staff not tested and on [DATE] with 3% of staff not tested . The testing revealed one resident and two staff members tested positive and documented on the facility's new line listing. Review of the available documentation revealed that there was no evidence that R#10, R#18, R#11, R#19, R#13, R#20 were tested prior to [DATE] or that R #22, R#23 were tested prior to [DATE]. An interview with the Administrator on [DATE] at 3:15 p.m. revealed that the facility did not have a line listing of positive residents and/or staff in the facility. The Administrator revealed that she was keeping the positive residents' names on a wall calendar in her office and there was no tracking for staff members. An interview with the Administrator on [DATE] at 6:20 p.m. revealed the facility does not document COVID-19 testing in medical record except for notification to family/Responsible Party when resident tests positive for COVID-19. The Administrator revealed there is no documentation that tests were performed, or results of negative status documented for residents. Administrator stated that test results are not being uploaded into electronic medical record (EMR) and she felt like it was not necessary to upload negative test results. An interview with DON on [DATE] at 1:00 p.m. revealed that staff reports to testing site (salon) on Mondays and Thursdays which is on the honor system. The DON further revealed that she checks staff off on HR roster, as they come through for testing. She further revealed once testing is completed for that day, the paperwork is stored in a box with no further investigation of who did not test on her checklist. She has no explanation as to why there is no follow-up for staff not tested . Cross refer to F880

Based on a review of the facility policy titled, Administrative Management (Governing Body) revised ,d+[DATE] and interviews, the facility's Governing Body failed to ensure oversight and monitoring of the QAPI programs effectiveness in identifying, developing, and implementing corrective actions to address concerns with the facilities Infection Control program specifically after notification of the current outbreak of COVID-19 in the facility. The census was 53. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator, Assistant Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were notified on [DATE], at 12:00 p.m. of the Immediate Jeopardy. The Immediate Jeopardy is outlined as follows: 1. The facility failed to ensure an effective Infection Prevention Control Program (IPCP) was implemented and maintained that would investigate and identify an infection outbreak to prevent or reduce the spread of Covid-19 to residents and staff. 2. The facility failed to implement outbreak testing of residents and staff when a resident (R#27) tested positive for Covid-19 on [DATE]. 3. The facility failed to implement outbreak guidance of the Centers for Disease Control (CDC), Centers for Medicare/Medicaid Services (CMS) and the Georgia Department of Public Health (GDPH) for isolation, appropriate cohorting of residents, baseline testing of all staff and residents on [DATE] when a resident tested positive for Covid-19, failed to consistently test staff, and failed to provide evidence that unvaccinated staff were being tested per the community positivity/transmission rate since [DATE] to prevent or reduce the spread of Covid-19 to residents and staff. 4. The facility failed to have a Certified Infection Control Preventionist on staff, who was responsible for the Infection Control Program. 5. The facility failed to educate staff on the use of Personal Protective Equipment (PPE). 6. The facility failed to ensure that staff were trained and utilized the appropriate PPE throughout the facility once the Covid-19 outbreak was identified. 7. The facility was unable to provide documentation of ongoing facility-wide surveillance which included data collection, root-cause analysis, interpretation, and dissemination of surveillance information utilizing the tools identified in the facility's policy and procedure. 8. The facility failed to have an effective Quality Assurance Performance Improvement Plan (QA/PI) to address a Covid-19 outbreak. 9. The facility failed to ensure the Governing Body provided effective oversight to prevent or reduce the spread of Covid-19 infection. As a result of these failures 21 residents and 29 staff have tested positive for Covid-19. In addition, six Covid-19 positive residents (R#11, R#12, R#17, R#18, R#19, and R#21) were hospitalized due to Covid-19 as of [DATE], and two residents (Resident (R)#10 and R#12) died as a result of Covid-19. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2) Governing Body, F837; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867; 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control, F880; 42 CFR 483.80(b)(1)-(4)(c) Infection Preventionist Qualifications/role, F882; 42 CFR 483.80 (h)(1)-(6) -- Covid-19 Testing-Residents & Staff, F886. All IJ deficiencies were cited at a Scope and Severity (S/S) of L. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings Include: A review of the facility policy titled Administrative Management (Governing Board) was revised on ,d+[DATE]. The policy states that the governing board shall be responsible for the management and operation of the facility. Policy Interpretation and Implementation: 2. The Administrator is appointed by and accountable to the governing board. 3. The governing board is responsible for, but not limited to: d. Establishment and ongoing review of all administrative programs governing facility management and operations including: (1). Corporate Compliance Program; (2) Emergency Preparedness and Response program; (3) Quality Assurance and Performance Improvement program; and (4) Staff orientation, training and development programs. e. Creation of and participation in the annual (or as needed) facility-wide assessment; f. Establishment and annual review of policies and procedures governing facility operations; g. Provision of a safe physical environment equipped and staffed to maintain the facility and services; j. Establishment of a system whereby the Administrator reports to the governing body, including: (1) Method of communication; (2) Frequency of reports; (3) Specific information that will be reported; (4) How and when the board will respond to the Administrator's reports; and (5) How the Administrator will be held accountable for facility management and operations. Review of the Quarterly QAPI meeting minutes for August, September and [DATE] revealed under new business, the facility had a new Director of Nursing. The minutes revealed that in [DATE] the facility had four COVID-19 positive staff and no positive residents. The minutes included that the former DON would continue to follow infection control. Infection Control education would include mask use, Personal Protecting Equipment (PPE), and social distancing. In September minutes revealed the facility had four COVID-19 positive staff and one COVID-19 resident. We continue to test twice per week for both residents and staff. Screening process continues at front of the building. Temps taken and mask given. Resident transferred to COVID-19 unit. In October minutes revealed the facility had 15 COVID-19 positive staff and 19 COVID-19 positive residents. Working with Georgia Department of Public Health. Continue to search for ICP. DON will serve as the ICP until a permanent replacement can be found. An interview with the Administrator (ADM) on [DATE] at 10:30 a.m. revealed the facility does not have a line listing or tracking mechanism for negative or positive residents. There is no evidence to support that the facility had been testing staff and residents consistently according to the Community Transmission rate and/or County Positivity rate. She keeps a list of the positive residents on her personal calendar hanging on the wall in her office. She stated the medical records would not show test results for any residents who tested negative, only positive results. She stated that all results for staff and residents are placed in a box in her office for safekeeping. The ADM revealed she did not have a mechanism in place to put positive residents or staff back in rotation for testing after 90 days of becoming positive for Coronavirus (COVID-19). An interview with the ADM on [DATE] at 6:20 p.m. revealed the facility does not document COVID-19 testing in the medical record except for notification to family and family representatives when resident tests positive for COVID-19. There is no documented evidence available that documents that test were performed, nor are the results documented. The ADM stated that test results are not being uploaded into the Electronic Medical Record (EMR). An interview with the ADM on [DATE] at 9:30 a.m. she confirmed not having a Certified Infection Control Preventionist (ICP) serving in that role for the facility since the previous ICP left on [DATE]. An interview on [DATE] at 2:50 p.m. with Chief Operating Officer (COO), a governing body member revealed the staff who make decisions for the facility are himself, the Corporate Nursing Office (CNO), ADM, and Director of Nursing (DON). The governing body meets weekly by phone to discuss support issues, reimbursement, COVID-19, and regulatory issues. Further discussion revealed that the COO, CNO, and ADM met this morning by phone to discuss current issues in the facility. He was aware of the current outbreak in the facility but was not aware of the facility's lack of testing, hospitalization s, and deaths. The COO stated that the governing body assists the facility with COVID-19 by giving recommendations, jumping in when issues are identified, and having the CNO accessible. He stated that the responsibility of the ADM is to ensure the safety of each resident. An interview on [DATE] at 9:00 a.m. with COO, a governing body member, revealed he does not receive QAPI minutes. The Administrator and CNO deal more directly with the facility. An interview with the ADM on [DATE] at 2:00 p.m. revealed she was aware of an outbreak beginning on [DATE], when two staff members were positive. The ADM stated that during the outbreak they tested weekly for 14 days until no additional positive cases were noted. In [DATE] the facility had another outbreak when they increased testing and instructed staff to wear face shields with their mask. On [DATE] they had another outbreak with positive staff and one resident (R#27). They moved the resident to the COVID-19 unit. She sent out an electronic voice mail to inform the resident and families and shut down inside visitation. Further actions taken by the ADM were walking around, making sure face shields were on employees, and talking to unit managers about monitoring residents for signs and symptoms of COVID-19. Staff were to notify her 24 hours per day of any new positive staff or residents. An interview with Director of Nursing (DON) on [DATE] at 2:15 p.m. revealed she made the Quality Assurance Process Improvement (QAPI) Committee aware of the increase in COVID-19 positive residents in late [DATE]. She continued to state the facility had zero positive COVID-19 cases in August however there were four positive COVID-19 employee during the same month. The DON continued to state it was at this time infection control education for all employees began to include wearing a mask, Personal Protective Equipment (PPE) use, and the importance of social distancing. She continued to explain Georgia Department of Public Health (GDPH) involvement with process improvement through FaceTime and Zoom meetings to include where proper signage should be placed as well as individual bottles of hand sanitizers at each PPE station. The DON stated the QAPI Committee was involved in developing an action plan in September to include testing employees and residents twice a week, monitor hand hygiene, and continuing screening employees before entering the facility for signs and symptoms of COVID-19. The facility was unable to provide evidence of consistent testing of both staff and residents or of education provided to staff except for [DATE] to wear face shields. Cross refer to F880

Based on staff interview, record review, and review of facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, the facility failed to have an effective Quality Assurance process that identified concerns related to the Infection Control Prevention Program. The QAPI committee failed to identify deficient practice related to the policies and procedures for control and mitigation of Covid-19. The census was 53. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator, Assistant Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were notified on [DATE], at 12:00 p.m. of the Immediate Jeopardy. The Immediate Jeopardy is outlined as follows: 1. The facility failed to ensure an effective Infection Prevention Control Program (IPCP) was implemented and maintained that would investigate and identify an infection outbreak to prevent or reduce the spread of Covid-19 to residents and staff. 2. The facility failed to implement outbreak testing of residents and staff when a resident (R#27) tested positive for Covid-19 on [DATE]. 3. The facility failed to implement outbreak guidance of the Centers for Disease Control (CDC), Centers for Medicare/Medicaid Services (CMS) and the Georgia Department of Public Health (GDPH) for isolation, appropriate cohorting of residents, baseline testing of all staff and residents on [DATE] when a resident tested positive for Covid-19, failed to consistently test staff, and failed to provide evidence that unvaccinated staff were being tested per the community positivity/transmission rate since [DATE] to prevent or reduce the spread of Covid-19 to residents and staff. 4. The facility failed to have a Certified Infection Control Preventionist on staff, who was responsible for the Infection Control Program. 5. The facility failed to educate staff on the use of Personal Protective Equipment (PPE). 6. The facility failed to ensure that staff were trained and utilized the appropriate PPE throughout the facility once the Covid-19 outbreak was identified. 7. The facility was unable to provide documentation of ongoing facility-wide surveillance which included data collection, root-cause analysis, interpretation, and dissemination of surveillance information utilizing the tools identified in the facility's policy and procedure. 8. The facility failed to have an effective Quality Assurance Performance Improvement Plan (QA/PI) to address a Covid-19 outbreak. 9. The facility failed to ensure the Governing Body provided effective oversight to prevent or reduce the spread of Covid-19 infection. As a result of these failures 21 residents and 29 staff have tested positive for Covid-19. In addition, six Covid-19 positive residents (R#11, R#12, R#17, R#18, R#19, and R#21) were hospitalized due to Covid-19 as of [DATE], and two residents (Resident (R)#10 and R#12) died as a result of Covid-19. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2) Governing Body, F837; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867; 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control, F880; 42 CFR 483.80(b)(1)-(4)(c) Infection Preventionist Qualifications/role, F882; 42 CFR 483.80 (h)(1)-(6) -- Covid-19 Testing-Residents & Staff, F886. All IJ deficiencies were cited at a Scope and Severity (S/S) of L. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include: Review of the facility policy Quality Assurance and Performance Improvement (QAPI) Program, revised [DATE], revealed a statement that the facility shall develop, implement, and maintain an ongoing, facility wide QAPI program that builds on the QAPI Program to actively pursue quality of care and quality of life goals. Policy Interpretation and Implementation revealed the primary purpose of the QAPI Program is to establish data-driven facility-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents. The QAPI program was developed with five strategic elements in mind. 1. Design and scope: a. The program is ongoing and comprehensive. b. It involves the full range of services and departments in the facility. c. It covers all systems of care and management practices, with priority given to quality care, quality of life and resident choice. d. Goals, targets, and benchmarks are established and measured base on the best available evidence. 2. Governance and leadership: a. Input is sought from facility staff, residents, family members and individuals who are involved in the care of residents. b. Resources are allocated to conduct QAPI efforts. c. Members of the facility leadership are accountable for QAPI efforts. d. Staff are trained in QAPI systems and culture. e. Staff are encouraged to identify and report quality concerns as well as opportunities for improvement. 3. Feedback, data systems and monitoring: a. Systems are in place to monitor care and services. b. Systems are designed to incorporate feedback from caregivers, residents, family, and staff as appropriate. c. Care processes and outcomes are monitored using performance indicators. These performance indicators are measured against quality benchmarks and targets that the facility has established. d. Adverse events are tracked, monitored, and investigated as they occur. e. Action plans are implemented to prevent recurrence of adverse events. 4. Performance improvement projects: a. Performance improvement projects (PIPs) are initiated when problems are identified. b. PIPs involve systematically gathering information to clarify issues and to intervene for improvements. 5. Systematic analysis and systematic action: a. Root Cause Analysis (RCA) is used to determine whether identified issues are exacerbated by the way care and services are organized or delivered, and if so, how. b. RCA serves as highly structured approach to fully understanding other nature of an identified problem, its cause, and the implications of making changes to improve the program. Review of the Quarterly QAPI meeting minutes dated [DATE] through [DATE] revealed that the Medical Director was in attendance and the topics discussed did not include anything COVID-19 related. The Quarterly, meeting minutes dated [DATE] revealed the Medical Director was in attendance and the topic discussed include 1 employee tested positive for COVID-19 and the facility initiated the outbreak protocol to include personal protective equipment (PPE) attire and how to don and doff as well as infection control practices. Review of Quality Assurance and Performance Improvement (QAPI), Quarterly, meeting minutes dated August through [DATE] revealed the Medical Director was in attendance and the topics discussed include in [DATE] the facility had four employees test positive for COVID-19 and 0 COVID-19 positive residents; in [DATE] the facility had four employees test positive for COVID and one resident (R#27) test positive for COVID-19; in October the facility had fifteen employees test positive for COVID-19 and nineteen residents test positive for COVID-19. An interview with Director of Nursing (DON) on [DATE] at 2:15 p.m. revealed she made the Quality Assurance Process Improvement (QAPI) Committee aware of the increase in COVID-19 positive residents in late [DATE]. She continued to state the facility had zero positive COVID cases in August, however there were four positive COVID-19 employee during the same month. The DON continued to state it was at this time infection control education for all employees began to include wearing a mask, PPE use, and the importance of social distancing. She further revealed that the Department of Public Health's (DPHs) involvement with process improvement through FaceTime and Zoom meetings to include where proper signage should be placed as well as individual bottles of hand sanitizers at each PPE station. The DON stated the QAPI Committee was involved in developing an action plan in [DATE]to include testing employees and residents twice a week, monitor hand hygiene, and continuing screening employees before entering the facility for signs and symptoms of COVID-19. A telephone interview on [DATE] at 3:00 p.m with Medical Director (MD) PP, revealed she is no longer the Medical Director for the facility. MD PP stated an addendum to the Medical Director contract was sent to the facility in [DATE] or [DATE]. MD PP revealed that MD QQ has been appointed Medical Director for the facility and MD RR, is the Medical Director over the Vent Unit and she works closely with both Physicians. She continued to state that she continues to attend the QAPI meetings at the facility as well as give input to policy and procedures affecting the facility and the residents. The facility was able to provide one staff education, dated [DATE], titled Face Shields On and 37 staff attended. The facility could not provide evidence that staff were tested twice weekly in [DATE], [DATE], [DATE] or [DATE]. Additionally, hand sanitizer was not readily available for staff on PPE carts with only one hand sanitizer station per hallway. Staff were observed going between residents on the Observation Unit who had been exposed to COVID-19 then caring for negative, un-exposed residents. Cross refer to F880

Based on observation, record review, interviews, and review of the facility policy Covid-19 Policy and Procedure (updated [DATE]), the facility failed to initiate appropriate infection control policies and, practices for a Covid-19 outbreak, and guidance as recommended by Center for Disease Control and Prevention (CDC), Center for Medicaid and Medicare Services (CMS), and the Georgia Department of Public Health (GDPH) to lessen the exposure of Covid-19. The facility failed to maintain an effective Infection Control Program evidenced by lack of documentation of testing of residents and staff consistently, according to outbreak testing guidelines from the CDC, failed to provide staff education for practices to decrease the spread of COVID-19, such as handwashing, cough etiquette, COVID updates, signs and symptoms of COVID-19, procedure for don/doff of personal protective equipment. The census was 53. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator, Assistant Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were notified on [DATE], at 12:00 p.m. of the Immediate Jeopardy. The Immediate Jeopardy is outlined as follows: 1. The facility failed to ensure an effective Infection Prevention Control Program (IPCP) was implemented and maintained that would investigate and identify an infection outbreak to prevent or reduce the spread of Covid-19 to residents and staff. 2. The facility failed to implement outbreak testing of residents and staff when a resident (R#27) tested positive for Covid-19 on [DATE]. 3. The facility failed to implement outbreak guidance of the Centers for Disease Control (CDC), Centers for Medicare/Medicaid Services (CMS) and the Georgia Department of Public Health (GDPH) for isolation, appropriate cohorting of residents, baseline testing of all staff and residents on [DATE] when a resident tested positive for Covid-19, failed to consistently test staff, and failed to provide evidence that unvaccinated staff were being tested per the community positivity/transmission rate since [DATE] to prevent or reduce the spread of Covid-19 to residents and staff. 4. The facility failed to have a Certified Infection Control Preventionist on staff, who was responsible for the Infection Control Program. 5. The facility failed to educate staff on the use of Personal Protective Equipment (PPE). 6. The facility failed to ensure that staff were trained and utilized the appropriate PPE throughout the facility once the Covid-19 outbreak was identified. 7. The facility was unable to provide documentation of ongoing facility-wide surveillance which included data collection, root-cause analysis, interpretation, and dissemination of surveillance information utilizing the tools identified in the facility's policy and procedure. 8. The facility failed to have an effective Quality Assurance Performance Improvement Plan (QA/PI) to address a Covid-19 outbreak. 9. The facility failed to ensure the Governing Body provided effective oversight to prevent or reduce the spread of Covid-19 infection. As a result of these failures 21 residents and 29 staff have tested positive for Covid-19. In addition, six Covid-19 positive residents (R#11, R#12, R#17, R#18, R#19, and R#21) were hospitalized due to Covid-19 as of [DATE], and two residents (Resident (R)#10 and R#12) died as a result of Covid-19. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2) Governing Body, F837; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867; 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control, F880; 42 CFR 483.80(b)(1)-(4)(c) Infection Preventionist Qualifications/role, F882; 42 CFR 483.80 (h)(1)-(6) -- Covid-19 Testing-Residents & Staff, F886. All IJ deficiencies were cited at a Scope and Severity (S/S) of L. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include: Review of the facility policy titled Chulio Hills Health and Rehabilitation Pandemic COVID-19 Plan, updated [DATE] revealed: Section 2: COVID-19 Surveillance and Detection 1. The facility has established a program for surveillance and detection of COVID-19 in resident's, facility staff, and visitors. Facility staff includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. 2. Heightened surveillance activities will be implemented to limit the transmission of COVID-19. These include, but are not limited to screening visitors, facility staff to include essential and non-essential health care personnel, and residents. 3. A screening protocol was developed to monitor for signs and symptoms of COVID-19 illnesses in residents, facility staff, and visitors. The screening tool(s) will be updated as needed per guidance from the CDC, GDPH, and CMS. a. Limited points of entry into the facility have been established where screening occurs of all facility staff, including essential and non-essential health care providers, and visitors as allowed-see section 7 of this policy regarding visitors and non-essential health care personnel. b. All facility staff are being screened prior to the beginning of each shift or if they are not an employee prior to entering the facility. If they have signs/symptoms, they are sent home- facility staff should have on mask-if none they will be given one. They will follow the guidelines established for testing, quarantine, and return to work. c. All residents will be actively screened for signs and symptoms of COVID-19, to include a full set of vital signs including SPO2 as follows: · Resident screening each shift for a minimum of three times a day for facilities in outbreak status or in Yellow or Red community status. · For facilities in GREEN community status and not in outbreak status, residents should be screened at least once per day. · d. Information from the monitoring systems will be used to implement prevention interventions, such as cohorting, implementing transmission-based precautions, and testing. e. If residents are identified with signs and symptoms of COVID-19: · The facility will follow the policy in section 5 resident cohorting Managing Symptomatic Residents. · They will be tested for COVID-19 (see COVID-19 testing/plan/policy) · They will be monitored for signs and symptoms of COVID-19, vital signs with oxygen saturation via pulse oximetry every 4 hours if positive for COVID-19 or until results of confirmatory negative PCR are obtained. · They will be listed on the Long Term Care Respiratory Surveillance Line List. 5. Screening for visitors a. Signs or symptoms of respiratory infection, such as fever, cough, shortness of breath, or sore throat or other symptoms of coronavirus (i.e. chills, muscle pain, headache, new loss of taste or smell, fatigue, congestion, or runny nose, nausea or vomiting, diarrhea). b. In the last 14 days, has had contact with someone with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . c. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Visitors will be denied entry into the facility if they exhibit any of the criteria listed above. They may be directed to the Infection Preventionist, Director of Nursing, or nurse manager on duty if they have any questions. (Note: Refer to Interim COVID-19 visitation policy for full restrictions.) Education and Training: 1. The Infection Preventionist is responsible for coordinating education on COVID-19 using resources from recognized resources such as the GDPH, CDC, WHO, AHCA, GHCA, our state trade association. b. Education and training of staff members regarding infection prevention and control precautions- to include signs and symptoms of COVID-19, how COVID-19 is transmitted, hand hygiene, transmission-based precautions- to include donning and doffing of PPE, as well as respiratory hygiene/ cough etiquette should be ongoing to prevent the spread of infections. c. Education and training should include the usage of language and reading-level appropriate, informational materials, such as brochures, posters on COVID-19. Pandemic and updated as information and guidance changes. d. Informational materials should be disseminated during the COVID-19 pandemic and updated as information and guidance changes. e. Staff has been trained and competency testing has been done for hand hygiene and donning and doffing of PPE. f. Orientation education on hand hygiene, and donning and doffing of PPE, and COVID-19 will be added or updated. Competencies will be administered as part of the orientation process. g. Ongoing compliance monitoring will be done for hand hygiene and donning and doffing of PPE. Infection Prevention and Control: 1. Implement Universal Source Control Measures at all times regardless of County positivity rates or vaccination status. Source Control refers to the use of cloth face coverings or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing or coughing. 2. Universal face shields (or goggles if unable to wear face shields) will be implemented if there is an outbreak in the facility (1 positive staff member or resident is considered an outbreak), or if the county positivity rate is in the yellow or red-see guidelines below. If the county positivity rates drop to green and is in the green for two weeks and the facility is not in an outbreak the staff may discontinue universal face shields. If the county positivity rate moves to yellow or red or upon a resident or staff member testing positive (this includes [MEDICATION(S)] test even if you are performing confirmatory testing) then the facility will resume universal face shield use regardless of vaccination status. Universal face shields will be used as described in A-G below. A. All visitors/vendors should ideally wear their own face covering upon arrival to the facility, and while in the facility or on the facility grounds. If they do not have a face covering, they should be offered a facemask. Facemask and cloth coverings should not be placed on young children under 2 years of age. All visitors participating in outdoor visits (other than window visits) or that enter the facility will be required to don a face shield. B. Residents should wear a cloth facemask, if tolerated, covering their nose and mouth throughout their stay at the facility as listed below: a. Residents should wear a cloth face covering or facemask (if tolerated) covering their nose and mouth whenever they leave their room, including for procedures outside the facility (e.g., medical appointments, [CONDITION(S)] etc.). b. Residents may remove their cloth facemask/covering when in their rooms but should put it back on when a visitor or staff member enters the room. c. Facemasks should not be placed on anyone who has difficulty breathing, unconscious, or incapacitated. d. Staff will apply cloth facemask on resident or assist with putting on cloth facemask or covering when a resident leaves their room or when in room providing care and/or services if the resident is unable to apply. If the resident can't tolerate a cloth covering, a tissue may be used to cover the resident's nose and mouth while providing care. C. All staff and other outside health care providers to wear a personal mask covering their nose and mouth upon arrival to the facility. The personal mask should be in place prior to exiting their vehicle or if arriving in another manner, upon entering the facility grounds. They will remove their personal mask and apply a well fitted facemask (or respirator N-95 or NIOSH approved equivalent) after completing screening prior to entering the building or in the designated donning area prior to entering resident care areas of the facility. D. All staff and outside health care providers will wear a well fitted face mask always covering their nose and mouth when in the facility or on the facility grounds including breakrooms, offices, and any spaces where they might encounter other co-worker. The following are exceptions: E. Facility employees may remove face shield and facemask in the breakroom or designated outside break areas, if eating or drinking, and if applicable outside while smoking (facemasks facility wide implemented [DATE]. F. All facility employees and health care providers should remove their face shield and respirator facemask, perform hand hygiene, and put on their cloth face covering when leaving the facility at the end of their shift. G. All staff (with the exception of dietary staff) will wear eye protection at all times, except when they are alone in their offices, or in a facility designated indoor or outdoor break and or eating area. Preferable face shields will be worn, but if unable to wear face shield, then goggles. Dietary staff will don a face shield prior to entering resident care areas or interactions with staff outside of the kitchen area. Staff may remove their face shield only if they are alone in their office or in a facility designate break (including designated smoke area) and or eating area. H. If there is a COVID outbreak (staff or resident) consider implementing universal use of N-95 or higher NIOSH approved respirator. 7. Other A. Alcohol Based hand rub will be available inside of each resident room, on the wall in hallways, and in common areas. If not possible due to supply chain issues individual, pump style or other ABHR delivery mechanisms will be available or placed on the halls in common areas for staff to use. Section 5: Resident Cohorting: 1. COVID-19 Positive Unit (for laboratory confirmed COVID positive residents only) D. The staff will don all required PPE before entering the unit. As part of our gown conversation strategy the same gown will be worn to care for multiple residents if the resident has no other epidemiologically significant organisms (e.g., [CONDITION(S)], CRE, VRE, C-diff, etc.). 3. Managing Exposed Residents includes but not limited to: D. The exposed residents will be placed on Transmission-based precautions for COVID-19 which includes use of a N-95 or higher respirator, face shield or goggles, gloves, and gown. A new gown must be used for each resident each time you enter the room. During the initial observation tour and interview on [DATE] at 10:00 a.m., the Administrator (ADM) revealed the facility is in an Outbreak with Coronavirus (Covid-19), and residents are in the COVID unit. The surveyors observed that the screening process, went into a zippered plastic unit, and through standard screening questions with temperature taken, and then given a face shield with an N-95 mask. The front desk clerk stated that regular staff screen at the current station, but COVID-19-unit staff self-screen at the COVID-19 unit. Observation on [DATE] at 10:15 a.m. revealed a Physical Therapist exiting the COVID-19 unit then entering the non-COVID-19 area of building. Observation on [DATE] at 10:45 a.m. revealed the Activities Director (AD) entered resident room [ROOM NUMBER], who was under isolation due to the resident's roommate being COVID-19 positive, then continued to 104 (semi-private room) who is not under isolation without changing mask in-between rooms. Further observation at this time revealed Certified Nursing Assistant (CNA) DD entering room [ROOM NUMBER] with residents under isolation for exposure for COVID-19 and then entered 204, who is not under isolation, without changing mask in-between rooms. Continued observation revealed that Licensed Practical Nurse (LPN) CC in room [ROOM NUMBER], who is under isolation due to COVID-19 positive roommate, then entered 104 without changing mask in-between rooms. The Registered Respiratory Therapist (RRT) FF was observed to entered room [ROOM NUMBER] which was under isolation due to exposure to COVID-19, then entered 205, who is not under isolation without changing mask between rooms. Observation on [DATE] at 11:30 a.m. revealed that hand sanitizer was not available on the PPE carts outside the observation rooms. One automatic hand sanitizer was observed per hall for the staff to utilize. Observation on [DATE] at 6:45 p.m., while leaving the facility, a family member outside the room of R#24, who tested positive for COVID-19 on [DATE], and was located on the COVID-19 unit was visiting the resident. The family member was not observed to be screened or tested at the entrance to the facility. The family member was not wearing a mask although the staff member was in full PPE. The staff member was observed to raise the window for the resident and family member to talk. The resident nor the family member were wearing a mask. Review of the Georgia Department of Health, Infection Control Assessment Report (ICAR) dated [DATE], [DATE] and [DATE] revealed Center for Disease Prevention, Staff Source Control recommends that staff working in the COVID-19 or Observation units should wear full COVID-19 Personal Protective Equipment (PPE) which includes NIOSH-approved N95 mask, gown, gloves and eye protection. The lack of full PPE or the movement of staff between the exposed and isolated residents was not documented on the Zoom ICAR with GDPH. Finding of the ICAR revealed on [DATE] and on [DATE] that staff were not changing their N95 mask between the observation residents. The ICAR additionally recognized on [DATE] inconsistencies in maintaining status of infection control and that staff are not changing their N95 mask between observation unit residents. An interview on [DATE] at 10:30 a.m. with Administrator (ADM) and the Corporate Nursing Officer (CNO) revealed the facility was currently in outbreak status with positive COVID-19. The ADM further revealed not having a line listing of positive residents or staff nor was there a tracking mechanism in place. The ADM was unable to provide evidence for either staff or resident that testing was being performed and that she keeps a list of positive residents on her personal calendar hanging on the wall in her office. She further revealed that only positive results are added to the resident's medical record. She confirmed that the facility did not have a tracking process for any positive staff or residents to ensure they would be placed back into the testing rotation after 90 days. She confirmed that the facility had two staff test positive in [DATE], two additional staff tested positive in [DATE], then four staff and one resident (R#27) in [DATE]. Then in [DATE] residents tested positive for COVID-19 and 17 staff members tested positive. An interview with Director of Nursing (DON) on [DATE] at 1:00 p.m. revealed that staff reports to testing site (salon) on Mondays and Thursdays. She stated the staff report for testing on an honor system, but she checks staff off on Human Resource (HR) staff roster, as they come through for testing. She further revealed that once testing is completed for that day, then the paperwork is stored in a box, although she does not follow-up to ensure that all staff has been tested . She has no explanation as to why there is no follow-up for staff not tested . An interview on [DATE] at 6:20 p.m. with ADM, revealed the facility does not document COVID-19 testing in medical record except for notification to family/responsible party (RP) when resident tests positive. She confirmed there is no documentation that tests were performed, or results of negative status documented. She further revealed that test results are not being uploaded into electronic medical record (EMR) and didn't feel like it was necessary to upload negative test results. Observation on [DATE] at 9:00 a.m., [DATE] at 10:00 a.m., [DATE] at 2:45 p.m., [DATE] at 1:00 p.m. and on [DATE] at 9:30 a.m. that hand sanitizer was not available on the PPE carts outside the observation rooms. An interview on [DATE] at 9:30 a.m. with ADM revealed the facility did not have a Certified Infection Control Preventionist (ICP) serving in that role for the facility since the previous ICP left on [DATE]. An interview on [DATE] at 11:45 a.m. with the Activity Director and LPN DD revealed that hand sanitizer is carried in the pockets to sanitize their hands prior to donning PPE and after doffing PPE although neither had hand sanitizer, at this time, in their pockets. An interview with the Director of Physical Therapy (PT) on [DATE] at 3:00 p.m. revealed that once staff enter the COVID-19 unit, they should not return to non-COVID-19 areas of the building. All needed supplies are available to treat residents on the COVID-19 unit, including walkers. She cannot explain why PT staff were seen leaving the COVID-19 unit then entering the non-COVID-19 unit. The Therapy staff are to take their personal belongings to their car prior to entering the COVID-19 unit then are instructed to leave for the day. An interview on [DATE] at 10:00 a.m. with the Infection Control Nurse (ICN) AA revealed that she assumed the role of ICN in [DATE] after the previous ICP left the faciity on [DATE]. She revealed starting the CDC ICP modules for training but had not completed them. She further revealed that many aspects of the ICP program was a challenge and had been reporting to the previous DON. The previous DON was on Family Medical Leave (FML) and handling the ICP program from home. She was reporting to the previous DON then awaiting instructions for how to manage the outbreak and if staff education should be done. It was her understanding that the previous DON was taking care of those areas in the facility. Review of the education sign-in sheet, dated [DATE], subject: face shields on, attended by 37 staff members was the only education provided to the staff prior to entry into the facility on [DATE]. Review of the line listing, for both residents and staff, provided by the CNO on [DATE] revealed that on [DATE] one CNA tested positive for COVID-19 and was symptomatic then one dietary staff tested positive on [DATE] and was symptomatic, although the last day of work was [DATE]. There was no evidence of outbreak testing at that time. Further review of the line listing revealed that on [DATE] one LPN and one CNA tested positive for COVID-19 and both were symptomatic. On [DATE] one LPN tested positive for COVID-19 without symptoms and her last day of work was [DATE]. There was no evidence that outbreak testing began. On [DATE], one CNA tested positive for COVID-19 without symptoms. On [DATE], one business office staff tested positive for COVID-19 and was symptomatic. On [DATE] one resident, R#27, tested positive for COVID-19, was symptomatic, and fully vaccinated in early 2021. On [DATE], one nurse tested positive for COVID-19 without symptoms. On [DATE] one dietary staff tested positive for COVID-19 and was symptomatic. On [DATE], [DATE], [DATE], [DATE] and [DATE] one staff person tested positive for COVID-19 each of these days. On [DATE], [DATE], [DATE] and [DATE] two staff persons tested positive for COVID-19 each of these days. On [DATE] three staff tested positive for COVID-19. On [DATE] two staff tested positive for COVID-19 and on [DATE] one staff person tested positive for COVID-19. Beginning on [DATE] through [DATE] 20 residents tested positive for COVID-19. The line listing was not consistent for when testing was negative. Record review revealed that R#27 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the five day, Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status of eight indicating moderate cognitive impairment. The resident was also assessed for extensive assessment for all ADL (Activities of Daily Living). Review of the facility positive line listing revealed the resident tested positive for COVID-19 on [DATE]. Review of the hospital records revealed the resident was hospitalized on [DATE] with a urinary tract infection ([CONDITION(S)]) and [CONDITION(S)]. An interview on [DATE] at 2:00 p.m. with ADM revealed she was aware of an outbreak beginning on [DATE], when two staff members were positive. She discussed with the previous DON about how we approach and handle the issue. The DON wanted to handle the nursing portion, although the ADM could not remember what this entailed. The ADM's action during the outbreak was to test for two weeks and if not other positive COVID-19 cases were identified then the facility was out of outbreak status. In [DATE], another outbreak began, and the ADM went back to the DON to find out where the facility should go from this point. The facility increased testing and began wearing face shields. The ADM realized a problem on [DATE], when a staff member and resident became positive. The resident was moved to the COVID unit, and the employee was taken out of work. The ADM stated the DON revealed she would start monitoring and do the contact tracing. The ADM shut down visitation on [DATE] and sent out automated notices to residents and resident representatives. Further actions taken by the ADM were walking around, making sure face shields were on employees, and talking to unit managers about monitoring residents for signs and symptoms of COVID-19. Record review revealed the facility began utilizing Monoclonal Antibodies (MAB) via subcutaneous injection on [DATE] for residents. Review of standing COVID-19 orders for both Dr. QQ and Dr. OO, without a date, revealed residents should be monitored every four hours and started on oxygen (O2) at 2 L (liters) per NC (nasal canula) for O2 saturation less than 90% and call for potential hospital transfer, Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), chest x-ray for all residents, if fevers greater than 100.4 will need rapid flu test, throat swap for Strep (if symptomatic), urine culture (if symptomatic). If resident unable to express symptoms, then get these test anyway, Vitamin C 500 milligrams (mg) by mouth (po) BID (twice daily) for 14 days, [MEDICATION(S)] 220 mg daily for 14 days, Vitamin D 2000 IU (international units) daily for 14 days, [MEDICATION(S)] 600 mg every 12 hours or [MEDICATION(S)] 100 mg BID PRN (as needed) for signs and symptoms (s/s) of cough/congestion, for any resident with O2 saturation less than 90% start [MEDICATION(S)] 6 mg, by mouth or IV (intravenous) as a single dose for 5 days. If [MEDICATION(S)] is not available then give [MEDICATION(S)] 40 mg PO as a single dose, daily for 5 days while the resident is considered for hospital transfer. If steroid needs to be administered notify MD (doctor)/NP (nurse practitioner) before administering, contact family for consent for Regeneron (MAB) injections through pharmacy if resident qualifies for injections. Review of the manufactures instructions for subcutaneous (SQ) injection of Regeneron (MAB) includes to clinically monitor patients after injections and observe patients for at least one hour. Record review for R#13 who received Regeneron SQ on [DATE], after testing positive for COVID-19 on [DATE], revealed no evidence that the resident was clinically monitored for one hour after receiving the MAB injections nor was there evidence the residents' vital signs were monitored every four hours. An interview with Unit Manager (UM) LL on [DATE] at 9:30 a.m. revealed that resident were placed on respiratory monitoring to include temperature checks every four hours once they become COVID-19 positive or have been exposed to COVID-19. She further confirmed that residents were not assessed for signs and symptoms prior to exposure, or a positive COVID-19 test. An interview on [DATE] at 4:00 p.m. with the Medical Doctor PP revealed that he expects the staff to obtain residents temperature and oxygen saturation prior to administration of MAB and to monitor the residents for one hour post administration, observing for signs/symptoms of adverse reaction. He further stated that the nurse should have [MEDICATION(S)] on hand for adverse reactions. He stated that the staff should be documenting the administration in the Nurse's Notes. An interview on [DATE] at 10:30 a.m. with Unit Manager (UM) revealed he does the consents for the Regeneron (MAB) and stated the only qualification for receiving Regeneron is if you have COVID-19. He further stated if a resident has any type of signs and symptoms the staff have an [MEDICATION(S)] pen on site to give as instructed by the Physicians. An interview on [DATE] at 2:57 p.m. with Medical Doctor QQ revealed that all residents over the age of [AGE] years are eligible for MAB therapy, if administered within 10 days of testing positive for COVID-19. He stated that the staff should be using the checklist from CMS (Center for Medicare/Medicaid Services) for criteria for administering MAB and that he would expect the checklist along with the consent to be scanned into the EMR. He further stated that nurses should stay with the resident for one full hour to observe for adverse reactions to the MAB. An interview on [DATE] at 2:50 p.m. with Chief Operating Officer (COO), a Governing Body member, revealed the staff who are responsible for decisions for the facility are the Chief Nursing Officer (CNO), the COO (himself), the ADM, and the DON. The Governing Body meets weekly by phone to discuss and support issues of reimbursement, COVID-19, and regulatory issues. Further discussion revealed that the COO, CNO, and the ADM met this morning by phone to discuss current issues in the facility. He was aware of the current outbreak in the facility but was not aware of the facility's lack of testing, hospitalization s, and deaths. The COO stated that the Governing Body assists the facility with COVID-19 by giving recommendations, jumping in when issues are identified, and having the CNO accessible. He stated that the responsibility of the ADM is to ensure the safety of each resident. Interview on [DATE] at 9:00 a.m. with COO, a Governing Body member, revealed he is not given QAPI minutes. The Administrator and CNO deal more directly with the facility. 1. Record review for R#10 revealed the resident was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was assessed as needing supervision/oversight by one person for all aspects of Activities of Daily Living (ADL) expect for eating and bathing and for walking in the room and corridor. Further record review revealed the resident had received the COVID-19 vaccine on [DATE] and [DATE]. The R#10 [NAME] [TRUNCATED]

Based on record review, review of facility policies Coronavirus (Covid-19) Policy and Procedure updated [DATE], Administrators Job Description, and staff interviews, the Administrator failed to ensure the facility followed Centers for Disease Control and Prevention (CDC), Center for Medicare and Medicaid Services (CMS), and Georgia Department of Public Health (GDPH) guidelines for outbreak testing, staff education for Personal Protective Equipment (PPE), failed to ensure adequate availability of hand sanitizer, and to include employment of a Certified Infection Control Preventionist (ICP), as of [DATE] when the previous ICP left the facility and to implement an effective IC program to decrease the spread of COVID-19. The census was 53. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator, Assistant Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were notified on [DATE], at 12:00 p.m. of the Immediate Jeopardy. The Immediate Jeopardy is outlined as follows: 1. The facility failed to ensure an effective Infection Prevention Control Program (IPCP) was implemented and maintained that would investigate and identify an infection outbreak to prevent or reduce the spread of Covid-19 to residents and staff. 2. The facility failed to implement outbreak testing of residents and staff when a resident (R#27) tested positive for Covid-19 on [DATE]. 3. The facility failed to implement outbreak guidance of the Centers for Disease Control (CDC), Centers for Medicare/Medicaid Services (CMS) and the Georgia Department of Public Health (GDPH) for isolation, appropriate cohorting of residents, baseline testing of all staff and residents on [DATE] when a resident tested positive for Covid-19, failed to consistently test staff, and failed to provide evidence that unvaccinated staff were being tested per the community positivity/transmission rate since [DATE] to prevent or reduce the spread of Covid-19 to residents and staff. 4. The facility failed to have a Certified Infection Control Preventionist on staff, who was responsible for the Infection Control Program. 5. The facility failed to educate staff on the use of Personal Protective Equipment (PPE). 6. The facility failed to ensure that staff were trained and utilized the appropriate PPE throughout the facility once the Covid-19 outbreak was identified. 7. The facility was unable to provide documentation of ongoing facility-wide surveillance which included data collection, root-cause analysis, interpretation, and dissemination of surveillance information utilizing the tools identified in the facility's policy and procedure. 8. The facility failed to have an effective Quality Assurance Performance Improvement Plan (QA/PI) to address a Covid-19 outbreak. 9. The facility failed to ensure the Governing Body provided effective oversight to prevent or reduce the spread of Covid-19 infection. As a result of these failures 21 residents and 29 staff have tested positive for Covid-19. In addition, six Covid-19 positive residents (R#11, R#12, R#17, R#18, R#19, and R#21) were hospitalized due to Covid-19 as of [DATE], and two residents (Resident (R)#10 and R#12) died as a result of Covid-19. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2) Governing Body, F837; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867; 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control, F880; 42 CFR 483.80(b)(1)-(4)(c) Infection Preventionist Qualifications/role, F882; 42 CFR 483.80 (h)(1)-(6) -- Covid-19 Testing-Residents & Staff, F886. All IJ deficiencies were cited at a Scope and Severity (S/S) of L. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include: Review of Job Description for the Administrator, dated 2003, revealed the purpose of your job position to direct day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. The Administrators Duties and Responsibilities: 1. Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board. 2. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. 3. Assist the Human Resources (HR) Director and department directors in the developing written job descriptions for each staff position. 4. Assist the HR Director and department directors in the development of performance-based job evaluations. 6. Assist department directors in the development, use, and implementation of departmental policies and procedures and procedures and professional standards of practice. 7. Review the facility's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations. 8. Interpret the facility's policies and procedures to employees, residents, family members, visitors, government agencies, etc., as necessary. 10. Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures. 11. Represent the facility at and participate in top-level meetings. 13. Make written and oral reports/recommendations to the governing board concerning the operation of the facility. 14. Assist the Infection Control Coordinator, and/or Committee, in identifying, evaluating, and classifying routine and job-related functions to ensure that task involving potential exposure to blood/body fluids are properly identified and recorded. 15. Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed. 18. Assist in providing survey team members with additional information during the survey that may aid in preventing deficiency citations. 22. Provide governing board with information relative to survey findings, plans of correction, monitoring guidelines, and follow-up survey results. 34. Assume the administrative authority, responsibility, and accountability of directing the activities and programs of the facility. Committee Functions: 1. Serves on various committees of the facility (i.e., Infection Control, Quality Assurance and Assessment, etc.) and provide written/oral reports of such committee meetings to the governing board as directed or as may become necessary. 2. Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. 3. Evaluate and implement recommendations from the facility's committee's as necessary. Personnel Functions: 4. Serve as a liaison to the governing board, medical staff, and other professional and supervisory staff. 5. Assist the Medical Director in the development and implementation of medical and nursing services policies and procedures and professional standards of practice. 6. Ensure that Physicians are in compliance with facility policies governing the admission, medical treatment, visit requirements, plan of care, orders, etc. Report problems areas to the Medical Director. 1. The Administrator failed to implement outbreak testing of residents and staff when a resident tested positive for Covid-19 on [DATE]. 2. The Administrator failed to ensure monitoring systems with feedback for data collection related to Infection Control, including Covid-19 outbreak testing logs, and failed to identify issues with outbreak testing for residents and staff. 3. The Administrator failed to have a Certified Infection Control Preventionist on staff, who was responsible for the Infection Control Program. 4. The Administrator failed to maintain a Quality Assurance/Performance Improvement (QAPI) committee that identified, developed, implemented, and analyzed the effectiveness of corrective action plans for residents in the facility related to infection control for Covid-19 An interview on [DATE] at 10:30 a.m. with the Administrator (ADM) revealed the facility did not have a line listing or tracking mechanism for negative or positive residents. There was no evidence to support that the facility had been testing staff and residents consistently according to the Community Transmission rate and/or County Positivity rate. The ADM revealed that she keeps a list of the positive residents on her personal calendar hanging on the wall in her office. She stated the medical records would not show test results for any residents who tested negative, only positive results. She stated that all results for staff and residents are placed in a box in her office for safekeeping. The ADM revealed she did not have a mechanism in place to put positive residents or staff back in rotation for testing after 90 days of becoming positive for COVID-19. Observation on [DATE] at 11:30 a.m. revealed that hand sanitizer was not available on the PPE carts outside the observation rooms. One automatic hand sanitizer was observed per hall for the staff to utilize. A line listing was created by Corporate Nurse on [DATE], after Surveyor inquiry, but the new facility line listing failed to identify six staff members who tested positive on [DATE]. An interview with the Director of Nursing (DON) on [DATE] at 1:00 p.m. revealed that staff reports to the testing site (salon) on Mondays and Thursdays although staff are on the honor system to be tested . The DON revealed that she checks staff names off on the HR roster when they come through for testing. She further stated that when testing is completed for that day, the paperwork is stored in a box and given to the ADM. The DON confirmed not checking to make certain all staff are tested and has no explanation as to why there is no follow-up for staff not tested . An interview with the ADM on [DATE] at 6:20 p.m. revealed the facility does not document COVID-19 testing in the medical record except for notification to family and family representatives when resident tests positive for COVID-19. She confirmed there is no documentation that tests were performed, or the results were documented. The ADM stated that test results are not being uploaded into the electronic medical record (EMR), and she felt like it was not necessary to upload negative test results. An interview with the ADM on [DATE] at 9:30 a.m. confirmed the facility does not have a Certified Infection Control Preventionist (ICP) serving in that role since the previous ICP left on [DATE]. Observation on [DATE] at 9:00 a.m., [DATE] at 10:00 a.m., [DATE] at 2:45 p.m., [DATE] at 1:00 p.m. and on [DATE] at 9:30 a.m. that hand sanitizer was not available on the PPE carts outside the observation rooms. An interview on [DATE] at 11:45 a.m. with the Activity Director and LPN DD revealed that hand sanitizer is carried in the pockets to sanitize their hands prior to donning PPE and after doffing PPE although neither had hand sanitizer, at this time, in their pockets. An interview with the ADM on [DATE] at 2:00 p.m. revealed that she was aware of an outbreak beginning on [DATE], when two staff members were symptomatic and tested positive for COVID-19. She worked with the previous DON on how we approach and handle the issue. The ADM's action during the outbreak was to test for two weeks and if no additional positive test were identified then the outbreak status would end. In August, another outbreak began, and the ADM work with the DON to find out where the facility should do at this point. The facility increased testing and began wearing face shields, although there was no evidence of the testing conducted during the [DATE] and [DATE] for either outbreak testing or routine testing. The ADM revealed that on [DATE] she realized they had a problem when a staff member and resident became positive for COVID-19. She stated there was concern and fear. The resident was moved to the COVID unit, and the employee was taken out of work. The ADM stated the DON revealed she would start monitoring and do the (contact) tracing. The ADM shut down visitation on [DATE]. She sent out voicemail notices to residents and the resident representatives. Further actions taken by the ADM were walking around, making sure employees were wearing face shields, and talking to unit managers about monitoring residents for signs and symptoms of COVID-19. The ADM revealed that the COVID-19 status was discussed during morning meetings. An interview with the Chief Operating Officer (COO) on [DATE] at 2:50 p.m. who is a member of the Governing Body revealed that the staff who make decisions for the facility include himself, the Corporate Nursing Office (CNO), ADM, and the DON. The COO further revealed that the Governing Body meets weekly by phone to discuss support issues, reimbursement, COVID-19, and regulatory issues. He confirmed being aware of the current outbreak in the facility but was not aware of the facility's lack of testing, hospitalization s, and deaths. The COO stated that the Governing Body assists the facility with COVID-19 by giving recommendations, jumping in when issues are identified, and having the CNO accessible. He revealed that the ADM is responsible for ensuring the safety of each resident. An interview on [DATE] at 9:00 a.m. with COO revealed he is not given QAPI minutes. The Administrator and CNO deal more directly with the facility. Cross refer 880

Based on record review, review of the facility policies titled Change in a Resident's Condition or Status, Documentation- Skilled Nurses Note and Documentation- Pertinent Charting, family and staff interviews, the facility failed to ensure resident clinical records were complete and accurate for two of eight sampled residents (R#1 and R#2). Specifically, the facility failed to: 1. Document a change in condition and document nursing and respiratory assessments, document the initiation of [MEDICAL CONDITION] (Biphasic Positive Airway Pressure) therapy for non-invasive ventilation secondary to respiratory distress, document [MEDICAL CONDITION] settings, and document re-assessments and/or monitoring of R #1. Actual harm occurred when at an undetermined time during the dayshift of [DATE], R#1 had acute respiratory distress with an oxygen saturation of 74% and was placed on [MEDICAL CONDITION] therapy as a means of non-invasive ventilation. R#1 was found unresponsive on [DATE] at 11:20 p.m. and pronounced deceased at 11:30 p.m. (Refer F281 and F328) 2. Document a change in condition, document a nursing assessment and document transfer to the hospital for R#2 on [DATE]. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio Hills Health and Rehabilitation beginning [DATE] and concluding on [DATE]. After review by the RO, a survey team re-entered on [DATE] through [DATE] to futher investigate the complaint and for a recertification survey. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. During the Recertification Survey conducted on [DATE] through [DATE] additional residents were reviewed for notification when a change of condition was noted. There were no additional issues identified for notification. The previous findings for R#1 were reviewed and the determination of immediate jeopardy were confirmed on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Findings include: Review of the undated facility policy titled Change in a Resident's Condition or Status documented: The Nurse Supervisor will notify the resident's attending physician when there is a significant change in the resident's physical, mental, or psychosocial status; or when there is a need to alter the resident's treatment significantly; or deemed necessary or appropriate in the best interest of the resident. The Nurse Supervisor will record in the resident's medical record any changes on the resident's medical condition or status. Review of the facility policy titled Documentation- Skilled Nurses Note revised ,[DATE] indicated A head to toe assessment will be completed each shift and documented on the Skilled Nurses Note for all New Admissions, Readmissions, Re-entries; and residents on Medicare. The Director of Nursing or designee may determine that a skilled nurse's note is needed for reasons other than those listed in the policy, this will be noted in the pertinent charting list. Review of the facility policy titled Documentation- Pertinent Charting revised [DATE] indicated Pertinent charting will be completed on a daily basis to ensure care is given when a resident has a new or changed condition. The list for pertinent charting will include, but not limited to; change in condition. Situations require documentation for 72 hours or longer if needed. This documentation will be completed each shift and will include full vital signs. The family will be notified when a resident is placed on the list. 1. Interview on [DATE] at 11:57 a.m. with the family of R#1 revealed she is the responsible party (RP) and the person that would be contacted for any changes in the resident. The RP stated that she did not receive a call from the facility until after R#1 expired late Saturday night on [DATE] and that the nurse did not have any details for her. The RP stated a couple of days later, she called the facility and spoke with someone else in charge and it was then that they told her that R#1 had declined that day and was having respiratory issues. The RP stated she was told that R#1's oxygen level dropped to 74% and they needed to put him on a [MEDICAL CONDITION] mask and when they checked on R#1 an hour later, he had passed away. R#1 was admitted to the facility on [DATE] from an acute care hospital with a [MEDICAL CONDITION] and tube feeding via PEG. [DIAGNOSES REDACTED]. On [DATE] the resident'[MEDICAL CONDITION] removed and on [DATE] the resident advanced to a puree diet, however, the PEG remained in place for the administration of medications. Record review for R#1 revealed no evidence of a skilled nursing assessment on [DATE]. Review of the Weights and Vitals Summary revealed no evidence on [DATE] of Sp02 results or vital signs (heart rate, respiratory rate, temperature or blood pressure) for R#1. There was no evidence of a Documentation- Pertinent Charting form or evidence that R#1 had been placed on the Pertinent Charting List. There was no evidence or documentation in the resident's clinical record of a Change in Condition Evaluation Assessment on [DATE]. Review of the Weights and Vitals Summary from [DATE] through [DATE] for R#1 documented Sp02 results ranging from ,[DATE]% and indicated that R#1 was on room air. There was no further documentation of vital signs or Sp02 results after [DATE]. Further record review for R#1 revealed no evidence or documentation on [DATE] of a respiratory assessment, when the resident presented with acute respiratory distress, when [MEDICAL CONDITION] therapy was initiated, documentation of the non-invasive protocols implemented related to determination of appropriate [MEDICAL CONDITION] settings or toleration of [MEDICAL CONDITION], oxygen saturation results, and re-assessments and/or monitoring of R#1 after being placed on [MEDICAL CONDITION]. Review of the electronic Physician Orders for [MEDICAL CONDITION] on [DATE] at 12:00 p.m., the day after R#1 had already expired. Further the [MEDICAL CONDITION] order did not specify the settings for IPAP (Inspiratory Positive Airway Pressure), EPAP (Expiratory Positive Airway Pressure) or an order for [REDACTED]. Further review of R#1's clinical record revealed the following Progress Notes: LPN AA created a Nurse's Note on [DATE] at 8:32 p.m. with an effective date and time of [DATE] at 10:17 a.m. which documented Resident coughing/spitting up thick greenish brown sputum. Mouth was suctioned out. Resident very sleepy. 02 sats 90% R[NAME] Gave all meds through feeding tube. Monitored resident throughout day. 02 sats started declining to 74. Resp. nurse informed, Dr. (name) NP called, [MEDICAL CONDITION] was ordered and placed on resident. Will continue to monitor resident. (sic) LPN CC created a Nurse's Note on [DATE] at 12:21 a.m. with an effective date and time of [DATE] at 12:00 a.m. which documented At approximately 11:20 p.m. I was making my rounds and when I went into resident room. I notice that resident was unresponsive and gray in color. Resident a DNR. I assessed resident by checking pulse and then proceeded to have the RN supervisor from the vent unit to confirm resident status. Next of kin was notified and funeral home of family choice was notified. (sic) There was no further documentation in the Progress Notes on [DATE] between the Nurse's Note that LPN AA created on [DATE] at 8:32 p.m. and the Nurse's Note created by LPN CC on [DATE] at 12:21 p.m. when R#1 was found unresponsive. Interview on [DATE] at 4:56 p.m. with the Director of Nursing (DON) revealed that R#1 was pronounced deceased at 11:30 p.m. on [DATE]. She stated the facility was aware that LPN AA did not document the resident's change of condition in the Change of Condition Evaluation Assessment pathway in the electronic charting system. The DON stated that in this section, documentation includes all pertinent information, notification of the Physician and if a resident is transferred to the hospital. Interview on [DATE] at 5:03 p.m. with the Licensed Practical Nurse (LPN AA) in care of R#1 revealed the morning of [DATE] on the dayshift (7:00 a.m. - 7:00 p.m.), R#1 seemed to be very depressed and staring out of the window. She stated the resident wasn't really lethargic but not himself. LPN AA stated around 2:00 p.m. - 3:00 p.m., the resident seemed sleepy and when she checked his oxygen saturation (Sp02), it was 74%. She stated that she placed the resident on oxygen at 2 LPM with a nasal cannula and there was no improvement. She stated she called the Respiratory Therapist (RT BB) and the Nurse Practitioner (NP GG) and received an order to place R#1 on [MEDICAL CONDITION] (Biphasic Positive Airway Pressure). LPN AA stated that RT BB place the resident on [MEDICAL CONDITION] but she did not remember the time. She stated she did make a notation at the end of her shift, but not a detailed notation. She stated she did not document a change of condition and she did not call the resident's RP. LPN AA further stated that she did not monitor or re-assess R#1 once he was placed on [MEDICAL CONDITION]. Interview on [DATE] at 5:17 p.m. with the Director of Nursing (DON) revealed she was on vacation when R#1 expired on [DATE] and returned to work on [DATE]. The DON stated she was made aware when she returned to work that the resident had respiratory distress and was placed on [MEDICAL CONDITION] over the weekend and aware that the nurse did not notify the family/responsible party of R#1's change in condition. The DON stated that she was aware that the resident's change of condition was not charted in the Change of Condition Evaluation Assessment in the electronic charting and that she educated the nursing staff. Telephone interview on [DATE] at 5:28 p.m. with the 7:00 p.m. - 7:00 a.m. LPN CC revealed the night of [DATE] she had received report from LPN AA that R#1 was placed on [MEDICAL CONDITION] due to respiratory distress. LPN CC stated she saw the resident first around 8:00 p.m. - 8:30 p.m. She stated she checked the resident's Sp02 and it was she believed 91%. LPN CC stated that she thought she had documented her assessment and the resident's Sp02 but she could not be sure without checking the computer. LPN CC stated that the next time she saw R#1 was about 10:30 p.m. and he seemed fine. LPN CC stated around 11:15 p.m. she checked on R#1 and he was not responsive. She called RN FF to come and check R#1 and it was determined the resident had expired. Interview [DATE] at 3:49 p.m. with the DON revealed the facility has a policy related to documentation of pertinent charting and stated that when a resident has a change in condition, they are placed on the pertinent charting list and it is kept at the nurse's station. She stated the residents vital signs are recorded on this list. The DON showed example of other residents on the list. The DON confirmed that R#1 was not on the pertinent charting list and should have been at the time he had a change in his condition. The DON stated that a Skilled Nursing Observation and Assessment should have been conducted and entered in the electronic charting system by both the dayshift LPN AA and the nightshift LPN CC. The DON confirmed there was no Skilled Nursing Observation/Assessment in the electronic charting for R#1 on [DATE]. Review of the Pronouncement of Death indicated the resident expired in the facility on [DATE]. Primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. 2. Review of the Hospital Transfers list provided by the facility on [DATE] at 10:38 a.m. revealed R#2 was transferred to the hospital on the evening shift of [DATE] for abnormal vital signs and high respiratory rate. R#2 was a [AGE] year old admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R#2 was admitted with a DNR (Do Not Resuscitate) order. Record review revealed a Discharge Minimum Data Set ((MDS) dated [DATE] with return anticipated. Review of the Progress Notes revealed the following: A Nurse's Note dated [DATE] at 12:54 a.m. created by LPN KK documented Noted decline in appetite. Did not eat supper, drank 25% of Boost, and very little Magic cup. Will continue to observe closely. A Nurse's Note dated [DATE] at 2:33 p.m. created by LPN LL documented Resident's POA (name) to facility with concerns. Requests medication options be explored. Dr. (name) notified and orders for [MEDICATION NAME] 7.5 mg received and entered in system. (POA name) notified. There is no evidence or documentation in the electronic charting system on [DATE] for a change in the resident's condition, skilled nursing assessment, or transfer to the hospital. Review of the electronic Physician Orders revealed no order to transfer R#2 to the hospital. Review of the Skilled Respiratory Assessment/Observation for R#2 dated [DATE] at 7:45 p.m. indicated the resident's heart rate was 102 and irregular and Sp02 was 97%. Unable to determine orientation. Mental Status- lethargic, confused, irregular RR (respiratory rate). Lung sounds clear but diminished in the right middle and bilateral lower lobes. Respiratory Character and Signs and Symptoms of Respiratory Distress- increases respiratory rate, possible Cheyne-Stokes. Oxygen at 2 LPM via nasal cannula. Review of the emergency transportation Patient Care report dated [DATE] indicated they arrived at the nursing facility 7:45 p.m. and departed at 8:10 p.m. The Narrative documented that Nursing staff advised patient's oxygen saturation and heart rate had not been consistent this date with heart rate dropping as low as 34. Patient was on oxygen via nasal cannula at 2 LPM. Patient was alert but unable to tell if patient oriented as patient could not answer questions and would just mumble. Patient was able to follow and appeared to have equal strength in hands and feet. Patient remained on oxygen via nasal cannula throughout transport at 2 LPM. Vitals obtained and monitored en route. 3-lead and 12-lead EKG obtained showing sinus rhythm with PACs. Patient heart rate were both irregular. Blood glucose obtained and noted to be 115. A Nurse's Note dated [DATE] at 4:13 p.m. created by LPN KK documented Resident expired at (name) Medical Center on [DATE]. Family picked up some of residents belongings. Orders discontinued and medications removed from medication cart. Review of the (name) Medical Center Death Summary dated [DATE] documented date of death [DATE]. Final Diagnosis: [REDACTED]. Interview on [DATE] at 11:25 a.m. with the DON revealed there should be a nurse progress note related to the R#2's change of condition on [DATE], when she was transferred to the hospital, a change of condition assessment and a hospital transfer form, all of which are documented in the electronic charting system. The DON reviewed the electronic charting for R#2 and confirmed that there was no nurse notes related to the residents change in condition, no Change of Condition Evaluation/Assessment documented and no physician order to transfer the resident to the hospital. The DON stated that there was an assessment by the respiratory therapist on [DATE] documented but that was all. The DON stated that notification to the Physician and responsible party is not documented in the respiratory assessments. The DON stated that based on the MDS, the resident was discharged to the hospital on [DATE] but there is no other way of knowing due to lack of documentation. Interview on [DATE] at 11:55 a.m. with the family/responsible party (RP) of R#2 revealed she really cannot remember the exact details on [DATE] or even if she was at the nursing home facility the day R#2 went to the hospital. RP stated that she was at the hospital on [DATE] with R#2 but really cannot remember any details, she stated her husband had recently passed and she just had been through a lot. Interview in [DATE] at 12:04 p.m. with Nurse Practitioner (NP YY) revealed she remembered seeing R#2 a couple days prior to her passing and that the resident had some decline related to dementia and weight loss secondary to her dementia. She stated that she cannot remember ever receiving a call about the resident's change of condition or ordering the resident to be transferred to the hospital. NP YY stated that she could call the attending Physician for R#2 but he is on vacation and he probably would not remember. Interview on [DATE] at 12:27 p.m. with attending Physician (Medical Director) for R#2 revealed that he does not remember the exact clinical situation or R#2 as it was three months ago. He stated he cannot say if the facility called him about a change of condition but that he does not recall being called about anything serious that sticks in his mind. He stated he does remember she was in the hospital. He stated he gets calls all the time form the facility, they are good about calling him for everything. Interview on [DATE] at 1:25 p.m. with the family of R#2 she could tell exactly what happened on [DATE] because she was there. She stated she visited R#2 on a regular basis. She stated when she came to the facility around 6:00 p.m. or 6:30 p.m. there were two Certified Nursing Assistants (CNA) in the room changing R#2's brief. She stated when they finished she noticed that R#2 was not communicating with her and her breathing was not right. She stated that R#2 would breathe really fast, then almost stop breathing or so shallow she could hardly tell, then she would start breathing fast again. Family T stated she asked to the CNA (did not know name) to please go get the nurse. She stated that she could not remember the name of the nurse but thought it was a head nurse. The family stated the nurse listened to the R#2's lungs and told her that she agreed and said something was wrong. She stated R#2 was transported to the hospital she thinks it was around 8:00 p.m. Interview on [DATE] at 2:10 p.m. with the Registered Nurse Weekend Supervisor (RN MM) revealed she worked the dayshift (7:00 a.m. - 7:00 p.m.) on [DATE]. She stated that it was at the end of her shift when the family T of R#2 was standing in the hall so she asked if the family needed something. The family T asked her if she would check on R#2. RN MM stated that the R#2 was breathing irregularly and she put a pulse oximeter on the resident. She stated the resident's heart rate was erratic and her oxygen saturation would drop low then come back up. RN MM stated she called the respiratory therapist and he placed R#2 on oxygen. RN MM She stated she reported to LPN LL, the nurse in care of R#2, that she was having problems and she needed to go and assess R#2. RN MM stated that she left and LPN LL took over. RN MM stated she was under the impression that LPN LL was her assigned nurse and would have documented an assessment and change of condition in the resident's clinical chart. RN MM stated that her shift was over and she left the building. Review of the 24 Hour Report/Change of Condition Report provided by the DON on [DATE] at 2:50 p.m. documented in Remarks- (name of Medical Center) [MEDICAL CONDITION]/[MEDICAL CONDITION], per family request. During interview at this time with the DON, she stated that the report is for internal use, it is not a part of the resident record, but shows that LPN LL filled in the report for R#2. Interview on [DATE] at 2:58 p.m. with LPN LL revealed she did not remember the incident on [DATE] with R#2 and did not remember RN MM coming to her to tell her R#2 was having respiratory complications. She stated it was a while ago and she just cannot remember the incident but if RN MM stated that is what happened, then that is what happened. LPN MM stated that in the event of a change in a resident's condition, she would be expected to document a skilled nurse's notes and complete a change of condition evaluation and notify the MD and the RP. 3. R#135 was admitted to the facility from her home on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] at 10:40 p.m. her PEG tube was noted to be causing concern to the family members and the family thought it was protruding from her abdomen more than usual. The Physician was notified on [DATE] at 10:45 p.m. An X Ray was ordered but could not be completed due to inclement weather. Transfer to the local hospital was ordered. On [DATE] at 11:15 p.m. the family was notified of the transfer and refused. On [DATE] at 2:30 a.m. the family decided the resident was to be transferred and the resident was sent to the hospital of the family's choice. Review of the medical record for R#135 revealed the resident was monitored and documented in the resident's medical record. 4. R#18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:00 a.m. he began to have [MEDICAL CONDITION] activity. The Physician was notified at 11:18 a.m. The Respiratory Therapist was notified at 11:30 a.m. when oxygen saturations began to drop. The family was notified at 11:42 a.m. The Physician was again called at 12:15 p.m. and the resident was transferred to the hospital. The family and DON were notified at 12:05 p.m. Review of the medical record for R#135 revealed the resident was monitored and documented in the resident's medical record. 5. R#120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Respiratory Therapist was in the room and continued to work with the resident and at 10:10 a.m. the Nurse Practitioner was notified the resident was not improving and ordered R#120 transferred to the hospital. The family had been notified at 9:45 a.m. The Nurse Manager was notified at 10:20 a.m. as the resident was transferred. Review of the medical record for R#135 revealed the resident was monitored and documented in the resident's medical record. An interview with the Director of RT on [DATE] at 11:04 a.m. revealed that after the incident with R#1 and after the initial survey team entered the building on [DATE], that she reviewed the policies and had made changes for resident in respiratory distress. She confirmed that the previous policy did not include continuous monitoring of SaO2 after initating treatment for [REDACTED]. Interview of the DON and the ADON on [DATE] at 2:00 p.m. revealed that after the complaint investigation regarding R#1, they recognized that staff had not documented monitoring, interventions or the status for R#1 and R#2 and this should have been done. The staff has been in-serviced since the complaint investigation exit on [DATE] related to documentation of a change in condition, status, monitoring and notification of the Physician/NP and the family. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Pertinent Charting Policy was revised on [DATE] to include completion of a Nursing Skilled Observation/Assessment Note every shift for 72 hours following a change in condition. This has been added to the Licensed Nursing Orientation as of [DATE]. 2. ,[DATE] of Nurses will be educated by the Unit Manager on the revised pertinent charting policy beginning [DATE]. 18 of 34 nurses were in-serviced at the facility and ,[DATE] were in-serviced by telephone. The remaining 2 will be in-serviced prior to their next scheduled shift. 3. New policies and procedures developed by DON, Dir. of Respiratory Therapy, CNO for Corp Office, and Medical Director: 24-hour Respiratory Report; Respiratory Assessment /Intervention for Non-¿ Respiratory Caseload Patients; Respiratory Pertinent Charting on [DATE]. 4. The policy for Non-Invasive Ventilation was revised by DON, Dir. Of Respiratory Therapy, CNO for Corp Office, and Medical Director and ,[DATE] of respiratory therapists were educated on the revised policy by the Director of Respiratory Therapy on [DATE]. ,[DATE] respiratory therapists were educated via telephone, ,[DATE] in facility. They were also reviewed again at the facility in-service on [DATE] and ,[DATE] attended. 5. New policies and procedures: 24-hour Respiratory Report; Respiratory Assessment/Intervention for Non-Respiratory Caseload Patients; Respiratory Pertinent Charting, added to orientation for Respiratory Therapists on [DATE]. There have been no new respiratory therapists hired since [DATE]. 6. Revised policy for Non-Invasive Ventilation was added to orientation for Respiratory Therapists on [DATE]. There have been no new respiratory therapists hired since [DATE]. 7. Six of six respiratory therapists were educated on documentation expectations of assessments/progress notes, entering complete orders, and signing off the RAR by the Director of Respiratory Therapy on ,[DATE] /17 ,[DATE] were in-serviced in facility. 8. 30 of 30 of nursing staff has been educated that they must observe/assess the resident when there is a change in condition, and that this assessment is to be documented in thee-interact Change in Condition Evaluation, that follow-up monitoring, re-assessment, transfer to the hospital, and any follow up communication with the family, and or responsible party will be documented in the nursing progress notes on [DATE] by the DON. In-service conducted on [DATE] by DON 22 of 30 nurses were in¿ serviced, any nurses who did not attend were educated via telephone on [DATE] 8 of 30 were in¿ serviced via telephone. 9. An audit was conducted for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that did not have a change in condition evaluation, transfer form, order for trans fer, notes documenting follow up, or change of condition documented on the 24-hour report, and if respiratory change in condition was respiratory assessment documented. There will be a QA meeting on [DATE] to review the findings. 10. Guidelines for notification of the nurse manager on call were developed on [DATE] by the CNO for Reliable Health Care Management, they include use of the Interact change in condition cards- if the resident meets the criteria for immediate notification or has a critical lab not covered by the change in condition cards and a nurse manager is not in the building or it is the weekend nurse manager on call will be notified. These have been submitted to the Quality Assurance Committee and added to the Licensed Nursing Orientation on ,[DATE] /17. 11. Review and follow-up guidelines for a change in condition for the nurse manager on call to follow were developed on [DATE] by the CNO for Reliable Health Care Management to include notification of the responsible party, MD or NP on call, a nurse manager or RN weekend supervisor if she/he is in the building on the weekend, and the on-call nurse if after hours or on the weekend, completion of the Interact Change of Condition Form and use of the Interact Clinical Pathways if applicable. The Review and follow-up guidelines have been submitted to the Quality Assurance Committee and added to Licensed Nursing Orientation on [DATE]. 12. 6 of 6 of the nurse managers were educated on the Guidelines for notification, their responsibilities while on call related to the review and follow up guidelines and documentation on the Nurse Manager On-Call Log. This education was done by the DON on [DATE], 6 out 6 nurse managers attended and were in-serviced. 13. 30 of 30 of nurses were educated by the DON on [DATE] regarding the guidelines for notification of the nurse manager in the building and the on-call nurse after hours and on weekends and the review and follow-up guidelines for a change in condition. In-service conducted on [DATE] by DON 22 of 30 nurses were in-serviced any nurses who did not attend were educated via telephone on [DATE], 8 of 30 were in-serviced via telephone. 14. A Change in Condition audit tool developed on [DATE] by the CNO for Reliable Health Care Management to ensure that the guidelines for notifying a nurse manage in the building, the on-call nurse after hours and weekends, as well as the RN supervisor on the weekend and that the guidelines for review and follow up for a change in condition are being followed. The audit tool will be completed weekly for 5 residents experiencing a change in condition, if there are changes in condition related to acute respiratory changes up to 2 of these will be included. This audit will be completed by the DON, if she is not available to complete the audit then it will be done by the ADON. 15. The CNO will in-service the DON, ADON, Director of Respiratory Services, and Administrator on completion of the Change in Condition Audit on [DATE], 4 out of 4 were present and in-serviced via conference call on [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. The Pertinent Charting Policy revised on [DATE] was reviewed. A pertinent daily charting list will be maintained at the nursing station. The list for pertinent charting will include Residents with a change of condition and will include a Skilled Nursing Note on all shifts. This requires documentation for a minimum of 72 hours. Nursing Management may determine that assessment/documentation is indicated for longer than the timeframe listed, but not less. This documentation will be completed on each shift and will include full vital signs. Rosters and education content were reviewed. The education roster from [DATE] including revision to the policy for pertinent charting, including a Skilled Nursing Note on all shifts, with required documentation for 72 hours, including full vital signs, was signed by twenty of thirty-four nurses, and the roster indicated fourteen were educated by telephone. See below interviews of nursing staff verifying this education. 2. Review of the education content and rosters for education conducted for Respiratory Therapists revealed education was given on [DATE] for new policies regarding completion of the 24-hour Respiratory Report, Respiratory Assessment and Interve

Based on record review, review of the facility policy titled Change in a Resident's Condition or Status, family and staff interviews, the facility failed to ensure notification of a change in a resident's status was appropriately made for one of eight sampled residents (R#1). Specifically, the facility failed to notify the family/responsible party of R#1 that he had acute respiratory distress during the dayshift on [DATE] and required non-invasive ventilation. The family/responsible party of R#1 was not notified until [DATE] at 11:35 p.m. after R#1 had expired. Additionally, the facility failed to notify the Nurse Practitioner after R#1 was placed on non-invasive ventilation to provide an update of the resident's status and failed to notify the Registered Nurse (RN) Weekend Supervisor that the resident had a change in his condition. This failure resulted in actual harm for R#1 when at an undetermined time on the dayshift of [DATE], R#1 had a change in condition related to respiratory distress with an oxygen saturation (Sp02) of 74% and required non-invasive ventilation via [MEDICAL CONDITION] (Biphasic Positive Airway Pressure). Due to the lack of notification related to the resident's change in condition/status to the responsible party, Nurse Practitioner and RN Weekend Supervisor, the facility was unable to make a collaborative determination for possible further treatment and/or need for hospitalization . R#1 was found unresponsive on [DATE] at 11:20 p.m. and pronounced deceased at 11:30 p.m. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio Hills Health and Rehabilitation beginning [DATE] and concluding on [DATE]. After review by the RO, a survey team re-entered on [DATE] through [DATE] to futher investigate the complaint and for a recertification survey. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents specifically for R#1 when at an undetermined time on the dayshift of [DATE], R#1 had a change in condition related to respiratory distress with an oxygen saturation (Sp02) of 74% and required non-invasive ventilation via [MEDICAL CONDITION] (Biphasic Positive Airway Pressure). Due to the lack of notification related to the resident's change in condition/status to the responsible party, Nurse Practitioner and RN Weekend Supervisor, the facility was unable to make a collaborative determination for possible further treatment and/or need for hospitalization . R#1 was found unresponsive on [DATE] at 11:20 p.m. and pronounced deceased at 11:30 p.m Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. During the Recertification Survey conducted on [DATE] through [DATE] additional residents were reviewed for notification when a change of condition was noted. There were no additional issues identified for notification. The previous findings for R#1 were reviewed and the determination of immediate jeopardy were confirmed on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Refer F281 and F328 Findings include: Review of the undated policy titled Change in a Resident's Condition or Status documented: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's condition and/or status. Unless otherwise instructed by the resident, the nurse supervisor will notify the resident's next of kin or representative (sponsor) when: there is a significant change in the resident's physical, mental or psychosocial status. Except for medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's condition or status. The Nurse Supervisor will notify the resident's attending physician when there is a significant change in the resident's physical, mental, or psychosocial status; or when there is a need to alter the resident's treatment significantly; or deemed necessary or appropriate in the best interest of the resident. 1. Interview on [DATE] at 11:57 a.m. with the family of R#1 revealed she is the responsible party (RP) for R#1 and the person that would be contacted for any changes in the resident. The RP stated that she did not receive a call from the facility until after R#1 expired late Saturday on [DATE] and that the nurse did not have any details for her. The RP stated a couple of days later, she called the facility and spoke with someone else in charge and it was then that they told her that R#1 had declined that day and was having respiratory issues. The RP stated she was told that R#1's oxygen level dropped to 74% and they needed to put him on a [MEDICAL CONDITION] mask and when they checked on R#1 an hour later, he had passes away. The RP stated that she did not understand why they did not call her sooner or why R#1 was not sent to the hospital if he was having breathing problems all day. R#1 was admitted to the facility on [DATE] from an acute care hospital with a [MEDICAL CONDITION] and tube feeding via percutaneous endoscopic gastrostomy (PEG). [DIAGNOSES REDACTED]. On [DATE] the resident'[MEDICAL CONDITION] removed and on [DATE] the resident advanced to a puree diet, however, the PEG remained in place for the administration of medications. Review of the Admissions Packet revealed's family member was the RP for R#1. The RP signed the Treatment Consent on [DATE]. The RP signed the Do Not Resuscitate Order for Resident without Decision Making Capacity on [DATE] and was signed by two physicians on [DATE] and [DATE]. Review of the care plan for R#1 initiated on [DATE] identified that the resident had an Advanced Directive: DNR- Do Not Resuscitate with an intervention that indicated If skilled nursing is unable to meet the care needs, review with MD, family, and resident for possible need to hospitalize. Review of the clinical record for R#1 revealed the following Progress Notes: Licensed Practical Nurse (LPN AA) created a Nurse's Note on [DATE] at 8:32 p.m. with an effective date and time of [DATE] at 10:17 a.m. which documented Resident coughing/spitting up thick greenish brown sputum. Mouth was suctioned out. Resident very sleepy. 02 sats 90% room air (RA). Gave all meds through feeding tube. Monitored resident throughout day. 02 sats started declining to 74. Resp. nurse informed, Dr. (name) NP called, [MEDICAL CONDITION] was ordered and placed on resident. Will continue to monitor resident. (sic) LPN CC created a Nurse's Note on [DATE] at 12:21 a.m. with an effective date and time of [DATE] at 12:00 a.m. which documented At approximately 11:20 p.m. I was making my rounds and when I went into resident room. I notice that resident was unresponsive and gray in color. Resident a DNR. I assessed resident by checking pulse and then proceeded to have the RN supervisor from the vent unit to confirm resident status. Next of kin was notified and funeral home of family choice was notified. (sic) Registered Nurse (RN FF) created a Nurse's Note on [DATE] at 12:43 a.m. with an effective date and time of [DATE] at 11:25 p.m. which documented Called to resident's room by charge nurse. Resident was found to be non-responsive, pallid, and apneic. Apical pulse was auscultated and carotid pulse palpated simultaneously one full minute without results. Death was pronounce at 11:30 PM. Dr. (name) notified. (sic) RN FF created a Nurse's Note dated [DATE] at 12:48 a.m. with an effective date and time of [DATE] at 11:35 p.m. on [DATE] which documented Responsible party (RP), (name), notified of resident's expiration via telephone. (Name) stated she was out of town and could not come. She also stated that she would like for resident to be sent to (name) Funeral Home in Tallapoosa, G[NAME] (Name) expressed appreciation for the notification. (sic) Interview on [DATE] at 4:19 p.m. with the Respiratory Therapist (RT) BB revealed that he had not notified the family of R#1 on [DATE] related to his change in condition and that the nursing staff is responsible for notifying family of a change in a resident's condition. Further interview on [DATE] at 4:50 p.m. with RT BB revealed that he had another resident on a ventilator that was going bad at the same time that R#1 was having respiratory distress and the nurse (LPN AA) handled the situation and called the Nurse Practitioner. He said the LPN AA called him and reported that NP GG ordered [MEDICAL CONDITION]. He stated that he had set the resident up on [MEDICAL CONDITION] he thought around 4:45 p.m. RT BB stated he did check R#1 around 6:00 p.m. and his Sp02 was in the 90's but stated that he was unable to find any documentation of his assessments or when he initiated [MEDICAL CONDITION] therapy for R#1 in the electronic charting system. Interview on [DATE] at 5:17 p.m. with the Director of Nursing (DON) revealed she was on vacation when R#1 expired on [DATE] and returned to work on [DATE]. The DON stated she was made aware when she returned to work that the resident had respiratory distress and was placed on [MEDICAL CONDITION] and aware that the nurse did not notify the family/responsible party of R#1's change in condition. She stated the RP had called her on Monday [DATE] and wanted to know what happened to R#1. The RP had reported to her that no one had called her until after R#1 had already passed away. The DON stated the nurse should have called the RP when R#1's condition changed. The DON stated that typically the respiratory therapist would report a resident's respiratory status to the nurse and the nurse would report that status to the Physician. The DON further stated she educated the nursing staff on documenting in the e-Interact Tool- Change in Condition Evaluation Assessment pathway in the electronic charting system and notifying family in the event of a change in condition. Interview on [DATE] at 5:03 p.m. with the Licensed Practical Nurse (LPN AA) in care of R#1 revealed the morning of [DATE] on the dayshift (7:00 a.m. - 7:00 p.m.). She stated R#1 seemed to be very depressed and staring out of the window. She stated the resident wasn't really lethargic but not himself. LPN AA stated around 2:00 p.m. - 3:00 p.m., the resident seemed sleepy and when she checked his oxygen saturation (Sp02), it was 74%. She stated that she placed the resident on oxygen at 2 liters per minute (LPM) with a nasal cannula and there was no improvement. She stated she called the Respiratory Therapist (RT BB) and the Nurse Practitioner (NP GG) and received an order to place R#1 on [MEDICAL CONDITION] (Biphasic Positive Airway Pressure). LPN AA stated that RT BB placed the resident on [MEDICAL CONDITION] but she did not remember the time. She stated she did make a notation at the end of her shift, but not a detailed notation. She stated she did not document a change of condition and she did not call the resident's RP. LPN AA further stated that she never returned to re-assess the resident and had not seen the resident again after he was placed on [MEDICAL CONDITION]. She stated she had no good answer for why she did not re-assess or monitor the resident, It gets busy at the end of the shift but I know that is not a good excuse. Interview on [DATE] at 2:08 p.m. with the Nurse Practitioner (NP GG) revealed she was covering for the attending physician of R#1 on [DATE] while he was out of town. NP GG stated a nurse had called her one time on [DATE]. She stated it was reported to her that the residents C02 (carbon [MEDICATION NAME]) was elevated and his oxygen saturation was low. She stated that she ordered [MEDICAL CONDITION] with the agreed decision to see how he would do on [MEDICAL CONDITION] first, but she never heard back from anyone at the facility. NP GG stated she cannot remember exactly what time she received the call but she believed that it was in the morning sometime. NP GG further stated that she does not document the calls she receives and that the nurses' are responsible for documenting a change of condition, the time of the change of condition and that she had been notified. NP GG stated that she did not order a chest x-ray because she wanted to see how R#1 would respond to the [MEDICAL CONDITION] first. She stated the [MEDICAL CONDITION] was ordered as noninvasive ventilation secondary to respiratory distress. She stated if the resident continued to decline, she would have ordered a chest x-ray and possible antibiotics for potential aspiration pneumonia and that would have been verified by chest x-ray, however, no one ever called her back about the resident's condition. Interview on [DATE] at 4:14 p.m. with the Registered Nurse Weekend Supervisor (RN HH) revealed she was working on [DATE] covering for the regular RN weekend supervisor. She stated neither the nurse nor respiratory therapist in care of R#1 reported to her that he was having respiratory complications. RN HH stated she did not know that R#1 had a change in condition or expired until the Corporate Nurse called her during the complaint survey and wanted to know if she knew what happened. RN HH stated that the nurse caring for R#1 should have informed her of the situation. She stated she would have helped assess R#1 and that she would have pushed for the resident to be sent to the hospital in his condition. Review of the Pronouncement of Death indicated the resident expired in the facility on [DATE]. Primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. 2. R#135 was admitted to the facility from her home on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] at 10:40 p.m. her percutaneous endoscopic gastrostomy (PEG) tube was noted to be causing concern to the family members and the family thought it was protruding from her abdomen more than usual. The Physician was notified on [DATE] at 10:45 p.m. An X Ray was ordered but could not be completed due to inclement weather. The Physician was notified and a transfer to the local hospital was ordered. On [DATE] at 11:15 p.m. the family was notified of the transfer and refused. On [DATE] at 2:30 a.m. the family decided the resident was to be transferred and the resident was sent to the hospital of the family's choice. 3. R#18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:00 a.m. he began to have [MEDICAL CONDITION] activity. The Physician was notified at 11:18 a.m. The Respiratory Therapist was notified at 11:30 a.m. when oxygen saturations began to drop. The family was notified at 11:42 a.m. The Physician was called, again, at 12:15 p.m. and the resident was transferred to the hospital. The family and DON were notified at 12:05 p.m. 4. R#120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Respiratory Therapist was in the room and continued to work with the resident and at 10:10 a.m. the Nurse Practitioner was notified the resident was not improving and ordered R#120 transferred to the hospital. The family had been notified at 9:45 a.m. The Nurse Manager was notified at 10:20 a.m. as the resident was transferred. An interview on [DATE] at 11:04 a.m. with Respiratory Director revealed that since the incident occurred with R#1, the facility has reviewed the notification policy for Physician's and family, and staff is aware to follow up with the Physician or the Physician extender if the resident is not improving. The Respiratory staff is notified should a resident have respiratory issues to ensure that the resident is monitored and that the notification occurs. She confirms that R#18, R#120 and R#135 were monitored closely by Respiratory staff and the Physician was notified, timely, should the resident's condition not improve. The facility implemented the following actions to remove the Immediate Jeopardy: 1. An audit was conducted for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that the MD/NP, and/other responsible party were not notified of a change in condition- Audit to be completed on [DATE]. 2. There will be a QA meeting on [DATE] to review the findings. 3. 30 of 30 of nurses have been educated that the responsible party, MD or NP on call, a nurse manager or RN weekend supervisor if she/he is in the building on the weekend, and the on-call nurse if after hours or on the weekend is to be notified if there is a change in condition. If the change in condition is an acute respiratory change the Respiratory Therapist will be notified. In-service conducted on [DATE] by DON 22 of 30 nurses were in-serviced, any nurses who did not attend were educated via telephone on [DATE] 8 of 30 were in-serviced via telephone. 4. Guidelines for notification of the nurse manager on call were developed on [DATE] by the Chief Nursing Officer(CNO) for Reliable Health Care Management, they include use of the Interact change in condition cards- if the resident meets the criteria for immediate notification or has a critical lab not covered by the change in condition cards and a nurse manager is not in the building or it is the weekend the nurse manager on call will be notified. The nurse manager will log this on the Nurse Manager On¿ Call Log. The DON or ADON will obtain this log for verification and follow through of process the next business day. These have been submitted to the Quality Assurance Committee and added to the Licensed Nursing Orientation [DATE]. Review and follow-up guidelines for a change in condition for the nurse manager on call to follow were developed on ,[DATE] /17 by the CNO for Reliable Health Care Management to include notification of the responsible party, MD or NP on call, a nurse manager or RN weekend supervisor if she/he is in the building on the weekend, and the on-call nurse if after hours or on the weekend, completion of the Interact Change of Condition Form and use of the Interact Clinical Pathways if applicable. The Review and follow-up guidelines have been submitted to the Quality Assurance Committee and added to licensed Nursing Orientation [DATE] no one will be allowed to work until completion of in service. 5. 6 of 6 of the nurse managers were educated on the Guidelines for notification, their responsibilities while on call related to the review and follow up guidelines and documentation on the Nurse Manager On Call Log. This education was done by the DON on [DATE] nurse managers attended and were in¿ serviced. 6. 30 of 30 nurses were educated by the DON on [DATE] regarding the guidelines for notification of the nurse manager in the building and the on-call nurse after hours and on weekends and the review and follow-up guidelines for a change in condition. In-service conducted on [DATE] by DON 22 of 30 nurses were in-serviced, any nurses who did not attend were educated via telephone on [DATE] 8 of 30 were in-serviced via telephone. 7. A Change in Condition audit tool developed on [DATE] by the CNO for Reliable Health Care Management to ensure that the guidelines for notifying a nurse manage in the building, the on-call nurse after hours and weekends, as well as the RN supervisor on the weekend and that the guidelines for review and follow up for a change in condition are being followed. The audit tool will be completed weekly for 5 residents experiencing a change in condition, if there are changes in condition related to acute respiratory changes up to 2 of these will be included. This audit will be completed by the DON, if she is not available to complete the audit then it will be done by the ADON. 8. The CNO will in-service the DON, ADON, Director of Respiratory Services, and Administrator on completion of the Change in Condition Audit on [DATE]. 4 out of 4 were present and in-serviced via conference call on [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. Review of audit including fifty-seven resident records with change in condition requiring transfer to the hospital, between [DATE] through [DATE] revealed thirteen records missing documentation of Physician notification, and seventeen records were missing documented notification of responsible party. The audit was completed on [DATE]. 2. The QA meeting held [DATE] sign in roster and minutes were reviewed. The audit review for fifty-seven resident records with thirteen records missing documentation of Physician notification, and seventeen records were missing documented notification of responsible party was discussed and nineteen signatures were included on the roster. Interview [DATE] at 4:30 p.m. with Corporate Chief Nursing Officer revealed during the QA meeting held [DATE] the audit of resident records regarding notification of change in condition requiring hospitalization between [DATE] and [DATE] was discussed. 3. In-service record reviewed. Dated [DATE], the in-service specified the procedure for notification of the Nurse Manager on call, the Physician, the Responsible Party and or family, and the Respiratory Therapist if the change in condition involves a respiratory issue, for any resident with a change in condition. The sign in roster and additional record of nurses educated by telephone included thirty nursing staff. Education provided on [DATE] regarding notification of Physician, family, Nurse Manager on call or in the building and the Respiratory Therapist was verified and understanding was confirmed by staff interviews. Interviews with License Practical Nurse (LPN) KK on [DATE] at 1:00 p.m., LPN LL on [DATE] at 1:12 p.m., LPN MM on [DATE] at 1:25 p.m., LPN NN on [DATE] at 1:30 p.m., LPN OO on [DATE] at 1:35 p.m., LPN FFF on [DATE] at 1:43 p.m., LPN UU on [DATE] at 1:50 p.m., LPN AAA on [DATE] at 2:15 p.m., LPN RR on [DATE] at 2:47 p.m., LPN GGG on [DATE] at 2:53 p.m., and LPN CCC on [DATE] at 7:50 p.m. revealed they had participated in in-services related to notification for change in conditions to the Physician, Nurse Manger on call or in the building and the Respiratory Therapist and were aware of the notification process for a change in condition of a resident. Interviews with Registered Nurses (RN) confirmed they had participated in the facility in-services on notification for a change in condition for a resident and were aware of their role in this process. RN DON on [DATE] at 1:40 p.m., RN PP on [DATE] at 1: 45 p.m., RN QQ on [DATE] at 2:00 p.m., and RN DDD on [DATE] at 7:45 p.m. 4. The guidelines for notification of the nurse manager on call, and follow up were reviewed and include use of Interact change in condition cards, and completion of the Nurse Manager on call log. The Nurse Manager on call log was reviewed. In-service records described on [DATE] revealed thirty of thirty nurses participated in this education. Nurse Managers were interviewed regarding receiving education and understanding the use of the Nurse Manager on call log. The roster for this in-service was signed by six Nurse Managers. 5. RN DON on [DATE] at 1:40 p.m. revealed she was educated regarding the duties of the Nurse Manager on call and understood the use of the on-call log and the guidelines for notification of Nurse Managers. LPN AAA on [DATE] at 2:15 p.m. indicated she had attended in-services describing her role as Nurse Manager on call and the appropriate use of the on-call log. LPN UU on [DATE] at 1:50 p.m. revealed she has been educated regarding the functions of the on-call Nurse Manager and understands how to use the on-call log. LPN FFF on [DATE] at 1:43 p.m. revealed she is a Nurse Manager and has received education regarding the guidelines of notification of the nurse manager and the on-call log. RN PP on [DATE] at 1: 45 p.m. revealed she is a weekend supervisor and takes call as a Nurse Manager and received recent education regarding the use of the on-call log and the guidelines for notification of Nurse Managers of residents change in condition. 6. In-service by the DON on [DATE] regarding guidelines for notification of Nurse Manager in and out of the building was reviewed. Dated [DATE], the in-service specified the procedure for notification of the Nurse Manager on call for any resident with a change in condition. The sign in roster and additional record of nurses educated by telephone included thirty nursing staff. 7. The Change in Condition audit tool, completed for five residents with a change of condition from [DATE] through [DATE] was reviewed. The Nurse Manager was notified, either in the building or by telephone for all five residents. The progress notes contain notification of Physician/ Nurse Practitioner and Responsible Party. Three of the five residents had a change in respiratory status and the Respiratory Therapist was notified. 8. The Change in Condition audit tool was reviewed by the QA committee. The sign in roster and content for the QA meeting was reviewed with nineteen signatures acknowledging review of the Change in Condition Audit on [DATE]. Interview on [DATE] at 4:30 p.m. with the Corporate Chief Nursing Officer revealed during the QA meeting held [DATE] the results of the audit of resident records regarding notification of change in condition between [DATE] and [DATE] was discussed. Additional education was provided to staff regarding negative findings, but there were no negative findings regarding notification of Physician, Responsible Party, Nurse Manager and Respiratory Therapy when applicable.

Based on record review, review of the policy titled Respiratory Policy and Procedure- Subject: Non-Invasive Ventilation and staff interviews, the facility failed to implement its policy related to the use of non-invasive ventilation for the treatment of [REDACTED].#1). Specifically, the facility failed to implement protocols for non-invasive ventilation and failed to monitor and reassess R#1 after being placed on [MEDICAL CONDITION] therapy secondary to respiratory distress. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio Hills Health and Rehabilitation beginning [DATE] and concluding on [DATE]. After review by the RO, a survey team re-entered on [DATE] through [DATE] to futher investigate the complaint and for a recertification survey. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. During the Recertification Survey conducted on [DATE] through [DATE] additional residents were reviewed for notification when a change of condition was noted. There were no additional issues identified for notification. The previous findings for R#1 were reviewed and the determination of immediate jeopardy were confirmed on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(k)(6)- Standard Respiratory Care (F328, S/S; J) Cross Refer to F157, F281, F282, F490, F514 and F520 Findings include: Review of the undated facility policy titled Respiratory Policy and Procedure- Subject: Non-Invasive Ventilation documented: A Licensed Respiratory Therapist will establish safe and uniform standard of practice for the application of non-invasive ventilation in adult patients with acute respiratory distress. Initiate/Titrate the pressure support to patient comfort. With a bi-level ventilator the difference between the inspiratory pressure and the expiratory pressure determines the level of pressure support. Gradually increase the inspiratory pressure beginning at 10 cmH20 (centimeters of water) to a target pressure of no greater than 20 cmH20, while observing accessory muscle use and respiratory rate and ask the patient if breathing is becoming more comfortable. Initiate/Titrate expiratory pressure per trigger effort and Sp02. Begin with an expiratory pressure of 5 cmH20 and increase as tolerated, and not exceed an expiratory pressure of 10 cmH20. Remember that an increase expiratory pressure requires an equivalent increase in inspiratory pressure to maintain the same level of pressure support. Titrate the FI02 (concentration of oxygen inhaled) to achieve and Sp02 of 90% or greater, unless specified by a physician. Avoid inspiratory pressure greater than 20 cmH20, which decreases patient comfort and increases risk of gastric insufflation. Continue to coach and reassure the patient. Make adjustments per patient comfort and adherence to therapy. It is acceptable to give the patient a break from NIV if the patient does not acutely decompensate when the mask is removed. R#1 was admitted to the facility on [DATE] from an acute care hospital with a [MEDICAL CONDITION] and tube feeding via PEG. [DIAGNOSES REDACTED]. On [DATE] the resident'[MEDICAL CONDITION] removed and on [DATE] the resident advanced to a puree diet, however, the PEG remained in place for the administration of medications. Record review for R#1 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] which documented in Section C- Cognitive Patterns a Brief Interview for Mental Status (BIMS) summary score of three, indicating severe cognitive impairment. Section J- Health conditions assessed that R#1 had a condition of shortness of breath while lying flat. Section O- Special Treatments and Programs documented the resident received oxygen therapy and suctioning and had a [MEDICAL CONDITION]. Review of the Quarterly MDS assessment dated [DATE] documented a BIMS of five, indicating severe cognitive impairment. Section G- Functional Status indicated the resident required extensive assistance with all Activities of Daily Living (ADL). Section J- Health Conditions assessed that R#1 had a condition of shortness of breath while lying flat. Section O- Special Treatments and Programs documented the resident received oxygen therapy and suctioning and had a [MEDICAL CONDITION]. Interview on [DATE] at 11:57 a.m. with the family/responsible party (RP Z) revealed R#1 was transferred to the facility after a hospitalization . She stated the resident had a [MEDICAL CONDITION] and tube feeding when admitted to the nursing home facility. She stated the resident's [MEDICAL CONDITION] had been removed and his tube feeding had been removed and he began an oral diet. The RP Z stated that she was told by a nurse, after the resident expired late Saturday night of [DATE] that he had been having difficulty breathing that day and his oxygen saturation was down to 74%. She stated they had put a [MEDICAL CONDITION] with mask on R#1 and the nurse told her when they checked him one hour later, he had passed away. The RP Z stated that she did not understand why they did not send R#1 to the hospital if he was having breathing problems all day. Record review for R#1 revealed no evidence or documentation on [DATE] of a respiratory assessment, when the resident presented with acute respiratory distress, initiation of [MEDICAL CONDITION] therapy, non-invasive protocols implemented related to determination of appropriate [MEDICAL CONDITION] settings or toleration of [MEDICAL CONDITION], oxygen saturation results for R#1, and re-assessments and/or monitoring of R#1 after being placed on [MEDICAL CONDITION]. Further record review revealed an order for [REDACTED]. Interview on [DATE] at 2:33 p.m. with the attending Physician for R#1 revealed the resident's stay in the nursing facility was relatively un-eventful. The Physician stated that eventually the resident'[MEDICAL CONDITION] tube feeding was removed and R#1 was cleared by speech therapy for an oral diet. The physician stated that the resident was doing well and his condition had improved. The Physician further stated that he was out of town when R#1 expired and his Nurse Practitioner (NP GG) was covering the facility. He stated that it was reported to him when he returned. The Physician stated that the resident most likely had an aspiration event or pneumonia. The physician stated that R#1 was placed on oxygen and [MEDICAL CONDITION] therapy. The physician further stated that because the nursing facility has a Vent Unit with respiratory therapy on staff , respiratory distress is typically handled in the facility unless the nature of condition required hospitalization . The protocol for a resident in respiratory distress is administer oxygen, [MEDICAL CONDITION], appropriate labs and x-rays. He stated the R#1 was a Do Not Resuscitate (DNR) and there would have been no further treatment than that even if he would have been transferred to the hospital. Interview on [DATE] at 4:19 p.m. with the Respiratory Therapist (RT BB) revealed that he worked on the dayshift of [DATE] when the Licensed Practical Nurse (LPN AA) asked him between 3:00 p.m. - 4:00 p.m. to evaluate R#1 due to the resident had coughed up some mucous and it was green. RT BB stated when R#1 was evaluated, the resident's respiratory status was stable and his oxygen saturation (Sp02) was in the 90's. He further stated that respiratory works 12 hours shifts and he gave report to the oncoming nightshift Respiratory Therapist (RT JJ) and added that R#1 was still stable at the end of his shift (7:00 a.m. - 7:00 p.m.). RT BB stated that he documented a note and that he had been unable to retrieve the note in the electronic charting system. Telephone interview on [DATE] at 4:40 p.m. with RT JJ revealed he worked the nightshift (7:00 p.m. - 7:00 a.m.) on [DATE] when R#1 expired but he had never seen the resident. He stated he never received report from the departing therapist RT BB that R#1 had a change in condition. He stated he did not set R#1 up on [MEDICAL CONDITION] and he did not receive report that the resident had been placed on [MEDICAL CONDITION] for respiratory distress. He stated he was never asked by the nurses during that shift to check or evaluate R#1. He stated when he found out the resident had expired, he was very surprised because the resident had been improving and doing so well. Further interview on [DATE] at 4:50 p.m. with RT BB revealed that he had another resident on a ventilator that was going bad at the same time that R#1 was having respiratory distress and the nurse (LPN AA) handled the situation and called the Nurse Practitioner. He said the LPN AA called him and reported that NP GG ordered [MEDICAL CONDITION]. He stated that he had set the resident up on [MEDICAL CONDITION] he thought around 4:45 p.m. RT BB stated he did check R#1 around 6:00 p.m. and his Sp02 was in the 90's but stated that he was unable to find any documentation of his assessments or when he initiated [MEDICAL CONDITION] therapy for R#1 in the electronic charting system. Interview on [DATE] at 4:52 p.m. with the Respiratory Director revealed when R#1 was placed on [MEDICAL CONDITION] for noninvasive ventilation related to respiratory distress, the resident should have had a respiratory assessment and the facility protocol should have been followed. This is to be documented in the Respiratory Assessment area of the electronic charting and that a note should have been documented in the Progress Notes. She further stated that resident should have absolutely been monitored and re-assessed after being placed on [MEDICAL CONDITION] therapy. The Respiratory Director confirmed that there was no respiratory documentation in the resident's clinical chart related to the resident's change of condition, respiratory status, respiratory assessment, [MEDICAL CONDITION] use or settings, oxygen saturation checks or re-assessments/monitoring. In an interview with the Licensed Practical Nurse (LPN AA) on [DATE] at 5:08 p.m., she reported that the morning of [DATE], R#1 seemed to be very depressed and was just staring out of the window. LPN AA stated R#1 wasn't really lethargic but not himself so she did not administer his [MEDICATION NAME] and that his Sp02 was in the 90's. LPN AA stated around 2:00 p.m. -3:00 p.m. the resident seemed sleepy and when she checked his Sp02, it was 74% (normal range is above 90%). She stated that she placed the resident on oxygen at two liters per minute (2 LPM) via nasal cannula and there was no improvement in the resident's condition. LPN AA stated she called RT BB and he did some sort of C02 test and told her to call the Nurse Practitioner (NP GG). LPN AA stated she received an order from the NP GG to initiate [MEDICAL CONDITION] therapy however, she could not remember the time. LPN AA stated that RT BB placed R#1 on [MEDICAL CONDITION] but she did not remember the time. Review of the Progress Notes revealed LPN AA created a Nurse's Note on [DATE] at 8:32 p.m. with an effective date and time of [DATE] at 10:17 a.m. which documented Resident coughing/spitting up thick greenish brown sputum. Mouth was suctioned out. Resident very sleepy. 02 sats 90% R[NAME] Gave all meds through feeding tube. Monitored resident throughout day. 02 sats started declining to 74. Resp. nurse informed, Dr. (name) NP called, [MEDICAL CONDITION] was ordered and placed on resident. Will continue to monitor resident. (sic) Interview on [DATE] at 5:20 p.m. with the RT Director revealed that the resident was set up on [MEDICAL CONDITION] as a means of noninvasive ventilation secondary to respiratory distress. She stated they have a policy for noninvasive ventilation. The Respiratory Director stated she made some changes to the policy to move the resident to the 200 Hall to be closer to the Vent Unit if a room is available. She stated the resident is to be checked after initiating [MEDICAL CONDITION] and [MEDICAL CONDITION] checks Q3 hours. If the resident does not improve after one hour, the physician is to be called. She stated the physician would make a determination if the resident should be sent to the hospital. Interview on [DATE] at 11:05 a.m. with the Respiratory Director confirmed that the [MEDICAL CONDITION] order for R#1 was dated [DATE] at 12:00 p.m. after R#1 had already expired. She confirmed and that the [MEDICAL CONDITION] order did not indicate the settings for IPAP, EPAP or oxygen and stated it should have. She stated the protocol for [MEDICAL CONDITION] is to start IPAP at 10 cmH20 (centimeters of water) and EPAP at 5 cmH20 and that is what the order should have read. She stated this is an initial setting and the policy instructs to titrate the pressure until optimal benefit is obtained. The Respiratory Director stated that any changes from the initial settings would require a respiratory assessment and documentation. The Respiratory Director also confirmed that there is no documentation of oxygen saturations for R#1 since [DATE]. She stated that R#1 should have been assessed and monitored per the policy for noninvasive ventilation and that RT BB did not follow the policy. She stated that although continuous pulse oximetry was not addressed in the policy for Non-Invasive Ventilation, the standard of practice would have been to initiate continuous pulse oximetry on a resident in respiratory distress. She stated the policy does address 02 saturation spot checks. She stated they do not require a physician order [REDACTED]. Respiratory Director stated she revised the policy yesterday ([DATE]) and that the last paragraph is the only change made. She stated that added paragraph addresses implementation of a continuous pulse oximeter and assessment requirements for a patient placed on [MEDICAL CONDITION] for noninvasive ventilation. The Respiratory Director provided a copy of the policy titled Non-Invasive Ventilation with the added revision on [DATE] at 11:25 a.m. Review of the revised policy titled Non-Invasive Ventilation dated [DATE] revealed an added paragraph which documented Document procedure/initial respiratory assessment in electronic charting system. Patient should be placed on Continuous Pulse Oximetry while receiving NIV. Patient should be started on Pertinent Respiratory assessments as follows: 30 minutes x 2, hourly x 2 and then Q3 hours while receiving Non-invasive ventilation. Patient should be moved to the ventilator unit/200 hall if room available. If patient shows no signs of improvement 1 hour after initiation of NIV, contact MD and consider sending patient to ER for further evaluation. Interview on [DATE] at 2:08 p.m. with the Nurse Practitioner (NP GG) revealed she was covering for the attending physician of R#1 on [DATE] while he was out of town. NP GG stated a nurse had called her one time on [DATE]. She stated it was reported to her that the residents C02 (carbon [MEDICATION NAME]) was elevated and his oxygen saturation was low. She stated that she ordered [MEDICAL CONDITION] with the agreed decision to see how he would do on [MEDICAL CONDITION] first, but she never heard back from anyone at the facility. NP GG stated she cannot remember exactly what time she received the call but she believed that it was in the morning sometime. NP GG stated that she did not order a chest x-ray because she wanted to see how R#1 would respond to the [MEDICAL CONDITION] first. She stated the [MEDICAL CONDITION] was ordered as noninvasive ventilation secondary to respiratory distress. She stated if the resident continued to decline, she would have ordered a chest x-ray and possible antibiotics for potential aspiration pneumonia and that would have been verified by chest x-ray, however, no one ever called her back about the resident's condition. NP GG stated that since R#1 was having drops in his oxygen saturation, the resident's Sp02 should have been monitored to make sure the resident was improving. She stated the resident should have been re-assessed after being placed on [MEDICAL CONDITION] and ongoing assessments should have been conducted by both the nurse and the respiratory therapist. Further interview on [DATE] at 2:17 p.m. with the attending Physician for R#1 revealed the resident was placed on [MEDICAL CONDITION] as a means of noninvasive ventilation secondary to respiratory distress. He stated that the impression was that the resident's C02 was elevated and oxygen alone was not improving his condition. The Physician stated that he was not aware that the resident had not been monitored or re-assessed after being placed on [MEDICAL CONDITION]. He stated that absolutely the resident should have been monitored and protocols are in place and they usually get feedback from staff on how the resident is doing. He stated the resident should have been assessed immediately after being placed on [MEDICAL CONDITION] then again in 30 minutes to an hour after being placed on [MEDICAL CONDITION]. He stated the nurse and respiratory therapist should have assessed and monitored the resident. He stated that although R#1 was a DNR, he was doing better, had increased awareness and was improving. He stated that he cannot say for certain that had the resident been properly monitored, that the outcome would have been different but that without even trying, we would never know. The Physician further stated that he recently became the co-medical director and oversees the Vent Unit. Interview on [DATE] at 2:47 p.m. with the Certified Nursing Assistant (CNA DD) revealed she was the CNA assigned to R#1 on [DATE]. She stated that when she came on her shift at 3:00 p.m., R#1 was on the [MEDICAL CONDITION] with a mask on his face. She stated when she got there, the resident was not really responding and was mostly out of it on her shift (3:00 p.m. - 11:00 p.m.). She stated at around 10:15 p.m. on her third rounds, she and CNA EE changed the resident's brief and that R#1 was the same at that time stating he was not alert and not responding to conversation. Interview on [DATE] at 2:52 p.m. with CNA EE revealed she was not assigned to R#1 on [DATE] but she passed his room many times and stated the resident was wearing [MEDICAL CONDITION] mask at 3:00 p.m. when she came on her shift (3:00 p.m. - 11:00 p.m.). She stated that during her third rounds she assisted CNA DD with changing the resident after a bowel movement. She stated it was about 10:15 p.m. because they start third rounds at 10:00 p.m. CNA EE stated that R#1's eyes were open but he was not responding. She stated he would take a breath, then pause, then take another breath. She stated it was a noticeable pause and not normal breathing. She stated it was not reported at that time to the nurse because R#1 had been that way and on the mask since she started her shift and everyone already knew of his condition. Interview on [DATE] at 4:27 p.m. with RT BB revealed he set R#1 on [MEDICAL CONDITION] settings of 12 over 6 (IPAP/EPAP). He stated that oxygen was bled into the [MEDICAL CONDITION] he thought at 3 LPM but not completely sure. He stated that he is aware of a policy for noninvasive ventilation but could not verbalize exactly what the protocol was. He stated that he believed he assessed the resident and followed the protocol. Interview on [DATE] at 4:14 p.m. with the Registered Nurse Weekend Supervisor (RN HH) revealed she was working on [DATE] covering for the regular RN weekend supervisor. She stated neither the nurse nor respiratory therapist in care of R#1 reported to her that he was having respiratory complications. RN HH stated she did not know that R#1 had a change in condition or expired until the Corporate Nurse called her during the complaint survey and wanted to know if she knew what happened. RN HH stated that the nurse caring for R#1 should have informed her of the situation. She stated she would have helped assess R#1. She stated that the nurse would have been responsible for documenting a skilled nursing note and the change of condition. She stated had she performed any of her own assessments, she would document her own skilled nursing note. She further stated that she would have pushed for the resident to be sent to the hospital in his condition. RN HH stated that she left the facility at around 2:30 p.m. on [DATE]. Review of the Pronouncement of Death indicated the resident expired in the facility on [DATE]. Primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. An interview with the Director of RT on [DATE] at 11:04 a.m. revealed that after the incident with R#1 and after the initial survey team entered the building on [DATE], that she reviewed the policies and had made changes for resident in respiratory distress. She confirmed that the previous policy did not include continuous monitoring of SaO2 after initating treatment for [REDACTED]. She is aware that the staff did not monitor this resident after starting the [MEDICAL CONDITION] and thererfore did not realize the resident was not improving in order to contact the Physician/NP timely. The facility implemented the following actions to remove the Immediate Jeopardy: 1. New policies and procedures developed by DON, Dir. of Respiratory Therapy, CNO for Corp Office, and Medical Director: 24-hour Respiratory Report; Respiratory Assessment/Intervention for Non¿ Respiratory Caseload Patients; Respiratory Pertinent Charting on [DATE]. 2. The policy for Non-Invasive Ventilation was revised by DON, Dir. Of Respiratory Therapy, CNO for Corp Office, and Medical Director and 6 of 6 of respiratory therapists were educated on the revised policy by the Director of Respiratory Therapy on [DATE]. ,[DATE] respiratory therapists were educated via telephone, ,[DATE] in facility. They were also reviewed again at the facility in-service on [DATE] and ,[DATE] attended. New policies and procedures: 24 hour Respiratory Report; Respiratory Assessment /Intervention for Non-Respiratory Caseload Patients; Respiratory Pertinent Charting, added to orientation for Respiratory Therapists on [DATE] 7. There have been no new respiratory therapists hired since [DATE]. Revised policy for Non-Invasive Ventilation was added to orientation for Respiratory Therapists on [DATE]. There have been no new respiratory therapists hired since [DATE]. 6 of 6 of respiratory therapists were educated by the Director of Respiratory Therapy on obtaining and entering physician orders [REDACTED]. 3. An audit was conducted for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that did not have a change in condition evaluation, transfer form, order for transfer, notes documenting follow up, or change of condition documented on the 24-hour report, and if respiratory change in condition was respiratory assessment documented. 4. There will be a QA meeting on [DATE] to review the findings. 5. A Change in Condition audit tool developed on [DATE] by the CNO for Reliable Health Care Management to ensure that the guidelines for notifying a nurse manage in the building, the on-call nurse after hours and weekends, as well as the RN supervi sor on the weekend and that the guidelines for review and follow up for a change in condition are being followed. The audit tool will be completed weekly for 5 residents experiencing a change in condition, if there are changes in condition related to acute respiratory changes up to 2 of these will be included. This audit will be completed by the DON, if she is not available to complete the audit then it will be done by the ADON. 6. The CNO will in-service the DON, ADON, Director of Respiratory Services, and Administrator on completion of the Change in Condition Audit on [DATE]. 4 out of 4 were present and in-serviced via conference call on [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. A review of the new policies and procedures developed on [DATE] included the 24-hour Respiratory Report, Respiratory Assessment and Intervention for Non-Respiratory Caseload Patients and Respiratory Pertinent Charting. 2. Review of the education content and rosters for education conducted for Respiratory Therapists revealed education was given on [DATE] for new policies regarding completion of the 24-hour Respiratory Report, Respiratory Assessment and Intervention for Non-Respiratory Caseload Patients, and Respiratory Pertinent Charting. One Respiratory Therapist was in the building and was in serviced and five were in serviced by telephone. On [DATE] an in-service was conducted and six of six Respiratory Therapists were present and signed the roster. Interview with Respiratory Therapist JJ on [DATE] at 2:35 p.m. and Respiratory Therapist EE on [DATE] at 3:00 p.m. confirmed education given on [DATE] and [DATE] regarding new policies including the completion of the 24-hour Respiratory Report, Respiratory Assessment and Intervention for Non-Respiratory Caseload Patients, and Respiratory Pertinent Charting, and acknowledged their understanding of the education. A review of the 24-hour Respiratory Report was conducted and R#18 and R#120 were included. Record review for R#18 revealed Pertinent Respiratory documentation occurred on [DATE] at 11:35 a.m. and 12:14 p.m. A skilled respiratory assessment was also completed at 11:30 a.m. Record review for R#120 revealed Pertinent Respiratory documentation recorded on [DATE] at 9:24 a.m. and [DATE] at 10:10 a.m. A full respiratory assessment was documented at 9:20 a.m. Documentation was completed according to policy and education for the two sampled residents with respiratory changes in condition. The policy for Non-Invasive Ventilation was revised by DON, Dir. Of Respiratory Therapy, CNO for Corp Office, and Medical Director and ,[DATE] of respiratory therapists were educated on the revised policy by the Director of Respiratory Therapy on [DATE]. ,[DATE] respiratory therapists were educated via telephone , ,[DATE] in facility. They were also reviewed again at the facility in-service on [DATE] and ,[DATE] attended. The revised policy for Non-Invasive Ventilation was reviewed. Education content and rosters were reviewed. Interview with Respiratory Therapist JJ on [DATE] at 2:35 p.m. and Respiratory Therapist EE on [DATE] at 3:00 p.m. confirmed education given on [DATE] and [DATE] regarding the revised policy for Non-Invasive Ventilation, and acknowledged understanding. 3. The audit for all residents transferred to the hospital between [DATE] and [DATE] was reviewed. Fifty-seven resident records were included. Thirty-two records did not include a change in condition evaluation. Twenty-one records did not have a transfer form. Forty-nine records did not include a documented Physician order [REDACTED]. 4. A review of the minutes and content of the QA meeting conducted on [DATE] revealed the findings of the audit of residents for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that did not have a change in condition evaluation, transfer form, order for transfer, notes documenting follow up, or change of condition documented on the 24-hour report and if respiratory change in condition was respiratory assessment documented. Nineteen QA committee members signed the roster. 5. Review of the Change in Condition Audit tool for the week of [DATE] through [DATE] revealed the Change in condition audit tool developed on [DATE] including five records of residents experiencing a change in condition. The Nurse Manager was notified of the five changes in condition. The on-call log was not filled out by the Nurse Manager for one resident. Follow up call to family and follow up documentation per education were not completed for one resident with a respiratory change in condition. Interview of the ADON on [DATE] at 2:00 p.m., the Administrator on [DATE] at 3:20 pm the DON on [DATE] at 4:45 p.m., and the Director of Respiratory Services on [DATE] at 3:10 p.m. acknowledged receiving education on conducting the Change in Condition audit tool from the Corporate Chief Nursing Officer, and confirmed their understanding. 6. Interview of the ADON on [DATE] at 2:00 p.m., the Administrator on [DATE] at 3:20 p.m. the DON on [DATE] at 4:45 p.m., and the Director of Respiratory Services on [DATE] at 3:10 p.m. acknowledged receiving education on conducting the Change in Condition audit tool from the Corporate Chief Nursing Officer, and confirmed their understanding. Additional residents reviewed: 1. R#135 was admitted to the facility from her home on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] at 10:40 p.m. her PEG tube was noted to be causing concern to the family members and the family thought it was protruding from her abdomen more than usual. The Physician was notified on [DATE] at 10:45 p.m. An X Ray was ordered but could not be completed due to inclement weather. Transfer to the local hospital was ordered. On [DATE] at 11:15 p.m. the family was notified of the transfer and refused. On [DATE] at 2:30 a.m. the family decided the resident was to be transferred and the resident was sent to the hospital of the family's choice. The resident was monitored appropriately, the Physician and family were notified timely. 2. R#18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:00 a.m. he began to have [MEDICAL CONDITION] activity. The Physician was notified at 11:18 a.m. The Respiratory Therapist was notified at 11:30 a.m. when oxygen saturations began to drop. The family was notified at 11:42 a.m

Based on record review, review of the State of Georgia Rule ,[DATE]-.01 Standards of Practice for Registered Professional Nurses and Rule ,[DATE]-.02 Standards of Practice for Licensed Practical Nurses, review of the facility policy titled Change in a Resident's Condition or Status and staff interviews, the facility failed to maintain professional nursing standards of quality and nursing standards of practice as evidenced by failing to conduct a skilled nursing assessment and by failing to re-assess and monitor one of five residents (R#1) with a change in condition related to acute respiratory distress. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio Hills Health and Rehabilitation beginning [DATE] and concluding on [DATE]. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. Additional residents were reviewed during the Recertification survey conducted [DATE] through [DATE] related to licensed nurses accessing residents with a change in condition and no further issues were identified. The survey team reviewed the complaint findings related to R#1 which was identified as an immediate jeopardy existing on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Cross refer to F328 Findings include: Review of the Georgia Rule ,[DATE]-.01 Standards of Practice for Registered Professional revealed that: The Board recognizes that assessment, nursing diagnosis, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the registered nurse in the practice of nursing. The Standards of Practice for Registered Professional Nurses delineate the quality of nursing care which a patient/client should receive regardless of whether it is provided solely by a registered nurse or by a registered nurse in collaboration with other licensed or unlicensed personnel. The Standards are based on the premise that the registered nurse is responsible for and accountable to the patient/client for the quality of nursing care rendered. The Standards of Practice for Registered Professional Nurses shall establish a baseline for quality nursing care; be derived from the Georgia Nurse Practice Act; apply to the registered nurse [MEDICATION NAME] in any setting; and, govern the practice of the licensee at all levels of competency. (a) Standards related to the registered nurse's responsibility to apply the nursing process (adapted from American Nurses' Association Code for Nurses and Standards of Practice). The registered nurse shall: 1. Assess the patient/client in a systematic, organized manner; 2. Formulate a nursing [DIAGNOSES REDACTED]. 4. Implement strategies to provide for patient/client participation in health promotion, maintenance and restoration; 5. Initiate nursing actions to assist the patient/client to maximize her/his health capabilities; Review of the Georgia Rule ,[DATE]-.02 - Standards of Practice for Licensed Practical Nurses revealed that: (1) The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice; Review of the undated facility policy titled Change in a Resident's Condition or Status documented that the Nurse Supervisor will notify the resident's attending physician when there is a significant change in the resident's physical, mental, or psychosocial status; or when there is a need to alter the resident's treatment significantly; or deemed necessary or appropriate in the best interest of the resident. The policy does not address nursing assessments, re-assessments or monitoring of a resident with a change of condition. 1. Resident #1 was admitted to the facility on [DATE] from an acute care hospital with a [MEDICAL CONDITION] and tube feeding via percutaneous endoscopic gastrostomy (PEG). [DIAGNOSES REDACTED]. On [DATE] the resident'[MEDICAL CONDITION] removed and on [DATE] the resident advanced to a puree diet, however, the PEG remained in place for the administration of medications. Review of the Weights and Vitals Summary documented the results of Sp02 and that R#1 was on room air from [DATE] through [DATE]. There was no further documentation after [DATE]. Review of the Quarterly Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental status (BIMS) summary score of five, indicating severe cognitive impairment. Section G- Functional Status indicated the resident required extensive assistance with all Activities of Daily Living (ADL). Section J- Health Conditions assessed that R#1 had a condition of shortness of breath while lying flat. Section O- Special Treatments and Programs documented the resident received oxygen therapy and suctioning and had a [MEDICAL CONDITION]. Interview on [DATE] at 11:57 a.m. with the family/responsible party (RP) of R#1 revealed that she was told by a nurse via telephone, after R#1 expired on Saturday of [DATE], that he had been having difficulty breathing that day and his oxygen saturation was down to 74%. The RP stated they (staff) had put a [MEDICAL CONDITION] with mask on R#1 and the nurse told her when they checked him one hour later, he had passed away. The RP stated she did not understand why R#1 was not sent to the hospital if he was having breathing problems all day. Record review for R#1 revealed no evidence of a skilled nursing assessment on [DATE]. Review of the Weights and Vitals Summary revealed no evidence on [DATE] of Sp02 results or vital signs (heart rate, respiratory rate, temperature or blood pressure) for R#1. The last time the Sp02 and vital signs were documented was [DATE]. Review of the Medication Administration Record [REDACTED]. Further review of R#1's clinical record revealed the following Progress Notes: LPN AA created a Nurse's Note on [DATE] at 8:32 p.m. with an effective date and time of [DATE] at 10:17 a.m. which documented Resident coughing/spitting up thick greenish brown sputum. Mouth was suctioned out. Resident very sleepy. 02 sats 90% R[NAME] Gave all meds through feeding tube. Monitored resident throughout day. 02 sats started declining to 74. Resp. nurse informed, Dr. (name) NP called, [MEDICAL CONDITION] was ordered and placed on resident. Will continue to monitor resident. (sic) LPN CC created a Nurse's Note on [DATE] at 12:21 a.m. with an effective date and time of [DATE] at 12:00 a.m. which documented At approximately 11:20 p.m. I was making my rounds and when I went into resident room. I notice that resident was unresponsive and gray in color. Resident a DNR. I assessed resident by checking pulse and then proceeded to have the RN supervisor from the vent unit to confirm resident status. Next of kin was notified and funeral home of family choice was notified. (sic) Registered Nurse (RN FF) created a Nurse's Note on [DATE] at 12:43 a.m. with an effective date and time of [DATE] at 11:25 p.m. which documented Called to resident's room by charge nurse. Resident was found to be non-responsive, pallid, and apneic. Apical pulse was auscultated and carotid pulse palpated simultaneously one full minute without results. Death was pronounce at 11:30 PM. Dr. (name) notified. (sic) RN FF created a Nurse's Note dated [DATE] at 12:48 a.m. with an effective date and time of [DATE] at 11:35 p.m. on [DATE] which documented Responsible party, (name), notified of resident's expiration via telephone. (Name) stated she was out of town and could not come. She also stated that she would like for resident to be sent to (name) Funeral Home in Tallapoosa, G[NAME] (Name) expressed appreciation for the notification. (sic) Interview on [DATE] at 4:56 p.m. with the Director of Nursing (DON) revealed that R#1 was pronounced deceased at 11:30 p.m. on [DATE]. She stated the facility was aware that LPN AA did not document the resident's change of condition in the Change of Condition Evaluation Assessment pathway in the electronic charting system. The DON stated that in this section, documentation includes all pertinent information, notification of the Physician and if a resident is transferred to the hospital. In an interview with the Licensed Practical Nurse (LPN AA) on [DATE] at 5:08 p.m., she reported that the morning of [DATE], R#1 seemed to be very depressed and was just staring out of the window. LPN AA stated R#1 wasn't really lethargic but not himself so she did not administer his [MEDICATION NAME] and that his Sp02 was in the 90's. LPN AA stated around 2:00 p.m. - 3:00 p.m. the resident seemed sleepy and when she checked his Sp02, it was 74% (normal range is above 90%). She stated that she placed the resident on oxygen at two liters per minute (2 LPM) via nasal cannula and there was no improvement in the resident's condition. LPN AA stated she received an order from the Nurse Practitioner (NP) to initiate [MEDICAL CONDITION] therapy however, she could not remember the time. LPN AA stated that the Respiratory Therapist (RT BB) placed R#1 on [MEDICAL CONDITION] but she did not remember the time. LPN AA further stated that she never returned to re-assess R#1 and had not seen the resident again after he was placed on [MEDICAL CONDITION] for the remainder of her shift (7:00 a.m. - 7:00 p.m.). LPN AA stated she had no good answer for why she did not re-assess or monitor R#1, It gets busy at the end of the shift but I know that is not a good excuse. She stated she did make a notation at the end of her shift but not a detailed notation. LPN AA stated she gave report to the oncoming nurse (LPN CC) and told her that R#1 had a change in his condition and was placed on [MEDICAL CONDITION]. Further interview on [DATE] at 5:17 p.m. with the DON revealed she was on vacation when R#1 expired on [DATE] and returned to work on [DATE]. The DON stated she was aware R#1 had respiratory distress and was placed on [MEDICAL CONDITION]. She stated she was aware that a change in condition evaluation assessment had not been conducted and aware that the nurse did not notify the family/responsible party. The DON stated she was not aware that LPN AA had not re-assessed or monitored R#1 after his change of condition and being placed on [MEDICAL CONDITION] for the rest of her shift. She stated that her expectation would include a skilled nursing assessment and ongoing monitoring after R#1 had a change in his condition and after being placed on [MEDICAL CONDITION]. Telephone interview on [DATE] at 5:28 p.m. with the 7:00 p.m. - 7:00 a.m. LPN CC revealed the night of [DATE] she had received report from LPN AA that R#1 was placed on [MEDICAL CONDITION] due to respiratory distress. LPN CC stated she saw the resident first around 8:00 p.m. - 8:30 p.m. She stated she checked the resident's Sp02 and it was she believed 91%. She stated she attempted to suction the resident's mouth but he did not like it and pushed her hand away. She stated that she thought she had documented her assessment and the resident's Sp02 but she could not be sure without checking the computer. LPN CC stated that the next time she saw R#1 was about 10:30 p.m. and he seemed fine. She stated two Certified Nursing Assistants (CNA DD and CNA EE) changed the resident's brief around 10:45 p.m. before they left their shift. LPN CC stated around 11:15 p.m. she checked on R#1 and he was not responsive. She called RN FF to come and check R#1 and it was determined the resident had expired. Interview on [DATE] at 2:08 p.m. with the Nurse Practitioner (NP GG) revealed she was covering for attending physician of R#1 on [DATE] while he was out of town. NP GG stated a nurse had called her one time on [DATE]. She stated it was reported to her that the residents C02 was elevated and his oxygen saturation was low. She stated that she ordered [MEDICAL CONDITION] with the agreed decision to see how he would do on [MEDICAL CONDITION] first, but she never heard back from anyone at the facility. NP GG stated she cannot remember exactly what time she received the call but she believed that it was in the morning sometime. NP GG stated that since R#1 was having drops in his oxygen saturation, the resident's Sp02 should have been monitored to make sure the resident was improving. She stated the resident should have been re-assessed after being placed on [MEDICAL CONDITION] and ongoing assessments should have been conducted by both the nurse and the respiratory therapist. Interview on [DATE] at 2:17 p.m. with the attending Physician for R#1 revealed the resident was placed on [MEDICAL CONDITION] as a means of noninvasive ventilation secondary to respiratory distress. He stated that the impression was that the resident's C02 was elevated and oxygen alone was not improving his condition. The Physician stated that he was not aware that the resident had not been monitored or re-assessed after being placed on [MEDICAL CONDITION]. He stated that absolutely the resident should have been monitored and they usually get feedback on how the resident is doing. He stated the nurse and respiratory therapist should have assessed and monitored the resident. He stated that although R#1 was a DNR he was doing better, had increase awareness and was improving. He stated that he cannot say for certain that had the resident been properly monitored, the outcome would have been different but that without even trying, we would never know. Interview on [DATE] at 2:47 p.m. with the Certified Nursing Assistant (CNA DD) revealed she was the CNA assigned to R#1 on [DATE]. She stated that when she came on her shift at 3:00 p.m., R#1 was on the [MEDICAL CONDITION] with a mask on his face. She stated when she got there, the resident was not really responding and was mostly out of it on her shift (3:00 p.m. - 11:00 p.m.). She stated at around 10:15 p.m. on her third rounds, she and CNA EE changed the resident's brief and that R#1 was the same at that time stating he was not alert and not responding to conversation. Interview on [DATE] at 2:52 p.m. with CNA EE revealed she was not assigned to R#1 on [DATE] but she passed his room many times and stated the resident was wearing [MEDICAL CONDITION] mask at 3:00 p.m. when she came on her shift (3:00 p.m. - 11:00 p.m.). She stated that during her third rounds she assisted CNA DD with changing the resident after a bowel movement. She stated it was about 10:15 p.m. because they start third rounds at 10:00 p.m. CNA EE stated that R#1's eyes were open but he was not responding. She stated he would take a breath, then pause, then take another breath. She stated it was a noticeable pause and not normal breathing. She stated it was not reported at that time to the nurse because R#1 had been that way and on the mask since she started her shift and everyone already knew of his condition. Interview on [DATE] at 4:14 p.m. with the Registered Nurse Weekend Supervisor (RN HH) revealed she was working on [DATE] covering for the regular RN weekend supervisor. She stated neither the nurse nor respiratory therapist in care of R#1 reported to her that he was having respiratory complications. RN HH stated she did not know that R#1 had a change in condition or expired until the Corporate Nurse called her during the complaint survey and wanted to know if she knew what happened. RN HH stated that the nurse caring for R#1 should have informed her of the situation. She stated she would have helped assess R#1. She stated that the nurse would have been responsible for documenting a skilled nursing note and the change of condition. She stated had she performed any of her own assessments, she would document her own skilled nursing note. She further stated that she would have pushed for the resident to be sent to the hospital in his condition. RN HH stated that she left the facility at around 2:30 p.m. on [DATE]. Review of the Pronouncement of Death indicated the resident expired in the facility on [DATE]. Primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. 2. R#135 was admitted to the facility from her home on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] at 10:40 p.m. her PEG tube was noted to be causing concern to the family members and the family thought it was protruding from her abdomen more than usual. The Physician was notified on [DATE] at 10:45 p.m. An X Ray was ordered but could not be completed due to inclement weather. Transfer to the local hospital was ordered. On [DATE] at 11:15 p.m. the family was notified of the transfer and refused. On [DATE] at 2:30 a.m. the family decided the resident was to be transferred and the resident was sent to the hospital of the family's choice. 3. R#18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:00 a.m. he began to have [MEDICAL CONDITION] activity. The Physician was notified at 11:18 a.m. The Respiratory Therapist was notified at 11:30 a.m. when oxygen saturations began to drop. The family was notified at 11:42 a.m. The Physician was again called at 12:15 p.m. and the resident was transferred to the hospital. The family and DON were notified at 12:05 p.m. 4. R#120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Respiratory Therapist was in the room and continued to work with the resident and at 10:10 a.m. the Nurse Practitioner was notified the resident was not improving and ordered R#120 transferred to the hospital. The family had been notified at 9:45 a.m. The Nurse Manager was notified at 10:20 a.m. as the resident was transferred. An interview with RN DON on [DATE] at 1:40 p.m. revealed she was educated regarding the Respiratory Change in Condition Plan and the duties of the Nurse Manager on call and understood the use of the on-call log, follow up guidelines, and the guidelines for notification of Nurse Managers. An interview with LPN AAA on [DATE] at 2:15 p.m. indicated she had attended in-services regarding the Respiratory Change in Condition Plan and describing her role as Nurse Manager on call, follow up guidelines and the appropriate use of the on call log after the incident with R#1. She confirmed that the facility staff did not monitor the resident and did not follow up with the Physician/NP for R#1. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Pertinent Charting Policy was revised on [DATE] to include completion of a Nursing Skilled Observation/Assessment Note every shift for 72 hours following a change in condition. This has been added to the Licensed Nursing Orientation as of [DATE]. 2. 30 of 30 of Nurses will be educated by the Unit Manager on the revised pertinent charting policy beginning [DATE]. 18 of 34 nurses were in-serviced at the facility and ,[DATE] were in-serviced by telephone. The remaining 2 will be in-serviced by [DATE] prior to the start of their scheduled shift. 30 of 30 of nursing staff has been educated that they must observe/assess the resident when there is a change in condition, and that this assessment is to be documented in thee-interact Change in Condition Evaluation, and that follow-up monitoring, re-assessment, and any follow up communication with the family, and or responsible party will be documented in the nursing progress notes. In-service conducted on [DATE] by DON 22 of 30 nurses were in-serviced , any nurses who did not attend were educated via telephone on [DATE] 8 of 30 were in-serviced via telephone. 3. An audit was conducted for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that did not have a change in condition evaluation, transfer form, order for transfer, notes documenting follow up, or change of condition documented on the 24 hour report, and if respiratory change in condition was respiratory assessment documented . 4. There will be a QA meeting on [DATE] to review the findings. 5. A respiratory change in condition plan was developed on [DATE] for resident ' s not on the ventilator unit. The following is the plan: a. For residents who have an acute change in respiratory status the respiratory therapist will be notified and the nurse will complete a change in condition (using information from the nurses assessment as well as the respiratory therapist), the respiratory therapist will complete respiratory assessment and follow the policy for Respiratory Assessment/Intervention for Non-Respiratory Caseload Patients. b. MD and family to be notified and documentation completed. If the person already has order for prn oxygen this will be applied, family will be notified. MD will be notified if the resident's 02 saturation does not improve within 15 minutes or immediately if the resident exhibits clinical signs or symptoms of acute respiratory distress. c. Resident will be moved to the vent unit if placed on NIV or [MEDICAL CONDITION]. If there is no bed available, then will be moved to 200 Hall, if no beds are available on either unit the MD will be contacted regarding possible transfer to the ER. d. If the resident remains in facility there will be charting at a minimum of,15 minute follow up, every 30 minutes x2 then hourly x2, then resume every shift pertinent charting if resident's respiratory condition has stabilized with rounding every two hours and documentation as needed in the chart related to status. 6. 30 of 30 of the nurses were educated regarding the respiratory change in condition plan by the DON. In¿ service conducted on [DATE] by DON 22 of 30 nurses were in-serviced , any nurses who did not attend were educated via telephone on [DATE] 8 of 30 were in-serviced via telephone. 7. Guidelines for notification of the nurse manager on call were developed on [DATE] by the CNO for Reliable Health Care Management , they include use of the Interact change in condition cards- if the resident meets the criteria for immediate notification or has a critical lab not covered by the change in condition cards and a nurse manager is not in the building or it is the weekend the nurse manager on call will be notified. The nurse manager will log this on the Nurse Manager On-Call Log. These have been submitted to the Quality Assurance Committee and added to the Licensed Nursing Orientation [DATE]. Review and follow-up guidelines for a change in condition for the nurse manager on call to follow were developed on [DATE] by the CNO for Reliable Health Care Management to include notification of the responsible pai1y, MD or NP on call, a nurse manager or RN weekend supervisor if she/he is in the building on the weekend, and the on-call nurse if after hours or on the weekend, completion of the Interact Change of Condition Form and use of the Interact Clinical Pathways if applicable. The Review and follow-up guidelines have been submitted to the Quality Assurance Committee and added to Licensed Nursing Orientation [DATE]. 8. 6 of 6 of the nurse managers were educated on the Guidelines for notification , their responsibilities while on call related to the review and follow up guidelines and documentation on the Nurse Manager On Call Log. This education was done by the DON on [DATE] 6 out 6 nurse managers attended and were in-serviced. 30 of 30 of nurses were educated by the DON on [DATE] regarding the guidelines for notification of the nurse manager in the building and the on-call nurse after hours and on weekends and the review and follow-up guidelines for a change in condition. In-service conducted on [DATE] by DON 22 of 30 nurses were in-serviced, any nurses who did not attend were educated via telephone on [DATE] 8 of 30 were in-serviced via telephone. 9. A Change in Condition audit tool developed on [DATE] by the CNO for Reliable Health Care Management to ensure that the guidelines for notifying a nurse manage in the building, the on-call nurse after hours and weekends, as well as the RN supervisor on the weekend and that the guidelines for review and follow up for a change in condition are being followed. The audit tool will be completed weekly for 5 residents experiencing a change in condition, if there are changes in condition related to acute respiratory changes up to 2 of these will be included. This audit will be completed by the DON, if she is not available to complete the audit then it will be done by the ADON. 10. The CNO will in-service the DON, ADON, Director of Respiratory Services, and Administrator on completion of the Change in Condition Audit on [DATE]. 4 out of 4 were present and in-serviced via conference call on [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. The Pertinent Charting Policy revised on [DATE] was reviewed. A pertinent daily charting list will be maintained at the nursing station. The list for pertinent charting will include Residents with a change of condition and will include a Skilled Nursing Note on all shifts. This requires documentation for a minimum of 72 hours. Nursing Management may determine that assessment/documentation is indicated for longer than the timeframe listed, but not less. This documentation will be completed on each shift and will include full vital signs. 2. On [DATE] education was conducted by the facility for 30 of 30 nursing staff. The policy revision conducted on [DATE] was included in an in-service education conducted on [DATE]. Rosters and education content were reviewed. Twenty-two nurses signed the roster on [DATE] and eight were educated by telephone. The education roster from [DATE] including revision to the policy for pertinent charting was signed by twenty of thirty-four nurses, and the roster indicated fourteen were educated by telephone. See below list of nursing staff verifying this education. 3. An audit of fifty-seven resident records for all residents transferred to the hospital between [DATE] and [DATE], completed on [DATE], was reviewed. Thirty-two records did not include a change in condition evaluation. Twenty-one records did not have a transfer form. Forty-nine records did not include a documented Physician order for [REDACTED]. 4. The roster and content of the QA meeting held on [DATE] to discuss the The minutes and roster of the QA meeting held on [DATE]. Findings related to the audit for all residents transferred to the hospital between [DATE] and [DATE] were discussed. The roster was signed by nineteen Quality Assurance Committee Members. 5. The Respiratory Change in Condition Plan was reviewed. The Respiratory Therapist is to be notified of any residents having an acute change in respiratory status. The nurse will complete a change in condition form. The Respiratory Therapist will complete a respiratory assessment and follow the policy for Respiratory Assessment/Intervention for Non-Respiratory Caseload Patients. The Physician and family are to be notified and the documentation completed. If the residents oxygen saturation does not improve the Physician is to be notified in 15 minutes or immediately if the resident exhibits signs of acute respiratory distress. If the resident is placed on non invasive ventilation (NIV) or bilevel positive airway pressure ([MEDICAL CONDITION]), they are to be moved to the ventilator unit. If there is no bed available on the ventilator unit the resident should be moved to the 200 hall. If there are no beds available on the 200 hall the Physician should be notified for possible transfer to the Emergency Department. If the resident is not transferred to the Emergency Department there will be charting at a minimum of fifteen minute follow up, then every thirty minutes twice, then every hours twice, then resume every shift if the respiratory status has stabilized, with rounding every two hours and documentation as needed. 6. Education content and rosters were reviewed for the respiratory change in condition plan, conducted on [DATE]. The roster included the signatures of twenty-two licensed nursing staff and indicated eight were educated by telephone. See below interviews of nursing staff confirming education regarding the respiratory change in condition plan and acknowledging understanding. 7. Guidelines, developed on [DATE] for notification of the nurse manager of resident change in condition, required notifications, completion of Interact Change of Condition form, follow up guidelines, and use of the Interact Clinical Pathways were reviewed. Interview conducted [DATE] at 4:45 p.m. with the Director of Nurses revealed the guidelines had been submitted to the QA committee and no revisions were recommended at the meeting held [DATE]. 8. Education content and rosters were reviewed regarding an in-service conducted on [DATE] including the guidelines of notification of Nurse Managers of resident change in condition, and follow up guidelines for a change in condition. The in-service was also presented

Based on record review, and staff interviews, the facility failed to follow the respiratory care plan interventions for one of eight sampled residents (R#1) that experienced acute respiratory distress. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio Hills Health and Rehabilation beginning [DATE] and concluding on [DATE]. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. During the Recertification Survey conducted on [DATE] through [DATE] additional residents were reviewed for a change of condition was noted. There were no additional issues identified. The previous findings for R#1 were reviewed and the determination of immediate jeopardy were confirmed on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Cross Refer to F328 Findings include: 1. R#1 was admitted to the facility on [DATE] from an acute care hospital with a [MEDICAL CONDITION] and tube feeding via PEG. [DIAGNOSES REDACTED]. On [DATE] the resident'[MEDICAL CONDITION] removed and on [DATE]. Record review for R#1 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] which documented in Section C- Cognitive Patterns a Brief Interview for Mental Status (BIMS) summary score of three, indicating severe cognitive impairment. Section J- Health conditions assessed that R#1 had a condition of shortness of breath while lying flat. Section O- Special Treatments and Programs documented the resident received oxygen therapy and suctioning and had a [MEDICAL CONDITION]. Further record review for R#1 revealed a Physician order [REDACTED]. Review of the Weights and Vitals Summary from [DATE] through [DATE] documented Sp02 results ranging from ,[DATE]% and indicated that R#1 was on room air. There was no further documentation after [DATE]. Review of respiratory care plan initiated [DATE] identified that R#1 has oxygen at four liters per minute (4 LPM) via nasal cannula (NC) related to [MEDICAL CONDITIONS]. The Goal documented the resident will have no signs or symptoms or poor oxygen absorption through the review date. Interventions included, but not limited to; 1. Monitor for signs and symptoms of respiratory distress and report to MD (Physician) PRN (as needed): respirations, pulse oximetry (Sp02), increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle use and skin color. 2. Provide reassurance and allay anxiety. Have an agreed method for the resident to call for assistance (e.g. call light, bell). Stay with the resident during episodes of respiratory distress. Interview on [DATE] at 4:19 p.m. with RT BB) revealed that on the dayshift of [DATE], LPN AA asked him between 3:00 p.m. - 4:00 p.m. to evaluate R#1 due to the resident had coughed up some mucous and it was green. RT BB stated when R#1 was evaluated, the resident's respiratory status was stable and his oxygen saturation (Sp02) was in the 90'sand stated that he documented a note and that he had been unable to retrieve the note in the electronic charting system. RT BB further stated that he gave report to the oncoming nightshift Respiratory Therapist (RT JJ). Telephone interview on [DATE] at 4:40 p.m. with RT JJ revealed he worked the nightshift (7:00 p.m. - 7:00 a.m.) on [DATE] when R#1 expired but he had never seen the resident. He stated he never received report from the departing therapist RT BB that R#1 had a change in condition. He stated he did not set R#1 up on [MEDICAL CONDITION] and he did not receive report that the resident had been placed on [MEDICAL CONDITION] for respiratory distress. He stated he was never asked by the nurses during that shift to check or evaluate R#1. Further interview on [DATE] at 4:50 p.m. with RT BB revealed that he had another resident on a ventilator that was going bad at the same time that R#1 was having respiratory distress and the nurse (LPN AA) handled the situation and called the Nurse Practitioner. He stated that he had set the resident up on [MEDICAL CONDITION] he thought around 4:45 p.m. RT BB stated he did check R#1 around 6:00 p.m. and his Sp02 was in the 90's but stated that he was unable to find any documentation of his assessments or when he initiated [MEDICAL CONDITION] therapy for R#1 in the electronic charting system. Interview on [DATE] at 4:52 p.m. with the Respiratory Director revealed when R#1 was placed on [MEDICAL CONDITION] for noninvasive ventilation related to respiratory distress, the resident should have had a respiratory assessment and the facility protocol should have been followed. This is to be documented in the Respiratory Assessment area of the electronic charting and that a note should have been documented in the Progress Notes. She further stated that resident should have absolutely been monitored and re-assessed after being placed on [MEDICAL CONDITION] therapy. The Respiratory Director confirmed that there was no respiratory documentation in the resident's clinical chart related to the resident's change of condition, respiratory status, respiratory assessment, [MEDICAL CONDITION] use or settings, oxygen saturation checks or re-assessments/monitoring. In an interview with the LPN AA on [DATE] at 5:08 p.m., she reported that the morning of [DATE], R#1 seemed to be very depressed and was just staring out of the window. LPN AA stated R#1 wasn't really lethargic but not himself. LPN AA stated around 2:00 p.m. -3:00 p.m. the resident seemed sleepy and when she checked his Sp02, it was 74% (normal range is above 90%). She stated that she placed the resident on oxygen at two liters per minute (2 LPM) via nasal cannula and there was no improvement in the resident's condition. LPN AA stated she received an order from the Nurse Practitioner (NP) to initiate [MEDICAL CONDITION] and that the Respiratory Therapist (RT BB) placed R#1 on [MEDICAL CONDITION] but she did not remember the time. LPN AA further stated that she never returned to re-assess R#1 and had not seen the resident again after he was placed on [MEDICAL CONDITION] for the remainder of her shift (7:00 a.m. - 7:00 p.m.). LPN AA stated she had no good answer for why she did not re-assess or monitor R#1, It gets busy at the end of the shift but I know that is not a good excuse. Telephone interview on [DATE] at 5:28 p.m. with the 7:00 p.m. - 7:00 a.m. LPN CC revealed the night of [DATE] she saw the resident first around 8:00 p.m. - 8:30 p.m. She stated she checked the resident's Sp02 and it was she believed 91%. She stated that she thought she had documented her assessment and the resident's Sp02 but she could not be sure without checking the computer. LPN CC stated that the next time she saw R#1 was about 10:30 p.m. and he seemed fine. LPN CC stated around 11:15 p.m. she checked on R#1 and he was not responsive. She called RN FF to come and check R#1 and it was determined the resident had expired. Interview on [DATE] at 2:08 p.m. with the Nurse Practitioner (NP GG) revealed she was covering for the attending physician of R#1 on [DATE] while he was out of town. NP GG stated a nurse had called her one time on [DATE]. She stated it was reported to her that the residents C02 (carbon [MEDICATION NAME]) was elevated and his oxygen saturation was low. She stated that she ordered [MEDICAL CONDITION] with the agreed decision to see how he would do on [MEDICAL CONDITION] first, but she never heard back from anyone at the facility. NP GG stated she stated the [MEDICAL CONDITION] was ordered as noninvasive ventilation secondary to respiratory distress. She stated if the resident continued to decline, she would have ordered a chest x-ray and possible antibiotics for potential aspiration pneumonia and that would have been verified by chest x-ray, however, no one ever called her back about the resident's condition. NP GG stated that since R#1 was having drops in his oxygen saturation, the resident's Sp02 should have been monitored to make sure the resident was improving. She stated the resident should have been re-assessed after being placed on [MEDICAL CONDITION] and ongoing assessments should have been conducted by both the nurse and the respiratory therapist. An interview with the Director of Respiratory Therapy, LL, on [DATE] at 11:04 a.m. revealed that she was aware that both nursing and RT department did not follow the care plan for R#1 on [DATE] although her department has been in-serviced on care plans, monitoring and notification since that time. Interview of the ADON on [DATE] at 2:00 p.m. revealed that after the incident with R#1, when staff did not follow the Respiratory care plan, that all resident's care plans were reviewed to ensure the care plans were accurate and that staff was in-serviced to follow the care plans for residents. The facility implemented the following actions to remove the Immediate Jeopardy: 1. New policies and procedures developed by DON, Dir. of Respiratory Therapy, CNO for Corp Office, and Medical Director: 24 hour Respiratory Report; Respiratory Assessment /Intervention for Non-Respiratory Caseload Patients; Respiratory Pertinent Charting on [DATE]. 2. 6 of 6 of respiratory therapists were educated on the new polices by the Director of Respiratory Therapy on [DATE]. ,[DATE] respiratory therapists were educated via telephone, ,[DATE] in facility. They were also reviewed again at the facility in-service on [DATE] and ,[DATE] attended. 6 of 6 of Respiratory therapists were educated on documentation expectations of Assessments, documentation of respiratory progress notes, and providing care according to the resident's comprehensive plan of care by the Director of Respiratory Therapy on [DATE] ,[DATE] were in-serviced in facility. 3. The policy for Non-Invasive Ventilation was revised by DON, Dir. Of Respiratory Therapy, CNO for Corp Office, and Medical Director and ,[DATE] of respiratory therapists were educated on the revised policy by the Director of Respiratory Therapy on [DATE]. ,[DATE] respiratory therapists were educated via telephone , ,[DATE] in facility. They were also reviewed again at the facility in-service on [DATE] and ,[DATE] attended. 4. New policies and procedures: 24-hour Respiratory Report; Respiratory Assessment /Intervention for Non-Respiratory Caseload Patients; Respiratory Pertinent Charting, added to orientation for Respirator y Therapists on [DATE]. There have been no new respiratory therapists hired since [DATE]. 5. Revised policy for Non-Invasive Ventilation was added to orientation for Respirator y Therapists on [DATE]. There have been no new respiratory therapists hired since [DATE]. 6. An audit was conducted for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that did not have a change in condition evaluation, transfer form, order for transfer, notes documenting follow up, or change of condition documented on the 24 hour report , and if respiratory change in condition was respiratory assessment documented . 7. There will be a QA meeting on [DATE] to review the findings. 8. A Change in Condition audit tool developed on [DATE] by the Chief Nursing Officer for Reliable Health Care Management to ensure that the guidelines for notifying a nurse manage in the building, the on-call nurse after hours and weekends , as well as the RN supervisor on the weekend and that the guideline s for review and follow up for a change in condition are being followed. The audit tool will be completed weekly for 5 residents experiencing a change in condition, if there are changes in condition related to acute respiratory changes up to 2 of these will be included. This audit will be completed by the DON, if she is not available to complete the audit then it will be done by the ADON. 9. The CNO will in-service the DON, ADON, Director of Respiratory Services, and Administrator on completion of the Change in Condition Audit on [DATE]. 4 out of 4 were present and in-serviced via conference call on [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. A review of the new policies and procedures developed on [DATE] included the 24-hour Respiratory Report, Respiratory Assessment and Intervention for Non-Respiratory Caseload Patients and Respiratory Pertinent Charting. 2. Review of the education content and rosters for education conducted for Respiratory Therapists revealed education was given on [DATE] for new policies regarding completion of the 24-hour Respiratory Report, Respiratory Assessment and Intervention for Non-Respiratory Caseload Patients, and Respiratory Pertinent Charting. One Respiratory Therapist was in the building and was in serviced and five were in serviced by telephone. On [DATE] an in-service was conducted and six of six Respiratory Therapists were present and signed the roster. Interview with Respiratory Therapist JJ on [DATE] at 2:35 p.m. and Respiratory Therapist EE on [DATE] at 3:00 p.m. confirmed education given on [DATE] and [DATE] regarding new policies including the completion of the 24-hour Respiratory Report, Respiratory Assessment and Intervention for Non-Respiratory Caseload Patients, and Respiratory Pertinent Charting, and acknowledged their understanding of the education. A review of the 24-hour Respiratory Report was conducted and R#18 and R#120 were included. Record review for R#18 revealed Pertinent Respiratory documentation occurred on [DATE] at 11:35 a.m. and 12:14 p.m. A skilled respiratory assessment was also completed at 11:30 a.m. Record review for R#120 revealed Pertinent Respiratory documentation recorded on [DATE] at 9:24 a.m. and [DATE] at 10:10 a.m. A full respiratory assessment was documented at 9:20 a.m. Documentation was completed according to policy and education for the two sampled residents with respiratory changes in condition. 3. The revised policy for Non-Invasive Ventilation was reviewed. Education content and rosters were reviewed. Interview with Respiratory Therapist JJ on [DATE] at 2:35 p.m. and Respiratory Therapist EE on [DATE] at 3:00 p.m. confirmed education given on [DATE] and [DATE] regarding the revised policy for Non-Invasive Ventilation, and acknowledged understanding. 4. During an interview conducted on [DATE] at 3:10 p.m. the Director of Respiratory Services confirmed there had been no new Respiratory Therapists hired since [DATE]. Any newly hired Respiratory Therapists will be educated to complete the 24-hour Respiratory Report, the Respiratory Assessment/Intervention for Non-Respiratory Caseload Patients, Respiratory Pertinent Charting before they are allowed to begin working with residents. 5. An interview conducted on [DATE] at 3:10 p.m. with the Director of Respiratory Services revealed the revised policy for Non-Invasive Ventilation will be a part of orientation for all newly hired Respiratory Therapists beginning [DATE]. There have not been any new Respiratory Therapists since [DATE]. 6. The audit for all residents transferred to the hospital between [DATE] and [DATE] was reviewed. Fifty-seven resident records were included. Thirty-two records did not include a change in condition evaluation. Twenty-one records did not have a transfer form. Forty-nine records did not include a documented Physician order [REDACTED]. 7. A review of the minutes and content of the QA meeting conducted on [DATE] revealed the findings of the audit of residents for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that did not have a change in condition evaluation, transfer form, order for transfer, notes documenting follow up, or change of condition documented on the 24-hour report and if respiratory change in condition was respiratory assessment documented. Nineteen QA committee members signed the roster. 8. Review of the Change in Condition Audit tool for the week of [DATE] through [DATE] revealed the Change in condition audit tool developed on [DATE] including five records of residents experiencing a change in condition. The Nurse Manager was notified of the five changes in condition. The on call log was not filled out by the Nurse Manager for one resident. Follow up call to family and follow up documentation per education were not completed for one resident with a respiratory change in condition. 9. Interview of the ADON on [DATE] at 2:00 p.m., the Administrator on [DATE] at 3:20 pm the DON on [DATE] at 4:45 p.m., and the Director of Respiratory Services on [DATE] at 3:10 p.m. acknowledged receiving education on conducting the Change in Condition audit tool from the Corporate Chief Nursing Officer, and confirmed their understanding. 10. R#135 was admitted to the facility from her home on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] at 10:40 p.m. her PEG tube was noted to be causing concern to the family members and the family thought it was protruding from her abdomen more than usual. The Physician was notified on [DATE] at 10:45 p.m. An X Ray was ordered but could not be completed due to inclement weather. Transfer to the local hospital was ordered. On [DATE] at 11:15 p.m. the family was notified of the transfer and refused. On [DATE] at 2:30 a.m. the family decided the resident was to be transferred and the resident was sent to the hospital of the family's choice. The resident was monitored appropriately, the Physician and family were notified timely. 11. R#18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:00 a.m. he began to have [MEDICAL CONDITION] activity. The Physician was notified at 11:18 a.m. The Respiratory Therapist was notified at 11:30 a.m. when oxygen saturations began to drop. The family was notified at 11:42 a.m. The Physician was again called at 12:15 p.m. and the resident was transferred to the hospital. The family and DON were notified at 12:05 p.m. The resident was monitored appropriately, the Physician and family were notified timely. 12. R#120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Respiratory Therapist was in the room and continued to work with the resident and at 10:10 a.m. the Nurse Practitioner was notified the resident was not improving and ordered R#120 transferred to the hospital. The family had been notified at 9:45 a.m. The Nurse Manager was notified at 10:20 a.m. as the resident was transferred. The resident was monitored appropriately, the Physician and family were notified timely.

Based on record review, review of the policy titled Quality Assessment and Assurance Program and staff interview, the facility failed to ensure that it was administered in manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and/or psychosocial wellbeing of each resident. Specifically, the Administrator was made aware on [DATE] that a resident (R#1) had a change in his condition on [DATE] secondary to respiratory distress and that the nursing staff failed to document the resident's change in condition and failed to notify the family/responsible party until after R#1 expired at 11:20 p.m. The Administrator failed to implement its Quality Assessment and Assurance Program and therefore, was not aware that R#1 had not been properly monitored and re-assessed by the nursing and respiratory staff after the R#1 was placed on [MEDICAL CONDITION] (Biphasic Positive Airway Ventilation) as a means of non-invasive ventilation secondary to acute respiratory distress. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio Hills Health and Rehabilitation beginning [DATE] and concluding on [DATE]. After review by the RO, a survey team re-entered on [DATE] through [DATE] to futher investigate the complaint and for a recertification survey. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. During the Recertification Survey conducted on [DATE] through [DATE] additional residents were reviewed for notification when a change of condition was noted. There were no additional issues identified for notification. The previous findings for R#1 were reviewed and the determination of immediate jeopardy were confirmed on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. (Refer F157, F281, F328, F514 and F520) Findings include: Review of the undated facility policy titled Quality Assessment and Assurance Program documented that It is the policy of Reliable Healthcare, Inc. that each facility actively participates in a formalized and written quality assessment, assurance and improvement program. The process is comprehensive (involving all departments) and includes monitoring, evaluation and follow up actions. All care provide residents/patients in the facility operations affecting resident/patient care shall be included in the Quality Assurance Program (QA). Section IV Meetings- Emergency meetings of the Committee may be called by the Chairperson or a quorum of the Committee. A quorum will be considered fifty (50%) of the membership. Section VI Responsibilities of the Administrator- follows the QA/CQI Programs. Ensures that each department carries out their QA/CQI program accurately and uniformly through report reviews: Each individual department will be responsible for monitoring and evaluating the resident/ patient care services they provide. Interview on [DATE] at 2:27 p.m. with the Administrator revealed he was aware that there was no change of condition documented for R#1 and that the nurse did not call the RP. He stated that he and the Director of Nursing (DON) got together and put a plan together to educate the nursing staff. He stated this concern and plan was not formally placed in QA and would have been discussed in the next QA meeting. The Administrator was asked that if an identified quality concern involved a resident death, should it have been placed QA, he responded that he was not sure and he would have to review the policy. The Administrator further stated he was not aware that the staff did not re-assess or monitor the R#1's condition after placing him on [MEDICAL CONDITION]. Further interview with the Administrator at 3:58 p.m. revealed the facility does not have a specific policy for governing body or job description for the Administrator. He stated the responsibilities of the Administrator is outlined in the policy titled Quality Assessment and Assurance Program. During a subsequent interview conducted on [DATE] at 3:08 p.m. with the Administrator, he stated that after he became aware that there was no change of condition documented for R#1 and that the responsible party was not notified until after R#1 had passed away, he and the DON got together and put a plan in place to educate the nursing staff but nothing further than that was implemented. He stated the concerns were not placed in QA and that an Emergency Meeting with at least 50% of the QA Committee in attendance was not conducted. The Administrator stated that when a concern is placed in QA, the committee discusses a route cause analysis to identify the underlying problem and will gather a sample of other residents for review. He stated that a plan of action or correction is put in place and followed through by the appropriate department head by means of data collection, monitoring and audits until the concern is resolved. When the Administrator was asked at 3:15 p.m. if they had placed these concerns in QA at the time they were identified to discuss the route cause and sample and review additional residents; would he have found that R#1 was not appropriately assessed and monitored by either the nursing staff or the respiratory staff and that respiratory staff did not document in R#1's clinical record and would he have potentially identified another resident (R#2) (Refer F514) that had a change in condition related to respiratory distress on [DATE] that did not have the appropriate documentation? The Administrator responded It's possible we would have. An interview conducted on [DATE] at 3:20 p.m. with the Administrator revealed that he had been made aware of the incident with R#1 although he had not put this into QA until after the complaint investigation had begun. He confirmed that staff education had been initiated although nothing further had been implemented until after being notified of the IJ related to change in condition, notification of the Physician/NP and family, monitoring by staff after a change in condition. he received education on [DATE] regarding F490, including the citation, regulation, definition, guidance and probes, by the Chief Nursing Officer. The facility implemented the following actions to remove the Immediate Jeopardy: 1. An emergency Quality Assurance Meeting was held on [DATE] regarding the quality concerns identified regarding the care of Res #1 and Res #2 related to change of condition related to acute respiratory distress. The Quality Assessment and Assurance Program policy was reviewed. An addendum was added to the Quality Assessment and Assurance Program Policy section IV. Meeting subsection C. Emergency. 2. The Administrator was in-serviced on the Quality Assessment and Assurance Program policy including the addendum to the policy addressing emergency meetings of the Quality Assurance Committee. The A Committee will conduct a root cause analysis to identify the underlying issues and any trends that contributed to the recognized problem, develop a plan, execute the plan, review/study the results of the plan, Re-evaluate the plan and determine if the plan needs to be modified. This in-service was provided by the CNO of the Corp office on [DATE]. 3. The Quality Assurance Committee was in-serviced by the Administrator on the Quality Assessment and Assurance Program policy including the addendum to the policy addressing emergency meetings of the Quality Assurance Committee. The QA Committee will conduct a root cause analysis to identify the underlying issues and any trends that contributed to the recognized problem, develop a plan, execute the plan, review/study the results of the plan, Re-evaluate the plan and determine if the plan needs to be modified . This in-service was provided on [DATE] by the administrator ,[DATE] were in-serviced in facility on ,[DATE], of the remaining 2, 1 is no longer an employee and the other 1 will be in-serviced today [DATE]. 4. The Administrator' s personnel file was reviewed and a signed job description dated [DATE] was present. Interview with the Administrator on [DATE] at 5:30 p.m. revealed his job description is included in the Quality Assurance Coordinator description. The Administrator was in-serviced on F490 to include citation, definition, guidance and probes by the CNO on [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. Review of the policy titled Quality Assessment and Assurance Program documented that it is the policy of Reliable Healthcare, Inc. that each facility actively participates in a formalized and written quality assessment, assurance and improvement program. The process is comprehensive (involving all departments) and includes monitoring, evaluation and follow up actions. All care provided residents/patients in the facility operations affecting resident/patient care shall be included in the Quality Assurance Program (QA). VI- Responsibilities of the Administrator follows the QA/CQI Programs. Ensures that each department carries out their QA/CQI program accurately and uniformly through report reviews: Each individual department will be responsible for monitoring and evaluating the resident/ patient care services they provide. Each Committee or Department will submit his/her reports. The addendum IV- Meetings documented that emergency meetings will of the Committee may be called by the Chairperson or quorum of the Committee. A quorum will be considered 50% of membership. 2. The in-service of the Administrator, conducted on [DATE] by the Corporate Chief Nursing Officer, with the Administrator's signature was reviewed. Review of education topics received by the Administrator on [DATE] by the Corporate Chief Nursing Officer included the Quality Assessment and Assurance Program policy, including the addendum addressing emergency meetings. An interview conducted on [DATE] at 3:20 pm with the Administrator revealed he received education on [DATE] regarding issues to be addressed by the Quality Assurance Committee are identified by audit schedules for areas such as laboratory orders and reports, treatments, and foot care. Other methods of identifying issues include infection control or other trends, quality indicator flags such as psychiatric medications, pain, survey results, complaints, grievances and [MEDICATION NAME]. The Administrator explained he recently had identified a need for emergency Quality Assurance meetings and educated the committee and the policy addendum was approved by the committee on [DATE]. Action plans are developed by the department associated with the issue. The plans, audits, monitoring, revisions to the plan and to policies are all approved by the medical director if the issue is clinical. The audits for desired outcomes are taken to Quality Assurance Committee and adjusted, continued, or determined to be resolved. The issues of family notification of change in resident condition, and lack of documentation regarding change in condition had been identified and the Director of Nurses had educated licensed staff on [DATE]. 3. Eighteen signatures, including the Administrator and the Medical Director were included. The minutes included Nursing and Respiratory Plans of Correction, with monitoring and submission of monitoring to the Quality Assurance Committee every month for 3 months. The addendum to the Quality Assurance Policy Addendum providing for emergency meetings to address issues that cannot be held until the next regularly scheduled meeting. An emergency meeting will be held for all identified quality issues/concerns with the potential for harm. The QA committee was instructed to cause a root cause analysis to identify the underlying issues and any trends that contribute to the recognized problem, develop a plan, execute the plan, review/study the results of the plan, re-evaluate the plan and determine if the plan needs to be modified. The nineteenth signature was documented on [DATE]. 4. Interview with the Administrator on [DATE] at 5:30 p.m. revealed his job description is included in the Quality Assurance Coordinator description. 5. An interview conducted on [DATE] at 3:20 p.m. with the Administrator revealed he received education on [DATE] regarding F490, including the citation, regulation, definition, guidance and probes, by the Chief Nursing Officer.

Based on record review, review of the policy titled Quality Assessment and Assurance Program and staff interviews, the facility failed to maintain an effective Quality Assurance (QA) program which systematically identified, reviewed, developed, and implemented plans to correct quality deficiencies. Specifically, the facility identified a quality concern on [DATE] related to lack of documentation of a resident's (R#1) change in condition and failure to notify the responsible party. The facility provided education to the nursing staff on [DATE] but failed to place the quality concern in the QA program and was unaware that in addition to a lack of documentation, R#1 was not appropriately assessed, re-assessed or monitored by the nursing and respiratory staff after being placed on [MEDICAL CONDITION] (Biphasic Positive Airway Pressure) as a means of non-invasive ventilation secondary to acute respiratory distress. Additionally, the facility was not aware that the respiratory staff failed to document respiratory assessments, document the implementation of [MEDICAL CONDITION] therapy or document [MEDICAL CONDITION] settings. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio Hills Health and Rehabilitation beginning [DATE] and concluding on [DATE]. After review by the RO, a survey team re-entered on [DATE] through [DATE] to futher investigate the complaint and for a recertification survey. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. During the Recertification Survey conducted on [DATE] through [DATE] additional residents were reviewed for notification when a change of condition was noted. There were no additional issues identified for notification. The previous findings for R#1 were reviewed and the determination of immediate jeopardy were confirmed on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Cross refer to F328 Findings include: Review of the undated facility policy titled Quality Assessment and Assurance Program documented that It is the policy of Reliable Healthcare, Inc. that each facility actively participates in a formalized and written quality assessment, assurance and improvement program. The process is comprehensive (involving all departments) and includes monitoring, evaluation and follow up actions. All care provided residents/patients in the facility operations affecting resident/patient care shall be included in the Quality Assurance Program (QA). Each Committee or Department will submit his/her reports. IV- Meetings documented that Emergency meetings of the Committee may be called by the Chairperson or quorum of the Committee. A quorum will be considered 50% of membership. R#1 was admitted to the facility on [DATE] from an acute care hospital with a [MEDICAL CONDITION] and tube feeding via PEG. [DIAGNOSES REDACTED]. On [DATE] the resident'[MEDICAL CONDITION] removed and on [DATE] the resident advanced to a puree diet, however, the PEG remained in place for the administration of medications. On [DATE] during the dayshift at an undetermined time, R#1 presented with acute respiratory distress that required non-invasive ventilation via [MEDICAL CONDITION]. Record review for R#1 revealed a Nurse's Note created by LPN AA LPN on [DATE] at 8:32 p.m. with an effective date and time of [DATE] at 10:17 a.m. which documented Resident coughing/spitting up thick greenish brown sputum. Mouth was suctioned out. Resident very sleepy. 02 sats 90% R[NAME] Gave all meds through feeding tube. Monitored resident throughout day. 02 sats started declining to 74. Resp. nurse informed, Dr. (name) NP called, [MEDICAL CONDITION] was ordered and placed on resident. Will continue to monitor resident. (sic) There was no further documentation in the clinical record for R#1 related to his change in condition until LPN CC created a Nurse's Note on [DATE] at 12:21 a.m. with an effective date and time of [DATE] at 12:00 a.m. which documented At approximately 11:20 pm I was making my rounds and when I went into resident room. I notice that resident was unresponsive and gray in color. Resident a DNR. I assessed resident by checking pulse and then proceeded to have the RN supervisor from the vent unit to confirm resident status. Next of kin was notified and funeral home of family choice was notified. (sic) Review of the Weights and Vitals Summary revealed the last recorded vital signs on [DATE]. Continued review of R#1's clinical record revealed no evidence or documentation on [DATE] of a respiratory assessment, when the resident presented with acute respiratory distress, initiation of [MEDICAL CONDITION] therapy, non-invasive protocols implemented related to determination of appropriate [MEDICAL CONDITION] settings, toleration of [MEDICAL CONDITION], oxygen saturation, and re-assessments and/or monitoring of R#1 after being placed on [MEDICAL CONDITION]. An electronic Physician order [REDACTED]. Interview on [DATE] at 4:19 p.m. with the Respiratory Therapist (RT BB) revealed that he worked on the dayshift of [DATE] when the Licensed Practical Nurse (LPN AA) asked him between 3:00 p.m. - 4:00 p.m. to evaluate R#1 due to the resident had coughed up some mucous and it was green. RT BB stated when R#1 was evaluated, the resident's respiratory status was stable and his oxygen saturation (Sp02) was in the 90's. He further stated that respiratory works 12 hours shifts and he gave report to the oncoming nightshift Respiratory Therapist (RT JJ) and added that R#1 was still stable at the end of his shift (7:00 a.m.- 7:00 p.m.). RT BB stated that he documented a note and that he had been unable to retrieve the note in the electronic charting system. Telephone interview on [DATE] at 4:40 p.m. with RT JJ revealed he worked the nightshift (7:00 p.m. - 7:00 a.m.) on [DATE] when R#1 expired but that he never assessed R#1 or monitored the resident because he did not receive report that R#1 had a change in condition or that he was placed on [MEDICAL CONDITION] for respiratory distress. Interview on [DATE] at 4:52 p.m. with the Respiratory Director revealed when R#1 was placed on [MEDICAL CONDITION] for noninvasive ventilation related to respiratory distress, the resident should have had a respiratory assessment and the facility protocol should have been followed. This is to be documented in the Respiratory Assessment area of the electronic charting and that a note should have been documented in the Progress Notes. She further stated that resident should have absolutely been monitored and re-assessed after being placed on [MEDICAL CONDITION] therapy. The Respiratory Director confirmed that there was no respiratory documentation in the resident's clinical chart related to the resident's change of condition, respiratory status, respiratory assessment, [MEDICAL CONDITION] use or settings, oxygen saturation checks or re-assessments/monitoring. In an interview with LPN AA on [DATE] at 5:08 p.m., she reported that the morning of [DATE], R#1 seemed to be very depressed and was just staring out of the window. LPN AA stated R#1 wasn't really lethargic but not himself so she did not administer his [MEDICATION NAME] and that his Sp02 was in the 90's. LPN AA stated around 2:00 p.m. -3:00 p.m. the resident seemed sleepy and when she checked his Sp02, it was 74% (normal range is above 90%). She stated that she placed the resident on oxygen at two liters per minute (2 LPM) via nasal cannula and there was no improvement in the resident's condition. LPN AA stated she received an order from the Nurse Practitioner (NP) to initiate [MEDICAL CONDITION] therapy however, she could not remember the time. LPN AA stated that the Respiratory Therapist (RT BB) placed R#1 on [MEDICAL CONDITION] but she did not remember the time. LPN AA further stated that she never returned to re-assess R#1 for the remainder of her shift (7:00 a.m. - 7:00 p.m.). LPN AA stated she had no good answer for why she did not re-assess or monitor R#1, It gets busy at the end of the shift but I know that is not a good excuse. She stated she did make a notation at the end of her shift but not a detailed notation. Interview on [DATE] at 5:17 p.m. with the Director of Nursing (DON) revealed she was on vacation when R#1 expired on [DATE] and returned to work on [DATE]. The DON stated she was made aware when she returned to work that the resident had respiratory distress and was placed on [MEDICAL CONDITION] and aware that the nurse did not notify the family/responsible party (RP Z) of R#1's change in condition. She stated that RP Z had called her on Monday [DATE] and wanted to know what happened to R#1. RP Z had reported to her that no one had called her until after R#1 had already passed away. The DON stated the nurse should have called RP Z when R#1's condition changed. The DON stated she was not aware that LPN AA had not re-assessed or monitored R#1 after his change of condition and being placed on [MEDICAL CONDITION] for the rest of her shift. She stated that her expectation would include a skilled nursing assessment and ongoing monitoring after R#1 had a change in his condition and after being placed on [MEDICAL CONDITION]. The DON further stated she educated the nursing staff on documenting in the e-Interact Tool- Change in Condition Evaluation Assessment pathway in the electronic charting system and notifying family in the event of a change in condition. on [DATE]. Telephone interview on [DATE] at 5:28 p.m. with the 7:00 p.m. - 7:00 a.m. LPN CC revealed the night of [DATE] she had received report from LPN AA that R#1 was placed on [MEDICAL CONDITION] due to respiratory distress. LPN CC stated she saw the resident first around 8:00 p.m. - 8:30 p.m. She stated she checked the resident's Sp02 and it was she believed 91%. She stated that she thought she had documented her assessment and the resident's Sp02 but she could not be sure without checking the computer. LPN CC stated that the next time she saw R#1 was about 10:30 p.m. and he seemed fine and around 11:15 p.m. she checked on R#1 and he was not responsive. She called Registered Nurse (RN FF) to come and check R#1 and it was determined the resident had expired. Interview on [DATE] at 11:05 a.m. with the Respiratory Director confirmed that the [MEDICAL CONDITION] order for R#1 was dated [DATE] at 12:00 p.m. after R#1 had already expired. She confirmed and that the [MEDICAL CONDITION] order did not indicate the settings for IPAP, EPAP or oxygen and stated it should have. She stated the protocol for [MEDICAL CONDITION] is to start IPAP at 10 cmH20 (centimeters of water) and EPAP at 5 cmH20 and that is what the order should have read. She stated this is an initial setting and the policy instructs to titrate the pressure until optimal benefit is obtained. The Respiratory Director stated that any changes from the initial settings would require a respiratory assessment and documentation. The Respiratory Director also confirmed that there is no documentation of oxygen saturations for R#1 since [DATE]. She stated that R#1 should have been assessed and monitored per the policy for noninvasive ventilation and that RT BB did not follow the policy. She stated the policy did not previously address documentation because that is just common sense and a standard of practice and she did not think she had to address that in the protocol. Respiratory Director stated she revised the policy yesterday ([DATE]) and that the last paragraph is the only change made. Interview on [DATE] at 2:27 p.m. with the Administrator revealed Dr. (name) is the Medical Director of the facility and Dr. (name) is the Co-Medical Director over the Vent Unit. The Administrator stated he was aware that there was no change of condition documented for R#1 and that the nurse did not call the RP. He stated that he and the DON got together and put a plan together to educate the nursing staff. He stated this concern was not placed in QA and would have been discussed in the next QA meeting. The Administrator stated they are currently transitioning into monthly QA meetings but currently hold QA meetings quarterly. He stated he was not aware that the staff did not re-assess or monitor the R#1's condition after placing him on [MEDICAL CONDITION]. Review of the Quality Assurance Meeting sign in sheets indicate QA meetings were held for quarters January/February/March (YEAR) and April/May/June (YEAR). (Date is not specific). The Medical Director was in attendance for both meetings. Interview on [DATE] at 4:27 p.m. with RT BB revealed he set R#1 on [MEDICAL CONDITION] settings of 12 over 6 (IPAP/EPAP). He stated that oxygen was bled into the [MEDICAL CONDITION] he thought at 3 LPM but not completely sure. He stated he was unable to locate documentation in the resident's electronic chart. Interview on [DATE] at 12:27 p.m. with the Medical Director revealed he has been the Medical Director for the nursing facility for [AGE] years and that he does attend the QA meetings. He stated that quality concern related to documentation has come up at meetings from time to time but he does not remember it ever being continuous problem that required ongoing monitoring. He stated it is more of reminding the staff to document. The Medical Director stated that it is his expectation that documentation occur when there is a change in a resident's condition. He stated a resident with a modest change is treated and managed in the facility as they have a respiratory department, however, if a patient is unstable and more than the facility can manage, they would be sent to the hospital. The Medical Director stated that prior to the survey, he was not aware that a resident in the facility was not appropriately assessed and monitored after being placed on [MEDICAL CONDITION] secondary to respiratory distress. An interview was conducted on [DATE] at 3:08 p.m. with the Administrator and DON. The Administrator stated that after he became aware that there was no change of condition documented for R#1 and that the responsible party was not notified until after R#1 had passed away, He and the DON got together and put a plan in place to educate the nursing staff but nothing further than that was implemented. He stated the concerns were not placed in QA and that an Emergency Meeting with at least 50% of the QA Committee in attendance was not conducted. The Administrator stated that the QA Committee consist of the Administrator, DON, all Department Heads (Assistant DON, Respiratory Director, Business Office Manager, Admissions Coordinator, Unit Managers, Treatment Nurse, MDS Coordinator, Activities Director, Dietary/Dietitian, Social Services, Therapy Director, Medical Records, Maintenance Director, Housekeeping/Laundry) and Medical Director. The Administrator stated that when a concern is placed in QA, the committee discusses a route cause analysis to identify the underlying problem and will gather a sample of other residents for review. He stated that a plan of action or correction is put in place and followed through by the appropriate department head by means of data collection, monitoring and audits until the concern is resolved. Interview with the DON at 3:12 p.m. revealed she was only aware that there was a lack of documentation of a change in condition for R#1 by the nursing staff and that the responsible party was not notified. The DON stated she was not aware, until the survey process, that R#1 had not been appropriately assessed and was not aware that the respiratory staff did not document in R#1's clinical chart either. She stated that the she educated the nurses and the Respiratory Director would be responsible for educating the respiratory department. She stated she had not conducted any audits or monitoring and did not review other residents charts. The DON further stated that prior to the survey, she was not aware that another resident (R#2) (Refer F514) had a similar situation in which she had a change in condition with no documentation of the change in condition, documentation of MD notification or documentation of hospital transport. When the Administrator was asked at 3:15 p.m. if they had placed these concerns in QA to discuss the route cause and sample and review additional residents, would he have found that R#1 was not appropriately assessed and monitored by either the nursing staff or the respiratory staff after a change in his condition or that respiratory staff did not document in R#1's clinical record and that R#2 did not have appropriate documentation when she had a change of condition on [DATE]. The Administrator responded It's possible we would have. An interview conducted on [DATE] at 3:20 p.m. with the Administrator revealed he received education on [DATE] regarding issues to be addressed by the Quality Assurance Committee are identified by audit schedules for areas such as laboratory orders and reports, treatments, and foot care. Other methods of identifying issues include infection control or other trends, quality indicator flags such as psychiatric medications, pain, survey results, complaints, grievances and reportable incidents. The Administrator explained he recently had identified a need for emergency Quality Assurance meetings and educated the committee and the policy addendum was approved by the committee on [DATE]. Action plans are developed by the department associated with the issue. The plans, audits, monitoring, revisions to the plan and to policies are all approved by the medical director if the issue is clinical. The audits for desired outcomes are taken to Quality Assurance Committee and adjusted, continued, or determined to be resolved. The issues of family notification of change in resident condition, and lack of documentation regarding change in condition had been identified and the Director of Nurses had educated licensed staff on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. An emergency Quality Assurance Meeting was held on [DATE] and the quality concerns identified regarding the care of Res #1 and Res #2 related to change of condition related to acute respiratory distress. An addendum was added to the Quality Assessment and Assurance Program Policy section IV. Meeting Subsection C. Emergency. Emergency meetings will be called to address issues that cannot be held until the next regularly scheduled meeting. An emergency meeting will be held for all Identified quality issues/concerns with the potential for harm. 2. The Administrator was in-serviced on the Quality Assessment and Assurance Program policy including the addendum to the policy addressing emergency meetings of the Quality Assurance Committee. The QA Committee will conduct a root cause analysis to identify the underlying issues and any trends that contributed to the recognized problem, develop a plan, execute the plan, review /study the results of the plan, Re-evaluate the plan and determine if the plan needs to be modified. This in-service was provided by the CNO of the Corp office on [DATE]. 3. The Quality Assurance Committee was in serviced by the Administrator on the Quality Assessment and Assurance Program policy including the addendum to the policy addressing emergency meetings of the Quality Assurance Committee. The QA Committee will conduct a root cause analysis to identify the underlying issues and any trends that contributed to the recognized problem, develop a plan, execute the plan, review/study the results of the plan, Re-evaluate the plan and determine if the plan needs to be modified. This in-service was provided on [DATE] by the Administrator ,[DATE] were in-serviced in facility on [DATE], of the remaining 2, 1 is no longer an employee and the other 1 will be in-serviced today [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. Review of the policy titled Quality Assessment and Assurance Program documented that it is the policy of Reliable Healthcare, Inc. that each facility actively participates in a formalized and written quality assessment, assurance and improvement program. The process is comprehensive (involving all departments) and includes monitoring, evaluation and follow up actions. All care provided residents/patients in the facility operations affecting resident/patient care shall be included in the Quality Assurance Program (QA). VI- Responsibilities of the Administrator follows the QA/CQI Programs. Ensures that each department carries out their QA/CQI program accurately and uniformly through report reviews: Each individual department will be responsible for monitoring and evaluating the resident/ patient care services they provide. Each Committee or Department will submit his/her reports. IV- Meetings addendum developed on [DATE], documented that emergency meetings will of the Committee may be called by the Chairperson or quorum of the Committee. A quorum will be considered 50% of membership. 2. The in-service of the Administrator, conducted on [DATE] by the Corporate Chief Nursing Officer, with the Administrator's signature was reviewed. Review of education topics received by the Administrator on [DATE] by the Corporate Chief Nursing Officer included the Quality Assessment and Assurance Program policy, including the addendum addressing emergency meetings. An interview conducted on [DATE] at 3:20 p.m. with the Administrator revealed he received education on [DATE] regarding issues to be addressed by the Quality Assurance Committee are identified by audit schedules for areas such as laboratory orders and reports, treatments, and foot care. Other methods of identifying issues include infection control or other trends, quality indicator flags such as psychiatric medications, pain, survey results, complaints, grievances and reportable incidents. The Administrator explained he recently had identified a need for emergency Quality Assurance meetings and educated the committee and the policy addendum was approved by the committee on [DATE]. Action plans are developed by the department associated with the issue. The plans, audits, monitoring, revisions to the plan and to policies are all approved by the medical director if the issue is clinical. The audits for desired outcomes are taken to Quality Assurance Committee and adjusted, continued, or determined to be resolved. The issues of family notification of change in resident condition, and lack of documentation regarding change in condition had been identified and the Director of Nurses had educated licensed staff on [DATE]. 3. Eighteen signatures, including the Administrator and the Medical Director were included. The minutes included Nursing and Respiratory Plans of Correction, with monitoring and submission of monitoring to the Quality Assurance Committee every month for 3 months. The addendum to the Quality Assurance Policy Addendum providing for emergency meetings to address issues that cannot be held until the next regularly scheduled meeting. An emergency meeting will be held for all identified quality issues/concerns with the potential for harm. The QA committee was instructed to cause a root cause analysis to identify the underlying issues and any trends that contribute to the recognized problem, develop a plan, execute the plan, review/study the results of the plan, re-evaluate the plan and determine if the plan needs to be modified. The nineteenth signature was documented on [DATE].

Based on review of the past survey results, facility policy Diabetic Management-Compliance Monitoring, and staff interviews the facility failed to identify, ensure interventions correcting the issue are effective and failed to ensure residents received medications per physician ' s order. It was determined that the provider's noncompliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Director of Nursing (DON) were informed of Immediate Jeopardy on 1/29/16 at 6:05 p.m. and 3/10/16 at 5:55 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/17/15, the first date that R#101 should have had insulin per the sliding scale physician's order, and did not receive the insulin and remains ongoing. During an extended visit to the facility conducted 3/3/16 through 3/11/16 it was discovered the facility had completed a 100% audit of all physician ' s order and had reinstated their policy on Diabetic Management-Compliance Monitoring. One (1) resident received an error on 2/20/16 and on 3/11/16 the DON completed the Medication Error Report after it was identified by the Surveyor. After Supervisory review by the State Survey Agency the standard survey was re-opened to expand the sample and complete the investigation related to pressure sores and completed on 4/3/2016. Cross Refer to F 309 Findings include: Review of the facility ' s past survey history revealed that on 2/5/15 the facility was cited F 309 at a D level, on 6/6/13 cited F 309 at a D level, and 12/15/11 cited F 309 at a D level. Interview conducted with the Medical Director on 3/9/16 at 10:15 a.m. via telephone revealed medication errors are discussed in detail with him and have been taken to QA and addressed there. Interview with the Clinical Consultant on 3/11/16 at 9:00 a.m. revealed that the Unit Managers and the DON are responsible for checking MARs and the daily reports of unsigned meds. The nurses are responsible for checking at the end of the shift to ensure all holes are filled. She further revealed that had a Diabetic Management policy that was in place in the past and they have just reinstated it. The Consultant acknowledged that in the spring of last year (2015) she recognized audits of insulin was not being done. This was taken to QA and the policy was implemented. At that time the Assistant Director of Nursing (ADON) was responsible for ensuring the policy was followed and when she left it was dropped. She further acknowledged that the policy should have remained active. Review of the facility policy Diabetic Management-Compliance Monitoring Policy and Procedure provided by the Consultant during the interview on 3/11/16 at 9:00 a.m. noted a revision date on May 2009 and noted that Diabetic residents would receive their Finger Stick Blood Sugar (FSBS) monitoring per MD order, and that the correct dose of insulin would be given based on these results. It further noted that the DON or ADON would audit each resident ' s Diabetic MAR Monday - Friday for the prior 24 hours and complete the required documentation of this audit on the Diabetic MAR indicated [REDACTED]. Interview with the Administrator and DON at the same meeting on 3/11/16 at 9:00 a.m. revealed that when issues are identified they will set up sub-committees. In September 2015 they had set up a sub-committee to look at MARs, ADLs, and documentation. They met weekly and did in-services with staff, posters, made sure all shifts were covered and identified areas for improvement for the MARs and ADLs. We then met for the next two months and looked at MARs in general and the nursing documentation. Medication errors and documentation was taken to QA. It has been taken out of QA and then random checks are made but it is discussed in QA monthly. The Medical Director reviews QA minutes every other month and attends quarterly. Further interview revealed that each time the facility was cited for F 309 in the past audits were done to address the issues. It was not taken out of QA until it was evaluated and we were in compliance. We have never had an issue related to insulin. The policy that was implemented came about from another facility that the corporate had acquired. The facility implemented the following actions to remove the Immediate Jeopardy: An audit was completed using all incidents involving physically or sexually aggressive behavior from 8/1/16 to 1/31/16. This allowed the review were to identify any other residents that have the potential to be affected in the deficient practice the administrator and/or designee will educate all staff immediately with mandatory and service concerning resident abuse, including facility policy, test, and handout and/or video any staff member that cannot attend will be educated by telephone and will receive in-house training prior to returning to work completed by 1/30/16. A quality assurance audit tool for physical or sexual aggression was created on 1/31/16. Incidence of physically or sexually aggressive behavior will be audited by the DON using quality assurance audit for physical or sexual aggression to ensure interventions were implemented, any findings of noncompliance will be reported to the administrator immediately effective 1/31/16 any findings of noncompliance will be presented to the quality assurance committee monthly for six (6) to determine if additional action is needed, then quarterly to ensure ongoing compliance at 1/31/16. Residents determined to be the aggressor in a physically or sexually aggressive situation will be placed on every 15 minutes visual monitoring until the resident was transferred to an inpatient psychiatric behavioral unit for evaluation. If unable to determine the aggressor both will be considered an aggressor as of 1/31/16. If the resident is the victim of the physically or sexually aggressive situation the residents placed on every shift pertinent chart for 72 hours as of 1/30/16. If the resident is the victim of a physically or sexually aggressive behavior the social services department will be notified and they will monitor the residence psychological wellbeing concerned in the resident as well as the resident ' s reaction to his or her involvement in the investigation. Social services will document in the resident social service notes for three days. Social services will report any psychological changes to the administrator and the director of nurses to determine if further intervention is needed. Upon return from inpatient psychiatric/behavioral unit the resident will be placed on every 15 minutes visual monitoring for 24 hours, every 30 minutes visual monitoring 48 hours and then hourly visual monitoring for four days. Effective 1/31/16. During the seven-day period of visual monitoring of the resident exhibits physically or sexually aggressive behavior without injury to either party every 15 minutes visual she will checks will be resumed until the resident can be transferred to an inpatient psychiatric/behavioral unit for evaluation. If the recurrence of sexually physically aggressive behavior results in injury to either party one on one supervision will be initiated immediately and will continue until the resident can be transferred to an inpatient psychiatric/behavior unit. Effective 1/31/16. All residents with physically or sexually aggressive behavior will be placed on the patient at risk program and will be reviewed weekly at the behavior patient risk meeting until they are free of physically or sexually aggressive behavior for four weeks. Effective 1/30/16. All residents with physically or sexually aggressive behavior will be evaluated by the facility contracted psychiatric group. Effective 1/30/16 Your administrator and director nurses will be notified of any reports of physically or sexually aggressive behaviors immediately. Effective 1/30/16 The nursing staff will be in serviced on completing an incident entry in the electronic medical record for incidence of abusive behavior. Effective 2/14/16 Care plan coordinators will be educated to implement revision of approaches and interventions to the plan of care related to both physical and sexual behaviors by 2/20/16 care plan revisions related to physical and sexual behaviors will be audited by the director of nurses and a minimum data set coordinator as part as the behavior patient at risk process. Any resident that were not updated will be updated immediately during behavior patient at risk meeting on 2/20/16. All license nursing staff were in serviced on calculation of sliding scale insulin dose/reading the sliding scale orders to determine the correct dose of insulin to be administered based on finger stick blood sugar results education of the nurses on importance of following physician orders concerning sliding scale insulin and how to follow sliding scale, diabetic policies, posttest on the education provided, insulin verification process, insulin dose calculation verification beginning at 6:oo a.m. Twenty-five (25) nurses were educated on 1/30/16. All nurses were in serviced regarding reading and following physician orders carefully and observing all administration parameters. The nurses will completed to nurse check on the sliding scale insulin and sign off appropriately according to the steps for insulin verification until the facility is free of errors for 90 days. All newly hired nurses will be in serviced on diabetic management policies and calculation of Scott sliding scale insulin as part of the orientation process. All newly hired nurses will complete a to nurse check on the sliding scale insulin and sign off appropriately according to the steps for insulin verification for their first 30 days of employment to ensure they are determining the correct dose of insulin to be given. Nurse management and administrator to be educated regarding the diabetic compliance monitoring policy and their responsibilities related to oversight of this policy. Education will be provided by chief nursing officer - clinical nurse consultant on 1/30/16. The DON and/or unit manager will complete the electronic Medication Administration Record [REDACTED]. The results of the audit and any identified issues will be reviewed in morning meeting and signed off by the administrator to begin on 1/31/16. Any findings of noncompliance will be presented to the quality assurance committee monthly for six months to determine if additional action is needed, then quarterly to ensure ongoing compliance. An allegation of jeopardy removal was received on 2/19/2016 and an amended AoC was received on 3/11/16. Based on the corrective plans developed, implemented by the facility, which were validated by the SSA on 4/3/16, the immediacy of the deficient practice was determined to have been removed on 3/12/16, and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication, behavior interventions and abuse protocol.

Based on record review and interview the facility failed to ensure that the facility followed policy and procedures related to ensure Behavior Health Services, related to medication administration, investigation of and reporting abuse allegations, quality improvement functions including the Patient at Risk (PAR) meetings, failed to ensure the medications were not used past expiration dates, failed to ensure that dietary stored, labeled food to decrease the likelihood of food borne pathogens and failed to ensure that the residents quality of life and care were received to meet the individual residents highest practice wellbeing for nineteen (19) residents (18, 20, 21, 23, 25, 26, 41, 71, 74, 85, 88, 97, 101, 111, 115, 135, 143, 147, C and zz) of the sampled fifty-three (53) residents. The Administrator and Director of Nursing (DON) were informed of Immediate Jeopardy on 1/29/16 at 6:05 p.m. and 3/10/16 at 5:55 p.m. of Immediate Jeopardy (IJ) existed. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/17/15, the first date that R#101 should have had insulin per the sliding scale physician order, and did not receive the insulin. During an extended visit to the facility conducted 3/3/16 through 3/11/16 it was discovered the facility had completed a 100% audit of all physician's orders [REDACTED]. One (1) resident received an error on 2/20/16 and on 3/11/16 the DON completed the Medication Error Report after it was identified by the Surveyor. After Supervisory review by the State Survey Agency the standard survey was re-opened to expand the sample and complete the investigation related to pressure sores and completed on 4/3/2016. It was determined that the noncompliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment, or death to residents. Cross reference: CFR 483.13(b), 483.13(c) (1) (i) F-223 S/S: K Free from Abuse, effective on 10/14/15; CFR 483.1(g) (1) F-250 S/S: K Provision of Medically Related social Services, effective on 9/28/15; CFR 483.20(d) (3), 483.10(k) (2) F-280 S/S: K Right to Participate Planning Care-Revise CP, effective on 10/14/15; CFR 483.20(K) (3) (ii) F-282 S/S: K Services by Qualified Person/per Care plan, effective on 9/17/15; CFR 483.25 F-309 S/S: K Provide Care/services for Highest Well Being effective on 9/17/15; CFR 483.25 F-319 S/S: K TX/svc for Mental/psychosocial, effective on 9/28/15; CFR 483.75 F-490 S/S: K Effective Administration, effective on 9/17/15, and; CFR 483.75(o) (1) F-520 S/S: K Qaa Committee-Members/meet Quarterly/plans. The facility implemented the following actions to remove the Immediate Jeopardy: An audit was completed using all incidents involving physically or sexually aggressive behavior from 8/1/16 to 1/31/16. This allowed the review were to identify any other residents that have the potential to be affected in the deficient practice the administrator and/or designee will educate all staff immediately with mandatory and service concerning resident abuse, including facility policy, test, and handout and/or video any staff member that cannot attend will be educated by telephone and will receive in-house training prior to returning to work completed by 1/30/16. A quality assurance audit tool for physical or sexual aggression was created on 1/31/16. Incidence of physically or sexually aggressive behavior will be audited by the DON using quality assurance audit for physical or sexual aggression to ensure interventions were implemented, any findings of noncompliance will be reported to the administrator immediately effective 1/31/16 any findings of noncompliance will be presented to the quality assurance committee monthly for six (6) to determine if additional action is needed, then quarterly to ensure ongoing compliance at 1/31/16. Residents determined to be the aggressor in a physically or sexually aggressive situation will be placed on every 15 minutes visual monitoring until the resident was transferred to an inpatient psychiatric behavioral unit for evaluation. If unable to determine the aggressor both will be considered an aggressor as of 1/31/16. If the resident is the victim of the physically or sexually aggressive situation the residents placed on every shift pertinent chart for 72 hours as of 1/30/16. If the resident is the victim of a physically or sexually aggressive behavior the social services department will be notified and they will monitor the residence psychological wellbeing concerned in the resident as well as the resident ' s reaction to his or her involvement in the investigation. Social services will document in the resident social service notes for three days. Social services will report any psychological changes to the administrator and the director of nurses to determine if further intervention is needed. Upon return from inpatient psychiatric/behavioral unit the resident will be placed on every 15 minutes visual monitoring for 24 hours, every 30 minutes visual monitoring 48 hours and then hourly visual monitoring for four days. Effective 1/31/16. During the seven-day period of visual monitoring of the resident exhibits physically or sexually aggressive behavior without injury to either party every 15 minutes visual she will checks will be resumed until the resident can be transferred to an inpatient psychiatric/behavioral unit for evaluation. If the recurrence of sexually physically aggressive behavior results in injury to either party one on one supervision will be initiated immediately and will continue until the resident can be transferred to an inpatient psychiatric/behavior unit. Effective 1/31/16. All residents with physically or sexually aggressive behavior will be placed on the patient at risk program and will be reviewed weekly at the behavior patient risk meeting until they are free of physically or sexually aggressive behavior for four weeks. Effective 1/30/16. All residents with physically or sexually aggressive behavior will be evaluated by the facility contracted psychiatric group. Effective 1/30/16 Your administrator and director nurses will be notified of any reports of physically or sexually aggressive behaviors immediately. Effective 1/30/16 The nursing staff will be in serviced on completing an incident entry in the electronic medical record for incidence of abusive behavior. Effective 2/14/16 Care plan coordinators will be educated to implement revision of approaches and interventions to the plan of care related to both physical and sexual behaviors by 2/20/16 care plan revisions related to physical and sexual behaviors will be audited by the director of nurses and a minimum data set coordinator as part as the behavior patient at risk process. Any resident that were not updated will be updated immediately during behavior patient at risk meeting on 2/20/16. All license nursing staff were in serviced on calculation of sliding scale insulin dose/reading the sliding scale orders to determine the correct dose of insulin to be administered based on finger stick blood sugar results education of the nurses on importance of following physician orders [REDACTED]. All nurses were in serviced regarding reading and following physician orders [REDACTED]. The nurses will completed to nurse check on the sliding scale insulin and sign off appropriately according to the steps for insulin verification until the facility is free of errors for 90 days. All newly hired nurses will be in serviced on diabetic management policies and calculation of Scott sliding scale insulin as part of the orientation process. All newly hired nurses will complete a to nurse check on the sliding scale insulin and sign off appropriately according to the steps for insulin verification for their first 30 days of employment to ensure they are determining the correct dose of insulin to be given. Nurse management and administrator to be educated regarding the diabetic compliance monitoring policy and their responsibilities related to oversight of this policy. Education will be provided by chief nursing officer - clinical nurse consultant on 1/30/16. The DON and/or unit manager will complete the electronic Medication Administration Record [REDACTED]. The results of the audit and any identified issues will be reviewed in morning meeting and signed off by the administrator to begin on 1/31/16. Any findings of noncompliance will be presented to the quality assurance committee monthly for six months to determine if additional action is needed, then quarterly to ensure ongoing compliance. An allegation of jeopardy removal was received on 2/19/2016 and an amended AoC was received on 3/11/16. Based on the corrective plans developed, implemented by the facility, which were validated by the SSA on 4/3/16, the immediacy of the deficient practice was determined to have been removed on 3/12/16, and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication, behavior interventions and abuse protocol.

Based on record review, staff interview, and review of the Patients At Risk (PAR) Policy and Procedure, it was determined that the facility failed to obtain an order for [REDACTED]. The failure to obtain a consultation for ongoing psychiatric services and the failure to follow their PAR Behavior Tracking policy, caused harm to R#26 and is likely to cause serious injury, harm, impairment, or death to other residents. Immediate Jeopardy (IJ) was identified on 03/10/16, and was determined to exist as of 09/28/15. The facility was notified of the Immediate Jeopardy on 03/10/16 at 5:55 p.m. Findings include: 1. R#26 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed that R#26 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Continued review revealed that the R#26 did not have any behaviors in the last seven (7) days. Review of the care plan for R#26 dated 9/5/13 revealed that the resident was very critical of facility staff and had problems with roommates with an intervention for staff to consider psychologist intervention. Review of the March 2016 Physician orders [REDACTED].#26 received [MEDICATION NAME] 10 milligrams (mgs) every day for [MEDICAL CONDITION] since 5/7/13, [MEDICATION NAME] 6 mgs at bedtime for [MEDICAL CONDITION] since 8/29/13, [MEDICATION NAME] 50 mgs at bedtime for [MEDICAL CONDITION] pain since 9/22/14, [MEDICATION NAME] 50 mgs every day for major [MEDICAL CONDITION] since 2/12/15, Trazadone 25 mgs every (q) six (6) hours as needed (PRN) for anxiety since 11/21/13 and [MEDICATION NAME] 50 mgs q six (6) hours PRN pain since 9/22/14. Review of the electronic Nurses Notes revealed that R#26 verbally and /or physically abused nursing staff and other residents on the following dates: On 3/29/15 at 6:58 p.m., R#26 stated to a Certified Nursing Assistant (CNA) that she was lazy, ignorant and sorry. On 3/30/15 at 2:30 p.m., while being assisted to the bathroom, R#26 started swinging at the CNAs trying to hit them. On 3/30/15 (documented on 4/3/15 at 2:23 p.m., as a late entry for 3/30/16), when a CNA was assisting the resident's roommate to the bathroom, R#26 became agitated and pushed the wheelchair the roommate was sitting in into the CNA. On 4/3/15, (documented on 4/5/15 at 7:48 p.m., late entry for 4/3/15), R#26 returned from an appointment at 1:00 p.m. and was taken to dining room for lunch. R#26 became angry because he was not able to sit in his regular seat due to second dining. R#26 was returned to his room and when the nurse handed R#26 his cellphone, R#26 hit the nurse on her arm. On 6/11/15 at 9:48 a.m., R#26 hit a CNA in the back with his fist. On 6/18/15 at 2:00 p.m., two (2) CNAs were toileting R#26. When R#26 turned on the emergency light, the CNA turned it off. R#26 then scratched the inside of the CNA's arm resulting in an approximately six (6) inch raised area. Review of the physician orders [REDACTED]. On 6/26/15 at 8:55 a.m., a CNA assisted R#26 to the toilet and R#26 began calling the CNA a S-- of a B---- . On 7/24/15 at 2:33 p.m., a CNA was assisting R#26 to toilet and R#26 became agitated and scratched the CNA on the forearm resulting in a three (3) inch long abrasion. R#26 was educated that his behavior was hurtful to staff and R#26 stated Well, I do not like her . Review of the physician orders [REDACTED]. On 8/13/15 at 10:35 a.m., a resident was crying and stated that R#26 had made fun of her, told her that she did not know what she was talking about and said mean things to her. On 8/23/15 at 8:15 a.m., R#26 was sitting in his wheelchair at the foot of his bed. When his roommate requested to get by, R#26 became agitated and refused. When the roommate again requested that R#26 move, R#26 hit the roommate's arm with his open hand. The roommate's responsible party was notified and the roommate moved to another room per his request. Review of the physician progress notes [REDACTED].#26 was assessed with [REDACTED]. On 8/28/15 at 1:15 p.m., CNA OO transferred R#26 from the toilet to the wheelchair when R#26 became agitated and hit the CNA on her left thigh twice. Review of the physician progress notes [REDACTED].#26 was assessed with [REDACTED]. The physician ordered an increase in the Trazadone to 75 mgs. every twelve(12) hours and continue the 50 mgs. at 2 p.m. on that date. On 9/2/15 at 1:52 p.m., two (2) CNAs were transferring R#26 from the toilet to the wheelchair when R#26 hit the CNAs' hands with his balled fist and fussed at them the whole time. Review of the Family Nurse Practitioner (FNP) Progress Note dated 9/3/15 revealed that she had discussed R#26 behavior with staff and staff had stated that R#26 was not much better on the Trazadone. However, continued review revealed that the Trazadone was increased to 100 mgs every twelve (12) hours. Review of the Grievance/Complaint Report dated 9/9/15 revealed that CNA OO had filed a grievance that she had reported numerous times how R#26 had abused the CNA verbally, physically and that something needed to be done. The CNA refused to provide care for R#26. Continued review revealed that R#26's family member was notified and options were discussed including medication evaluation, Behavior Health Services and other facility placement. Further review revealed that on 9/7/15, the physician assessed R#26. Continued review revealed that on 9/9/15, the contracted Behavior Health Services would no longer provide psychiatric services for the facility and that the Social Services Director (SSD) would make an appointment for R#26 with the new provider. However, staff failed to make a referral for R#26 with the new Behavior Health Services contractor until 3/3/16. On 9/17/15 at 2:22 p.m., CNA KK, the Assistant Director of Nursing (ADON) and two restorative aids (RAs) assisted R#26 to the bathroom using the stand lift. R#26 told staff that he was going to hit them with his Handi Grip Grabber and proceeded to do so. R#26 also verbally abused staff. On 10/4/15 at 2:35 a.m., CNAs attempted to put R#26 to bed when R#26 became belligerent calling them foul names and yelling. On 10/18/15 at 6:32 p.m., the resident struck a CNA in the face with the Handi Grip Grabber. The physician was notified and R#26 was sent to a Behavioral Unit for medical evaluation. R#26 returned without any changes in his medications. Review of the list of staff names for the incidences provided by the facility revealed that the CNA struck in the face by R#26 was CNA MM. Review of the physician progress notes [REDACTED].#26 was treated for [REDACTED]. Continued review revealed that the physician believed that R#26's agitation was due to long term chronic behaviors, depression and possible [MEDICAL CONDITION] disorder. Review the physician's orders [REDACTED]. On 10/30/15 at 4:49 a.m., R#26 became combative when the CNAs attempted to take him to the bathroom per his request. Review of the physician progress notes [REDACTED].#26 with delusions, Alzheimer ' s disease with [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder. On 11/5/15 at 11:49 a.m., R#26 kicked the wound nurse under her chin when the nurse attempted to provide wound treatment to his heels. Review of the physician orders [REDACTED]. On 11/5/15, the physician discontinued the Trazadone 100 mgs every twelve (12) hours. On 11/11/15, the physician ordered [MEDICATION NAME] 7.5 mgs at bedtime for poor appetite. On 11/12/15, the physician decreased the [MEDICATION NAME] to 125 mgs three (TID) times a day due to over sedation. On 12/8/15, the physician discontinued the Trazadone 50 mgs at 2:00 p.m. On 12/17/15 at 4:29 p.m., R#26 became agitated when the wound nurse attempted to cover his wound after treatment and threatened to slap the nurse in the face. On 12/20/15 at 9:38 a.m., R#26 began to berate the CNAs when the CNAs assisted him to the bathroom. The CNAs called the nurse to the bathroom and R#26 told staff, You b---- are idiots and can't do anything right . On 1/29/16 at 10:00 a.m., R#26 attempted to hit the two CNAs who were transferring him to the bathroom using the stand lift. On 2/3/16 at 3:59 p.m., R#26 became agitated when the CNAs used the stand lift to transfer him to the toilet. While being transferred back to the wheelchair, R#26 deliberately slipped his arms out of the lift sling but, was almost seated in wheelchair at time. R#26 was educated on the risks of behavior and stated I don't give a d--- get the h--- out of my room. On 2/20/16 (documented on 2/21/16 at 11:48 a.m., late entry for 2/20/16 at 10:55 p.m.), CNA LL told two (2) nurses that she had assisted CNA MM to toilet R#26. Upon getting 2/20/16 on the stand lift, R#26 began hitting CNA MM pinching and twisting her ear. CNA MM then began pinching, hitting and twisting the ear of R#26. CNA MM also yelled in R#26 face daring him to hit her. CNA MM then shoved R#26 against the wall in the bathroom. CNA LL then put R#26 on the lift and transferred him back to the bed. On the way back to the bed, CNA MM struck R#26 in the back. The CNAs then provided incontinence care to him. Continued review of the Nurses Note revealed that CNA LL did not yell for help or remove CNA MM from the room. Further review revealed that CAN LL did not notify the nurse about the abuse until 10:45 p.m. at which time the nurse assessed R#26 with two (2) small scratches on the top of his left hand. CNA MM was escorted from the facility. The DON, Administrator, responsible party and police were notified and the facility began an investigation of the abuse. Both CNAs were terminated. On 2/21/16 the physician ordered Trazadone 25 mgs twice (BID) a day. On 2/24/16 (documented on 2/25/16, late entry for 2/24/16), R#26 became extremely agitated when a CNA attempted to place the oxygen canister on the back of his wheelchair. R#26 told the CNA that if the CNA did not leave him alone he would hit the CNA in the d----- face. The wound nurse attempted to redirect R#26 as the CNA placed the oxygen on the wheelchair and connect the tubing; however, R#26 continued to threaten to hit the CNA in the face. On 2/28/16, R#26 became combative attempting to strike the CNAs when the CNAs used the full body lift to transfer him. R#26 told the nurse I will slap the s--- out of you. Review of the physician progress notes [REDACTED].#26 had a general decline in condition with decreased appetite. Review of the Patient at Risk (PAR): Behavior PAR Tracking form dated 6/19/15 revealed that R#26 had physical behaviors toward staff with a goal that R#26 would have no further behaviors toward staff. R#26 was followed weekly by the Interdisciplinary team and was discharged on [DATE] after having no further behaviors. Review of the PAR tracking form dated 7/24/15 revealed that R#26 scratched a CNA when the CNA attempted to assist him. R#26 was educated on inappropriate behaviors and staff instructed to request assist from another CNA during care. Review of the PAR tracking form dated 8/23/15 revealed that R#26 hit his roommate. The roommate requested a room change and staff would continue to monitor the resident. Review of the PAR tracking form dated 9/1/15 revealed that R#26 became verbally abusive to staff calling them racial names. Staff redirected R#26 and he was to be seen by the physician for possible medication changes. R#26 was followed weekly by the Interdisciplinary team and was discharged on [DATE] after having no further behaviors. Continued review of R#26 medical record revealed that there was no indication that staff had monitored behaviors of R#26 after 10/2/15 and prior to 2/21/16. Review of the PAR tracking form dated 2/25/16 revealed that on 2/21/16, R#26 was striking out and attempted to kick a CNA during care. Medication changes were made on 2/22/16 and R#26 was to be referred to behavioral counseling. Review of the In-services Sign-In Sheets revealed that on 10/28/15, staff were provided an inservice on Management of Residents with Behaviors. However, there was no indication that CNA LL or CNA MM attended the inservice. On 1/28/16, an inservice on Behavior Management Strategies was provided; however, mostly licensed nursing staff attended. On 1/20/16, an inservice on Dementia with Behaviors was provided. However, there was no indication that CNA LL and CNA MM attended the inservice. Continued review of the In-services Sign-in Sheets revealed that both CNAS attended the 1/30/16 inservice on Abuse Policy, Abuse Reporting and Resident Rights and a 2/17/16 inservice on Abuse. On 2/21/16, an inservice was provided on dealing with job burnout, signs and symptoms of stress, causes and coping strategies and on immediately yelling for help and protecting the resident. Interview with the Social Services Director (SSD) on 3/4/16 8:20 a.m. revealed that R#26 had not been evaluated by Behavior Services but, was on the list to be seen and should be seen today. She provided a fax confirmation from Behavioral Health Services dated 3/3/16 that indicated R#26 was eligible for Behavioral Health Services. Interview with CNA KK on 3/4/16 at 8:10 a.m. revealed that when R#26 became combative, she left him alone, told the nurse and then attempted care later. On 3/5/16, R#26 was assessed by the psychologist from Behavioral Health Services. Review of the Initial Diagnostic Evaluation dated 3/5/16 revealed that R#26 was in middle to end stage dementia, most probably Alzheimer ' s type. Continued review revealed that R#26 aggression was most likely a function of his impaired neurological situation and not amenable to most psychological interventions beyond supportive therapy and pharmacological management. Further review revealed that R#26 was not capable of participating in and benefiting from psychotherapy and that psychotherapy was not expected to improve his health or function. Continued review revealed that the psychologist recommended increasing the [MEDICATION NAME] dose to ensure a therapeutic level and switching the [MEDICATION NAME] to bedtime to address daytime sedation and improve sleep. Interview with the Administrator on 3/7/16 at 4:10 p.m. revealed that the facility initiated an Employee Retention Committee, implemented raises, and provided meals/snacks to boost staff morale and help prevent burnout. Interview with LPN JJ on 3/8/16 at 8:25 a.m. revealed that she monitored staff-resident interactions while on the floor during medication administration and during rounds. Continued interview revealed that the nurses will have the same residents on a daily basis but, that the CNAs will have different residents in an attempt to prevent burnout. Further interview revealed that if a resident physically abused a staff member she would remove that staff member from providing care for the resident and notify the physician for possible medication changes. Continued interview revealed that R#26 requested to go to the bathroom but, did not like the stand lift. Staff had attempted to use the Hoyer lift but, the R#26 liked it less. Interview with the Director of Nursing (DON) on 3/8/16 at 8:45 a.m. revealed that she monitored resident-staff interactions by reviewing the 24 hour reports, morning meetings, and interview with staff, complaints from resident counsel and during rounds. Continued interview revealed that staff were educated on signs of burnout and that she had an open door policy and staff could come to talk to her about any problems with residents. Interview with the Administrator on 3/8/16 at 12:50 p.m. revealed that the contract with the new Behavior Health Service was effective 9/28/15. Continued interview revealed that Behavior Health Service received referrals for residents on 11/30/15. Reviewed of the 9/2/15 Grievance/Complaint Report with the Administrator at that time. The Administrator stated that the current Admissions Coordinator was the interim Social Services Director in 9/2015 and should have made a referral for R#26 to new Behavior Health Services at that time. Further interview with the Administrator revealed that no referral was made until 3/3/16. Interview with the Admissions Coordinator on 3/8/16 at 1:45 p.m. revealed that she was the interim SSD from 8/2015 to 9/2015. Continued interview revealed that she had looked in her referral book but did not find a faxed referral to Behavior Health Service for R#26. Further interview revealed that she had changed her position to Admissions Coordinator and that R#26 referral had fallen through the cracks . Continued interview revealed that R#26 was never treated by the former Behavior Health Service prior to the expiration of their contract in 9/2015. On 3/10/16 at 9:20 a.m., CNA KK with the assistance of two (2) additional CNAs transferred R#26 from the wheelchair to the bathroom using the stand lift. The CNA was observed to gently place the feet of R#26 on the lift and R#26 immediately began yelling Don't twist my legs you S--of a B---- . Staff slowly raised the lift to raise R#26 to a standing position and R#26 continued to yell Oh that hurts my back. Staff lowered R#26 onto the toilet gently and R#26 yelled Oh you S-- of a B----, go p--- on yourself . R#26 was assisted to stand up from the toilet to be cleaned by the CNA and did not yell out when upright. However, R#26 yelled out You ' re rubbing too hard even though the CNA provided gentle care. When R#26 was appropriately transferred back to his wheelchair, he told the CNAs Oh you need some lessons on how to do this . Once the CNAs were finished transferring R#26 and left him alone, R#26 had no other negative behaviors. Interview with the Behavioral Services Psychologist on 3/10/16 at 12:40 p.m. revealed that he did assess the pain level of R#26 but, could not determine if R#26 had actual physical pain or if his pain symptoms were part of his severe dementia with depression. Continued interview revealed that an increase in the pain medication for R#26 may contribute to respiratory problems. Further interview revealed that he wanted to get the [MEDICATION NAME] level therapeutic since the [MEDICATION NAME] would help with the physical aggression of R#26. Observation on 3/10/16 at 1:30 p.m., revealed R#26 in his wheelchair in the dining room yelling Oh! That hurts me several times. R#26 was not moving or being touched by anyone at that time. Staff wheeled the resident back to his room and the resident stopped yelling and closed his eyes. Although the physician adjusted the medications of R#28 in an attempt to address his verbal and physical abusive behaviors toward staff since 3/2015, there was no indication that the facility had attempted psychological intervention as care planned to address his behaviors. Although CNA OO had filed a grievance on 9/2/15 complaining about the continued abusive behaviors of R#26 and the lack of response from administrative staff, staff failed to obtain a psychological referral for R#26 as planned at that time. Review of the Policy and Procedure: Patient at Risk (PAR) revealed that the Interdisciplinary Team (IDT) would review and provide individualized PAR tracking for residents identified with an exacerbation of a behavior problem or new behavior for four (4) weeks or until the condition of the resident had stabilized. However, there was no indication that the IDT had monitored the behaviors in PAR from 10/2/15 until 2/21/16 after R#26 was abused by staff. R#26 had exhibited abusive behaviors three (3) times in 10/15, one (1) time in 11/2015, two (2) times in 12/2015, one (1) time in 1/2016 and one (1) time in 2/2016. This failure to obtain a timely psychological evaluation that may have effectively addressed the behaviors of R#26, resulted in the continued abuse of staff and the subsequent retaliation resulting in abuse of R#26 on 2/20/16 by a Certified Nursing Assistant. 2. R#97 was admitted to the facility on [DATE] from another long term care facility. The resident was alert, oriented, and able to make his needs known. His [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R#97 had a BIMS Score of eleven (11) which indicates moderately impaired cognitive function. Continued review of the Admission MDS revealed that R#97 mood was assessed as having a poor appetite or overeating and was assessed as exhibiting no behaviors during the look back period. Review of the Quarterly MDS assessment dated [DATE] revealed that R#97 had a BIMS Score of nine (9), moderately impaired cognitive function. Continued review of the Quarterly MDS revealed that R#97 mood was assessed as having a poor appetite or overeating. He was assessed as having trouble falling or staying asleep or sleeping too much, feeling tired or having little energy, feeling bad about self or that you feel you are a failure or have let yourself or your family down, frequency was two - six (2-6) days. Further review of the MDS revealed that R#97 was assessed as exhibiting no behaviors during the look back period. Review of the Quarterly MDS assessment dated [DATE] revealed that R#97 had a BIMS Score of thirteen (13), cognitively intact. Continued review of the MDS revealed that R#97 was assessed as having no mood concerns and no behaviors. Review of the care plan revealed that the problem onset was 02/20/16 and R#97 has a history of altercation with another resident. He has [MEDICAL CONDITION]'s disease and has spastic movements and also episodes of anxiety. The goal for the care plan was R#97 will have a decrease in aggressive behaviors with no injuries to self or others over next review. Approaches include to consider a psychiatrist consult, monitor and document behavior on behavior tracking sheet. Review of the electronic medication record for R#97 revealed that medication orders were as follows: [MEDICATION NAME] Sodium 40mg, [MEDICATION NAME] 50mg, [MEDICATION NAME] 250mg, [MEDICATION NAME] 40mg by mouth daily, and; [MEDICATION NAME] 500mg, [MEDICATION NAME] 400mg, [MEDICATION NAME] by mouth at bedtime. Review of the electronic medical record interdisciplinary progress notes the social worker documented on 10/27/15 a quarterly assessment which revealed R#97, was having difficulties falling asleep, feeling tired, eating too much, feeling bad and having trouble concentrating for a few days. The social worker revealed that the physician prescribed [MEDICATION NAME] for depression and anxiety. R#97 was receiving [MEDICATION NAME] and [MEDICATION NAME] for mood disorder. Continued review of the interdisciplinary progress notes revealed that the social worker documented a quarterly assessment on 01/25/16 quarterly. The progress note revealed that R#97 had gait and mannerisms that are very abrupt due to [MEDICAL CONDITION]'s disease and the resident was noted to become agitated by staff when asked to do certain things. The social worker revealed that R#97 was not abusive to staff but when he is agitated he might say some curse words. His relationship with his roommates varies. There are some weeks when they get along great, then there are times when R#97 becomes agitated and requests a room change. When the resident is notified that a room had become available for change he refuses to move and states that he likes his room. Further review of the interdisciplinary progress notes revealed that the social worker documented on 02/05/16 that a family member complained that R#97 was mean to her father who was his roommate and that he cussed at her. Social Worker looked in to the complaint and staff stated that R#97 had at times been sitting on the bed of the roommate watching his TV, had his bed over the line into the roommate ' s side and pushed the roommate out of the room against his will. Social Worker asked R#97 about these incidents and he confirmed that he did push the roommate out into the hall once but stated that he was in the way of the resident getting into the room. R#97 denied sitting on the roommate ' s bed. The facility will conduct a chart check for each Certified Nursing Assistant (CNA) shift for seventy two (72) hours. The interdisciplinary progress note dated 02/09/16 revealed that the social worker and witness talked to R#97 about his behavior that was brought to light by his roommate complaint. The social worker checked the 72 hour nurses notes which revealed that there was yelling, inappropriate language, and non-violent behaviors such as yanking the curtain. R#97 denied the yelling at staff and using inappropriate language. The social worker re-educated R#97 and discussed using appropriate language when speaking to staff. The social worker revealed that she re-educated R#97 and told him the repercussion of his behaviors do not improve there could be possible room change or a behavioral hospital visit. The interdisciplinary progress note dated 02/11/16 revealed that is was a late entry for a room change, R#97 continued to show aggressive behaviors towards the staff and roommate which was exhibited pushing his roommate out into the hall and then slamming the door. The interdisciplinary progress note dated 03/01/16 revealed that the social worker referred the resident for psychological and behavior services due to his behaviors. Review of the electronic medical record nurses notes revealed that on 09/29/15 that R#97 tried to break in the shower line. Another resident told him to get back where he was. R#97 got mad and went back in line and tapped the other resident in the right side of head. No injury noted. Residents were separated with no further problem. Continue review of the nurses note revealed on 12/12/15 the nurse documented a late entry that R#97 and roommate began arguing and got into a confrontation. R#97 stated that roommate hit him. Assessment no injury noted. The nurses note dated 01/23/16 revealed that at 4:00 p. m. R#97 had pushed his sleeping roommate out of room and into the hall and closed the door. The roommate was asleep in his wheelchair when R#97 wheeled him out and became upset at being woken up in this fashion. R#97 said he did not want the roommate in the room. The nurse explained that he had to share the room and that his roommate had not done anything to R#97 and for the resident to keep his hands to himself. The nurses notes dated 02/05/16 revealed that the CNA was getting the roommate up for dinner and R#97 drew back the separating curtain and said this is my fu**ing room, get out . The nurses notes dated 02/06/16 revealed that R#97 was yelling at staff to open the privacy curtain and when staff did not respond to R#97, he jumped up on his bed and grabbed the curtain. The nurse notes documented on 02/10/16 revealed that R#97 had an increase in behaviors and physician gave an order to increase [MEDICATION NAME] to 500mg twice daily and gave order for 0.5mg [MEDICATION NAME] by mouth twice daily. Review of the Patient at Risk (PAR) notes revealed that R#97 was discussed during a PAR meeting held on 10/02/15, reason was for an altercation with another resident. The PAR noted indicated that R#97 was waiting in line for a shower another resident told him to move, then R#97 turned around and struck him on the side of the head. R#97 has [MEDICAL CONDITION]'s and had a spastic movements. The PAR notes revealed that it is unclear if the altercation was intentional. R#97 was followed for behaviors for five (5) weeks and recorded on the PAR form. Review of the Behavioral Health Initial Diagnostic Evaluation revealed that it was completed on 03/10/16 by the psychiatrist. Continue review of the evaluation revealed that the psychiatrist stated that R#97 appeared to have a long standing psychiatric disorder, possibly as a function of his [MEDICAL CONDITION] ' s Disease as these are not uncommonly co-morbid. R#97 irritability appeared to be a function of his cognitive dissonance regarding his current situations and how he perceives he should be functioning. R#97 symptoms appear to be adequately managed on his current medication regimen and do not recommend any changes at this time. The psychiatrist revealed that he would provide supportive and cognitive therapy to address coping skills associated with his current adjustment issues however and R#97appeared amenable to this. Interview on 03/07/16 at 1:15 p. m. with the Director of Nursing (DON) when asked if the R#97 had ongoing behaviors she revealed that R#97 had an incident where he hit another resident on accident. The DON revealed that nursing staff did witness the situation. She revealed that R#97 has [MEDICAL CONDITION] ' s disease and was in the hallway walking toward the shower room when he had a [MEDICAL CONDITION]/spastic movement near another resident and accidentally hit the other resident in the shoulder. Continued interview with the DON revealed that R#97 has not had any issues/concerns with accidentally hitting other residents since. Interview on 03/09/15 at 9:15 a. m. with Social Service Director revealed she confirmed that the she had documented in the interdisciplinary notes that R#97 was having increased behaviors in February 2016. The social worker revealed that Behavior Health Services was not contacted until last week to assess R#97 and she contacted them due to staff notifying her that R#97 was having increase in behaviors such as using inappropriate language towards staff and residents. Continued interview with the social worker revealed that she did not obtain a psychiatric consult earlier because she thought his behaviors were improving. The social worker revealed that the psychiatrist from Behavior Health Services was in the facility on 03/04/16 but was not able to confirm if R#97 was seen and assessed by the psychiatrist during his visit to the facility. Interview on 03/09/15 at 10:50 a. m. with MDS Coordinator revealed that she co-leads the PAR meetings that are held weekly at the facility which the DON, unit managers, and department heads attend. She revealed at the PAR meetings residents that have behaviors are discussed, documented, and monitoring sheet is started to record observations of the residents behaviors. The MDS Coordinator revealed that she had not been made aware of the R#97 increase in behaviors of agitation with his roommate and cussing at staff and roommate. She revealed that if was notified she would have placed R#97 on the PAR list for behaviors and R#97 would have been monitored more closely for his behaviors. Interview on 03/10/16 at 8:45 a. m. with the Social Services Director revealed that she received notification from DD from Behavior Health Services that R#97 was not seen on 03/04/16. The social worker revealed that DD did not give a reason why the R#97 was not seen. Continued interview with the social worker revealed that the process for a resident to be a

Based on review of the medical records, the facility entitled, Policy and Procedure Diabetic Management-Compliance Monitoring, and staff interviews, the facility failed to follow physician's orders [REDACTED].#25, R#41, R#71, R#85, R#101, R#111, R#135 and R#143) of thirteen (13) residents reviewed out of twenty-four (24) diabetic residents receiving sliding scale insulin. The total sample size was fifty-three (53) residents. The facility census was ninety one (91) residents. It was determined that the provider noncompliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Director of Nursing (DON) were informed of Immediate Jeopardy (IJ) on 1/29/16 at 6:05 p.m. and 3/10/16 at 5:55 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/17/15, the first date identified that R#101 did not receive sliding scale insulin as ordered. An extended survey was conducted on 3/3/16 through 3/11/16. Three (3) additional insulin dependent diabetic residents were added to the sample. Interview with the Director of Nursing (DON) on 3/8/16 at 11:15 a.m. revealed that the Medication Administration Records (MARs) had not been checked for errors before the survey ending 1/29/16. That random audits were completed however, since that survey of 1/29/16, we have completed one-hundred percent (100%) audits of all MARs and we are auditing sliding scale insulin everyday now. During the extended survey an additional three (3) residents were added to the sample (R#41, R#71 and R#149), two (2) residents (R#41 and R#71) had medications errors after the exit date of the last survey of 1/29/16. The DON confirmed knowledge of one (1) error for R#71 however the Medication Error Report was not completed until 3/11/16 at 3:00 p.m. the last day of the extended survey. After Supervisory review by the State Survey Agency the standard survey was re-opened to expand the sample and complete the investigation related to pressure sores and completed on 4/3/2016. Findings include: Review of the Diabetic Management - Compliance Monitoring Policy and Procedure provided by the Corporate Consultant on 3/11/16 at 9:00 a.m. with a revision date of May 2009 and revealed that diabetic residents would receive their Finger Stick Blood Sugar (FSBS) monitoring per Medical Doctor (MD) order, and that the correct dose of insulin was given based on these results. It further indicated that the DON or Assistant Director of Nursing (ADON) would audit each Diabetic MAR Monday-Friday for the prior 24-hours and complete the required documentation of this audit on the Diabetic MAR indicated [REDACTED]. 1. Review of the medical record for R#25 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician order [REDACTED].*150 - 174 = 2 units; *175 - 204 = 3 units; *205 - 234 = 4 units; *235 - 264 = 5 units; *265 - 294 = 6 units; *295 - 324 = 7 units; *325 - 354 = 8 units; *355 - 384 = 9 units; *385 - 414 = 10 units; *415 - 444 = 11 units; *445 - 474 = 12 units; *475 - 500 = 13 units; Greater than 500 call MD Review of the November 2015 MAR indicated [REDACTED]= 344 and 3 units administered. Per the sliding scale, 8 units should have been administered. On 11/17/15 FSBS = 188 and 5 units administered. Per the sliding scale 3 units should have been administered. On 11/21/15 FSBS = 183 and no units were administered. Per the sliding scale 3 units should have been administered. On 11/26/15 at 8:00 p.m. FSBS = 214 and 3 units administered. Per the sliding scale 4 units should have been administered. On 11/28/15 at 8:00 p.m. FSBS = 174 and 3 units administered. Per the sliding scale 2 units should have been administered. Review of the December 2015 MAR indicated [REDACTED]= 295 and no units were administered. Per the sliding scale 7 units should have been administered. At 4:30 p.m. FSBS was documented as High and 4 units was administered. Further review of FSBS document at 6:30 a.m. and 4:30 p.m. revealed the documented FSBS at 4:30 p.m. was 168 and 2 units should have been the amount administered. On 12/15/15 at 6:30 a.m. FSBS = 150 and no insulin coverage required was documented. Per the sliding scale 2 units should have been administered. On 12/19/15 at 11:30 a.m. the FSBS = 180 and no units were administered. Per the sliding scale 3 units should have been administered. On 12/22/15 at 8:00 p. m. FSBS = 172 and 3 units administered. Per the sliding scale 2 units should have been administered. On 12/27/15 FSBS = 156 and no coverage required was documented. Per the sliding scale 2 units should have been administered. 3. Review of the medical record for R#41 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the March 2016 MAR indicated [REDACTED]=6u; 301-350=8u; 351-400=10u; 401-450=12u; 450-500=15u; Greater than 500 call MD. Further review revealed on 3/10/16 at 6:00 a.m. FSBS = 190 and 6 units were administered. Per the sliding scale no units should have been administered. At 9:00 p.m. FSBS = 268 and no units were administered. According to the sliding scale 6 units should have been administered. 4. Review of the medical record for R#71 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the February 2016 MAR indicated [REDACTED]=6u; 301-350=8u, 351-400=10u; 401-450=12u; 450-500= 15u; Greater than 500 Call MD. Further review revealed on 2/20/16 at 6:30 a.m. FSBS = 261 and 10u was administered. Per the sliding scale 6u should have been administered. Review of the January 2016 MAR indicated [REDACTED]= 82 and 4u was administered. No units should have been administered. Review of the December 2015 MAR indicated [REDACTED]= 359 and 6u was administered. Per the sliding scale 9u should have been administered.12/10/15 at 6:30 a.m. FSBS = 238 and no units required. Per the sliding scale 5 units should have been administered. 5. Review of the medical record for R#85 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the physician order [REDACTED].*150 - 174 = 2 units;*175 - 204 = 3 units;*205 - 234 = 4 units;*235 - 264 = 5 units;*265 - 294 = 6 units;*295 - 324 = 7 units;*325 - 354 = 8 units;*355 - 384 = 9 units;*385 - 414 = 10 units;*415 - 444 = 11 units;*445 - 474 = 12 units;*475 - 500 = 13 units; Greater than 500 call MD Review of the MAR indicated [REDACTED]. m. FSBS = 142. [MEDICATION NAME] 3 units was administered. Per the sliding scaled no coverage was required. 6. Review of the medical record for R#101 revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the physician order [REDACTED].#101 revealed an order for [REDACTED]. Review of the September 2015 MAR indicated [REDACTED]. On 9/17/15 FSBS = 150. No insulin coverage required was documented. Per sliding scale 2 units should have been administered. Review of the December 2015 MAR indicated [REDACTED]. Further review revealed on 12/5/15 FSBS = 154. No insulin coverage required was documented. Per sliding scale 2 units should have been administered. 7. Review of the medical record for R#135 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. Review of the January 2016 MAR indicated [REDACTED]= 176 and 2 units was administered. Per sliding scale 3 units should have been administered. Interview conducted with Licensed Practical Nurse Unit Manager BB on 1/29/16 at 3:00 p.m. revealed that the FSBS should have been obtained and documented. Subsequent interview conducted on 1/29/16 at 6:00 p.m. revealed there was no excuse for the insulin dosage errors because the sliding scale was right in front of the nurses. 8. Review of the medical record for R#143 revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the January 2016 MAR indicated [REDACTED]. Further review revealed on 1/24/16 at 8:00 p.m. FSBS = 164 and no insulin required was documented. Per sliding scale 2 units should have been administered. 1/27/16 at 6:00 a.m. FSBS = 151 and 1 unit was administered. Per sliding scale 2 units should have been administered. Interview conducted on 3/7/16 at 1:45 p.m. with the DON revealed that they have changed to using fewer sliding scales and they tell the nurse exactly the dosage to administer. The DON confirmed all of the above are medications errors and that they include in errors omissions in the MAR indicated [REDACTED]. She further confirmed that their policy is that if there is a medication error then they are to call the doctor and document on the Medication Error Sheet that they called the doctor and what is discussed with the doctor. Further, after the survey of 1/29/16 they did a 100% audit of all of the charts for medication errors. They worked with the doctors clarifying the orders, making necessary changes, and making sure they reflected exactly what the doctor wanted. At this time they have only three (3) residents receiving FSBS with sliding scale insulin. Interview with the DON on 3/8/16 at 11:15 a.m. revealed meal times are 7:15 a.m., 12:15 p.m., and 5:15 p.m. As to the appropriateness of the last meal and the bedtime (HS) FSBS check with sliding scale, that is what the doctor ordered. The DON state uncertainty about if the resident has been of different formulas used by the physician, now they are basically down to two (2). Before there has been as many as seven (7) different formulas used. And the nurses do not use the formula, they use the scale listed with the particular formula to get the amount of units to be administered. So I expect them to just use the scale. I expect nurses to report any and all errors to the physician, myself, the administrator and it is reported to the pharmacist. An example is: if a resident is given Tylenol instead of Aspirin. This is a medication error and should be reported. Right now we are auditing sliding scale insulin. If we find an error then we complete the Medication Error Report. Notify the nurse involved, the doctor, the administrator, pharmacist, etc. The errors before were not identified until after the surveyor identified them (1/29/16) so they had not been reported but from that time on they have all been reported and addressed. Further interview with the DON revealed each medication error was reviewed specifically and she acknowledged they were all medication errors. Interview conducted with the Medical Director on 3/9/16 at 10:15 a.m. via telephone revealed he expects the nurse to use the sliding scale chart for determining doses of insulin coverage during med pass. This way there should never be a math error in calculating dose. He also expects the nurse to notify him of medication errors. And more important is the severity of the error. If minor the nursing supervisor should be able to give some guidance. He has received reports of med errors in the past, and when he comes into the facility on ce a week we discussed errors and other things going on. Occasionally, I have received phone calls with reports of errors. Further revealed that 2-3 units of insulin absolutely, positively does not affect the residents ' health. In fact, I think it is so inconsequential to anyone. Even a person that is not diabetic. It does not affect any person. The Medical Director feels it would have to reach double digits to cause a reaction. Then you could give glucose or orange juice. Several things before it reached emergency level. The Medical Director further revealed medication errors are discussed in detail with him and have been taken to QA and addressed there. Interview on 3/9/16 at 10:30 a.m. the DON regarding the FSBS not in the computer revealed they have had many occasions where they would put things in the computer and then at the end of shift when they go back to check, everything would be gone. Interview conducted with the Pharmacy Consultant on 3/9/16 at 1:45 p.m. revealed he has been consulting here for about 3 years. They have met with the doctors. He stated he cannot say why the nurses would get the insulin wrong, the scale is right in front of them. Maybe there is so much on the screen. So much information they are not reading it correctly. Mostly when he does his review he will check the morning fasting BS, and the A1C. Really looks for reasons to reduce sliding scale insulin. He stated that he thinks residents are checked way too much. Anyway, the DON meets with the doctor and team once a week and discusses each resident. What I review is a sampling of issues going on in the facility. Interview conducted with the Pharmacist Consultant on 3/10/16 at 2:00 p.m. revealed that he visits the facility once a month but does not review MARs for medication errors. Usually focuses on the first Fasting Blood Glucose level in the morning. He further expects that nursing would be responsible for checking for medication administration errors. Interview conducted on 3/9/16 at 2:20 p.m. with the DON revealed they looked at orders and checked them but not necessarily the MARs. If I am in the morning meeting for example someone might say for example, Ms. (NAME REDACTED) has eye drainage -I will look to see if there is an order for [REDACTED]. Search for discrepancies - it would also show open blanks or holes in the MARs (indicating medication was not administered). We do not ask the nurses to fix these (holes in the MARs) because 1. We cannot ask the nurse to go and back date and 2. If you know you put it in and it disappeared-then we ask her to go to the nurses notes and document it there. We also have a Late Sign Off report. That is used when like someone goes out to hospital and maybe the nurse has not had time to take them out of the system yet so their meds show up with holes. Or if a med is given but at a later time. I do talk with the doctors. I am not necessarily checking the MAR. Interview conducted with the Corporate Consultant on 3/11/16 at 9:00 a.m. revealed that the Unit Managers and the DON were responsible for checking MARs and the daily reports of unsigned meds is ran daily by Unit Managers and the nurses were responsible for checking at the end of the shift to ensure are holes are filled. They had a Diabetic Management policy and it was in place in the past and has now been re-instated. Before it was listed as the DON and ADON were responsible for checking for FSBS errors and now they have added the Unit Managers also. She further revealed that it should have been followed all along but when the ADON left it was not done. We have done in-servicing to the nurses on documentation, follow ups and holes on the MARs, however we did not focus on any one medication. The facility implemented the following actions to remove the Immediate Jeopardy: An audit was completed using all incidents involving physically or sexually aggressive behavior from 8/1/16 to 1/31/16. This allowed the review were to identify any other residents that have the potential to be affected in the deficient practice the administrator and/or designee will educate all staff immediately with mandatory and service concerning resident abuse, including facility policy, test, and handout and/or video any staff member that cannot attend will be educated by telephone and will receive in-house training prior to returning to work completed by 1/30/16. A quality assurance audit tool for physical or sexual aggression was created on 1/31/16. Incidence of physically or sexually aggressive behavior will be audited by the DON using quality assurance audit for physical or sexual aggression to ensure interventions were implemented, any findings of noncompliance will be reported to the administrator immediately effective 1/31/16 any findings of noncompliance will be presented to the quality assurance committee monthly for six (6) to determine if additional action is needed, then quarterly to ensure ongoing compliance at 1/31/16. Residents determined to be the aggressor in a physically or sexually aggressive situation will be placed on every 15 minutes visual monitoring until the resident was transferred to an inpatient psychiatric behavioral unit for evaluation. If unable to determine the aggressor both will be considered an aggressor as of 1/31/16. If the resident is the victim of the physically or sexually aggressive situation the residents placed on every shift pertinent chart for 72 hours as of 1/30/16. If the resident is the victim of a physically or sexually aggressive behavior the social services department will be notified and they will monitor the residence psychological wellbeing concerned in the resident as well as the resident ' s reaction to his or her involvement in the investigation. Social services will document in the resident social service notes for three days. Social services will report any psychological changes to the administrator and the director of nurses to determine if further intervention is needed. Upon return from inpatient psychiatric/behavioral unit the resident will be placed on every 15 minutes visual monitoring for 24 hours, every 30 minutes visual monitoring 48 hours and then hourly visual monitoring for four days. Effective 1/31/16. During the seven-day period of visual monitoring of the resident exhibits physically or sexually aggressive behavior without injury to either party every 15 minutes visual she will checks will be resumed until the resident can be transferred to an inpatient psychiatric/behavioral unit for evaluation. If the recurrence of sexually physically aggressive behavior results in injury to either party one on one supervision will be initiated immediately and will continue until the resident can be transferred to an inpatient psychiatric/behavior unit. Effective 1/31/16. All residents with physically or sexually aggressive behavior will be placed on the patient at risk program and will be reviewed weekly at the behavior patient risk meeting until they are free of physically or sexually aggressive behavior for four weeks. Effective 1/30/16. All residents with physically or sexually aggressive behavior will be evaluated by the facility contracted psychiatric group. Effective 1/30/16 Your administrator and director nurses will be notified of any reports of physically or sexually aggressive behaviors immediately. Effective 1/30/16 The nursing staff will be in serviced on completing an incident entry in the electronic medical record for incidence of abusive behavior. Effective 2/14/16 Care plan coordinators will be educated to implement revision of approaches and interventions to the plan of care related to both physical and sexual behaviors by 2/20/16 care plan revisions related to physical and sexual behaviors will be audited by the director of nurses and a minimum data set coordinator as part as the behavior patient at risk process. Any resident that were not updated will be updated immediately during behavior patient at risk meeting on 2/20/16. All license nursing staff were in serviced on calculation of sliding scale insulin dose/reading the sliding scale orders to determine the correct dose of insulin to be administered based on finger stick blood sugar results education of the nurses on importance of following physician orders [REDACTED]. All nurses were in serviced regarding reading and following physician orders [REDACTED]. The nurses will completed to nurse check on the sliding scale insulin and sign off appropriately according to the steps for insulin verification until the facility is free of errors for 90 days. All newly hired nurses will be in serviced on diabetic management policies and calculation of Scott sliding scale insulin as part of the orientation process. All newly hired nurses will complete a to nurse check on the sliding scale insulin and sign off appropriately according to the steps for insulin verification for their first 30 days of employment to ensure they are determining the correct dose of insulin to be given. Nurse management and administrator to be educated regarding the diabetic compliance monitoring policy and their responsibilities related to oversight of this policy. Education will be provided by chief nursing officer - clinical nurse consultant on 1/30/16. The DON and/or unit manager will complete the electronic Medication Administration Record [REDACTED]. The results of the audit and any identified issues will be reviewed in morning meeting and signed off by the administrator to begin on 1/31/16. Any findings of noncompliance will be presented to the quality assurance committee monthly for six months to determine if additional action is needed, then quarterly to ensure ongoing compliance. An allegation of jeopardy removal was received on 2/19/2016 and an amended AoC was received on 3/11/16. Based on the corrective plans developed, implemented by the facility, which were validated by the SSA on 4/3/16, the immediacy of the deficient practice was determined to have been removed on 3/12/16, and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication, behavior interventions and abuse protocol.

Based on record review and staff interviews, the facility failed to follow the care plan related to monitoring/documenting [MEDICAL CONDITION] and insulin medication, failed to follow the care plan related to behavior health services and failed to follow the care plan related to Diabetes and other diseases requiring medication management for twelve (12) residents (R#23, R#25, R#41, R#71, R#85, R#88, R#97, R#101, R#111, R#115, R#135 and R#143) of the sampled fifty-three (53) residents. It was determined that the noncompliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment, or death to residents. The Administrator, Director of Nursing, and Chief Nursing Officer for Reliable Health Care Management were notified on 1/29/16 at 6:05 p.m. and 3/10/16 at 5:55 p.m. of the Immediate Jeopardy (IJ) existed. Cross Refer to F 309 Cross Refer to F 329 Findings include: 1. Review of the medical record for R#23 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] with the Assessment Reference Date (ARD) of 2/12/16 which assessed R#23 with a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section I indicates [DIAGNOSES REDACTED]. Section N: resident received antipsychotics, antidepressants and diuretics seven (7) of seven (7) days a week. Review of the Care Plan revealed a problem onset date of 10/2/11 indicating resident has alteration in system function related to Diabetes. The target date was 5/10/16 with a goal that the resident will be free from signs and symptoms of hypo/hyperglycemic reactions for 90 days. One of the approaches is to administer medications (meds) as ordered. Review of the January 2016 Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 3/9/16 at 10:30 a.m. verified that this is considered a medication omission thus a medication error. 2. Review of the medical record for R#25 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] with the ARD of 1/7/16 which assessed R#25 with a BIMS score of 5 indicating severe cognitive impairment. Section I indicates [DIAGNOSES REDACTED]. Section N: resident received insulin injections, antidepressants and anticoagulants seven (7) of seven (7) days. Review of the Care Plan revealed a problem onset date of 9/1/15 indicating R#25 is at risk for complications specific to DM. The target date was 4/21/16 with a goal that R#25 will be free from signs and symptoms of hypo/hyperglycemic reactions as evident by no complications over next review period. The approaches included an intervention to include medication management as ordered, monitor for adverse to insulin including blurred vision, dry mouth, rash, itching, and [MEDICATION NAME]. Review of the MARs revealed no evidence that a nurse had initialed the medication as administered in November six (6) times, and in December MAR indicated [REDACTED] 3. Review of the medical record for R#41 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] with the ARD of 1/21/16 which assessed R#41 with a BIMS score of 15 indicating the resident had no cognitive deficit. Section I indicates [DIAGNOSES REDACTED]. Section N: resident received insulin injections, antidepressants and diuretics seven (7) of seven (7) days. Review of the Care Plan revealed a problem onset date of 12/31/13 indicating resident at risk for complications specific to DM. The target date was 4/28/16 with a goal that the resident will be free from signs and symptoms of hypo/hyperglycemic reactions as evidence by no complications over next review period. The approaches is to observe for compliance with diet/med regimen. Another problem onset dated 12/31/13 indicating alteration in system functions related to decreased cardiac output specific to HTN, Coronary Arterial Disease (CAD), history of [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. The intervention to include medication management as ordered. Review of the MAR indicated [REDACTED]. 4. Review of the medical record for R#71 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] with the ARD of 12/2/15 which assessed R#71 with a BIMS score of 15 indicating no cognitive impairment. Section I indicates [DIAGNOSES REDACTED]. Section N: resident received insulin injections seven (7) of seven (7) days and hypnotics two (2) of 7 days. Review of the Care Plan revealed a problem onset date of 3/6/15 indicating resident at risk for complications specific to DM. The target date was 6/9/16 with a goal the resident will be free from signs and symptoms of hypo/[MEDICAL CONDITION] without complications over next review period. The intervention to include medication management as ordered. Review of the MAR indicated [REDACTED]. Review of the January 2016 MAR indicated [REDACTED]. 5. Review of the medical record for R#85 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] with the ARD of 12/17/15 which assessed R#85 with a BIMS score of 3 indicating severe cognitive impairment. Section I indicates [DIAGNOSES REDACTED]. Section N: resident received insulin injections and antidepressants 7 of 7 days. Review of the Care Plan revealed a problem onset date of 10/21/14 indicating resident at risk for complications specific to DM. The target date was 3/29/16 with a goal the resident will be free from signs and symptoms of hypo/[MEDICAL CONDITION] without complications over next review period. Listed under approaches is the intervention to include medication ordered. Review of the MAR indicated [REDACTED]. 6. Review of the medical record for R#101 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] with the ARD of 12/21/15 which assessed R#101 with a BIMS score of 15 indicating no cognitive impairment. Section I indicates [DIAGNOSES REDACTED]. Section N: resident received insulin injections 2 of 7 days, and antidepressants 7 of 7 days. Review of the Care Plan revealed a problem onset date of 7/6/16 indicating resident at risk for complications specific to DM. The target date was 4/7/16 with a goal the resident will be free from signs and symptoms of hypo/[MEDICAL CONDITION] without complications over next review period. Listed under approaches is the intervention to include medication ordered. Review of the MAR indicated [REDACTED]. 7. Review of the medical record for R#111 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] with the ARD of 12/29/15 which assessed R#111 with a BIMS score of 15 indicating no cognitive impairment. Section I indicates [DIAGNOSES REDACTED]. Section N: resident received antianxiety, anticoagulants 7 of 7 days. Review of the Care Plan revealed a problem onset date of 3/5/15 indicating resident at risk for complications specific to DM. The target date was 4/14/16 with a goal the resident will be free from signs and symptoms of hypo/[MEDICAL CONDITION] without complications over next review period. Listed under approaches is the intervention to monitor for adverse reactions to insulin: blurred vision, dry mouth, rash, itching, and [MEDICATION NAME]. Another approach listed is to observe for compliance with diet/med regimen. Review of the MAR indicated [REDACTED]. 8. Review of the medical record for R#115 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] with the ARD of 1/26/16 which assessed R#115 with a BIMS score of 15 indicating no cognitive impairment. Section I indicates [DIAGNOSES REDACTED]. Section N: resident received insulin injections, antianxiety, antidepressants, and hypnotics seven (7) out of seven (7) days a week. Review of the Care Plan revealed a problem onset date of 8/18/15 indicating resident at risk for complications specific to DM. The target date was 5/4/16 with a goal the resident will be free from signs and symptoms of hypo/[MEDICAL CONDITION] without complications over next review period. Listed under approaches is the intervention to include medication ordered. Review of the MAR indicated [REDACTED]. 9. Review of the medical record for R#135 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] with the ARD of 1/29/16 which assessed R#135 with a BIMS not conducted. Section I indicates [DIAGNOSES REDACTED]. Section N: resident received insulin injections and antianxiety meds 7 of 7 days. Review of the Care Plan revealed a problem onset date of 12/1/15 indicating resident at risk for complications specific to DM. The target date was 2/29/16 with a goal the resident will be free from signs and symptoms of hypo/[MEDICAL CONDITION] without complications over next review period. Listed under approaches is the intervention to include medication as ordered. Review of the MAR indicated [REDACTED]. 10. Review of the medical record for R#143 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] with the ARD of 1/29/16 which assessed R#143 with a BIMS score of 08 indicating moderate cognitive impairment. Section I indicates [DIAGNOSES REDACTED]. Section N: resident received insulin injections, anticoagulants and diuretics 7 of 7 days, antianxiety 3 of 7 days, hypnotics 5 of 7 days. Review of the Care Plan revealed a problem onset date of 1/29/16 indicating resident at risk for complications specific to DM. The target date was 4/28/16 with a goal the resident will be free from signs and symptoms of hypo/[MEDICAL CONDITION] without complications over next review period. Listed under approaches is the intervention to include medication as ordered. Review of the January 2016 MAR for R#143 revealed three (3) times. 11. Record review for R#88 indicated the resident was initially admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the Care Plan for R#88 identified on 9/10/15 a Problem Onset of alteration in mood state: s/s depression, history of depression, inappropriate and combative behaviors, need for [MEDICAL CONDITION] medications. The Goal documented R#88 will have stable mood, decrease in documented behaviors over the next review period and target date of 2/18/16. Review of the Approaches/Interventions included, but not limited to: dated on 9/10/15 Monitor effectiveness of prescribed medication, Provide non-drug related intervention as indicated and chart results, Monitor for s/s i.e.: sadness, crying, withdrawal/loss of interest in usual activities, appetite changes act., and Evaluate for s/s of side effects i.e.: nausea/vomiting, constipation, dizziness, altered mental status, and report. Review of the Electronic Medication Administration Record [REDACTED]. Review of the Nurses Notes referenced from October 2015 through January 2016 revealed inconsistent documentation of behavioral symptoms. 12. Record review for R#97 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the care plan For R#97 identified a Problem Onset dated 08/11/15 that the resident was at risk for alteration in mood such as sign/symptom of depression, difficulty sleeping, [MEDICAL CONDITION]'s disease and need for [MEDICAL CONDITION] medication. The care plan indicated updates on 11/04/15 and 01/27/15. The Goal is that the resident will be free adverse effects of [MEDICAL CONDITION] medication over next review period. Resident will have stable mood and decrease in documented behaviors over next review period. Review of the Approaches/Interventions that included, but not limited to: Monitor effectiveness of prescribed medication, Monitor for signs/symptoms of sadness, crying, withdrawal/loss of interest in usual activities, increased agitation, and Evaluate for sign/symptoms of side effects. Review of the Electronic Medication Administration Record [REDACTED]. R#97 received [MEDICATION NAME] 400mg as prescribed, however, there was no evidence of monitoring/documentation of effectiveness of medication, behavioral symptoms or medication side effects. Interview on 01/29/16 at 3:30 p.m. with the DON revealed that she expects nursing staff to order behavioral monitoring for residents that are ordered/receiving antipsychotic medication. She revealed that she had conducted several in-services with the nursing staff about the importance of behavioral monitoring and side effect monitoring with antipsychotic medication usage. She revealed that the behavioral monitoring is used to ensure that the resident is not having any side effects to the medication, the monitoring allows the facility to know if the medication is working, and also if the medication can be reduced if no behaviors are noted. She revealed that she conducts random chart audits quarterly or more often with the residents that receive antipsychotic medication. She revealed during the audits she checks to make sure behavioral monitoring is completed. 13. Review of the clinical record for R#23 revealed a [DIAGNOSES REDACTED]. Review of their Annual Minimum Data Set ((MDS) dated [DATE] noted they had no cognitive deficits; had multiple Mood symptoms including little interest or pleasure in doing things; feeling down; trouble sleeping; feeling tired; appetite problems; and trouble concentrating, with a Total Severity Score of 14. Review of a Care Plan for [MEDICAL CONDITION] Drug Use with a Problem Onset of 10/02/11 and revised on 03/03/15 noted an Approach for a Behavior Health Service psychiatrist evaluation as needed and ordered. Review of a contracted behavioral health providers 2015 Progress Notes revealed that the resident was seen monthly from January to May, and again in July. Review of this Behavior Health Service Treatment Plan Review for Behavioral Health Services dated 08/03/15 noted a Service Plan for individual psychotherapy one to two times a month for twelve weeks. Review of this Behavior Health Service (a Licensed Clinical Social Worker) Closing/Termination Summary dated 09/29/15 noted that the Reason for Termination was a contract expiration with the skilled nursing facility, and the Follow-up Recommendations were for the resident to be followed by the new psych provider's Social Worker. Review of a fax sent from the new contracted behavioral health provider to the Social Worker dated 12/01/15 noted that resident #23 was verified and eligible for receiving their services. Review of the clinical record for R#23 revealed that there was no documentation of a contracted behavioral health provider seeing the resident between 09/29/15 and 01/15/16. During interview with the Administrator on 03/09/16 at 9:55 a.m., he stated that the facility switched behavioral health providers on 09/29/15, and did not know why R#23 was not seen by the Behavior Health Service psychologist between the termination of the previous psych provider on 9/29/15, and the initial evaluation by the new provider on 01/15/16. During interview with the SW on 03/09/16 at 1:56 p.m., she stated that she did not know why the contracted Behavior Health Service psychologist did not actually see R#23 until January, despite fax confirmation from them on 12/01/15 that R#23 was eligible for services. During interview with the contracted behavioral health psychologist on 03/10/16 at 1:30 p.m., he stated it was not ideal that resident #23 had not been followed routinely by Behavior Health Service months with any decline in their mood or behaviors. Cross-refer to F 250. The facility implemented the following actions to remove the Immediate Jeopardy: An audit was completed using all incidents involving physically or sexually aggressive behavior from 8/1/16 to 1/31/16. This allowed the review were to identify any other residents that have the potential to be affected in the deficient practice the administrator and/or designee will educate all staff immediately with mandatory and service concerning resident abuse, including facility policy, test, and handout and/or video any staff member that cannot attend will be educated by telephone and will receive in-house training prior to returning to work completed by 1/30/16. A quality assurance audit tool for physical or sexual aggression was created on 1/31/16. Incidence of physically or sexually aggressive behavior will be audited by the DON using quality assurance audit for physical or sexual aggression to ensure interventions were implemented, any findings of noncompliance will be reported to the administrator immediately effective 1/31/16 any findings of noncompliance will be presented to the quality assurance committee monthly for six (6) to determine if additional action is needed, then quarterly to ensure ongoing compliance at 1/31/16. Residents determined to be the aggressor in a physically or sexually aggressive situation will be placed on every 15 minutes visual monitoring until the resident was transferred to an inpatient psychiatric behavioral unit for evaluation. If unable to determine the aggressor both will be considered an aggressor as of 1/31/16. If the resident is the victim of the physically or sexually aggressive situation the residents placed on every shift pertinent chart for 72 hours as of 1/30/16. If the resident is the victim of a physically or sexually aggressive behavior the social services department will be notified and they will monitor the residence psychological wellbeing concerned in the resident as well as the resident ' s reaction to his or her involvement in the investigation. Social services will document in the resident social service notes for three days. Social services will report any psychological changes to the administrator and the director of nurses to determine if further intervention is needed. Upon return from inpatient psychiatric/behavioral unit the resident will be placed on every 15 minutes visual monitoring for 24 hours, every 30 minutes visual monitoring 48 hours and then hourly visual monitoring for four days. Effective 1/31/16. During the seven-day period of visual monitoring of the resident exhibits physically or sexually aggressive behavior without injury to either party every 15 minutes visual she will checks will be resumed until the resident can be transferred to an inpatient psychiatric/behavioral unit for evaluation. If the recurrence of sexually physically aggressive behavior results in injury to either party one on one supervision will be initiated immediately and will continue until the resident can be transferred to an inpatient psychiatric/behavior unit. Effective 1/31/16. All residents with physically or sexually aggressive behavior will be placed on the patient at risk program and will be reviewed weekly at the behavior patient risk meeting until they are free of physically or sexually aggressive behavior for four weeks. Effective 1/30/16. All residents with physically or sexually aggressive behavior will be evaluated by the facility contracted psychiatric group. Effective 1/30/16 Your administrator and director nurses will be notified of any reports of physically or sexually aggressive behaviors immediately. Effective 1/30/16 The nursing staff will be in serviced on completing an incident entry in the electronic medical record for incidence of abusive behavior. Effective 2/14/16 Care plan coordinators will be educated to implement revision of approaches and interventions to the plan of care related to both physical and sexual behaviors by 2/20/16 care plan revisions related to physical and sexual behaviors will be audited by the director of nurses and a minimum data set coordinator as part as the behavior patient at risk process. Any resident that were not updated will be updated immediately during behavior patient at risk meeting on 2/20/16. All license nursing staff were in serviced on calculation of sliding scale insulin dose/reading the sliding scale orders to determine the correct dose of insulin to be administered based on finger stick blood sugar results education of the nurses on importance of following physician orders [REDACTED]. All nurses were in serviced regarding reading and following physician orders [REDACTED]. The nurses will completed to nurse check on the sliding scale insulin and sign off appropriately according to the steps for insulin verification until the facility is free of errors for 90 days. All newly hired nurses will be in serviced on diabetic management policies and calculation of Scott sliding scale insulin as part of the orientation process. All newly hired nurses will complete a to nurse check on the sliding scale insulin and sign off appropriately according to the steps for insulin verification for their first 30 days of employment to ensure they are determining the correct dose of insulin to be given. Nurse management and administrator to be educated regarding the diabetic compliance monitoring policy and their responsibilities related to oversight of this policy. Education will be provided by chief nursing officer - clinical nurse consultant on 1/30/16. The DON and/or unit manager will complete the electronic Medication Administration Record [REDACTED]. The results of the audit and any identified issues will be reviewed in morning meeting and signed off by the administrator to begin on 1/31/16. Any findings of noncompliance will be presented to the quality assurance committee monthly for six months to determine if additional action is needed, then quarterly to ensure ongoing compliance. An allegation of jeopardy removal was received on 2/19/2016 and an amended AoC was received on 3/11/16. Based on the corrective plans developed, implemented by the facility, which were validated by the SSA on 4/3/16, the immediacy of the deficient practice was determined to have been removed on 3/12/16, and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication, behavior interventions and abuse protocol.

Based on record review and interviews, the facility failed to revise interventions for one (1) resident (R#88) who exhibited recurring inappropriate behaviors towards other residents, including inappropriate touching, verbal and physical altercations to seven (7) residents (R#21, R#20, C, xx and zz, R#74, and R#88) of the sampled fifty-three (53) residents. The facility census was ninety one (91) residents. It was determined that the noncompliance in one or more requirements of participation has caused harm to R#21, R#20, C, xx and zz, R#74, and R#88, is likely to cause, serious injury, harm, impairment, or death to the ninety-one (91) residents reside in the facility. The Administrator, Director of Nursing, and Chief Nursing Officer for Reliable Health Care Management were notified on 1/29/16 at 6:05 p.m. and 3/10/16 at 5:55 p.m. of Immediate Jeopardy (IJ) existed. This noncompliance was identified to have existed as of 10/14/2015, when R#88 first attempted inappropriate sexual behaviors toward R#21 (female). The Administrator and Director of Nursing were informed of this Immediate Jeopardy (IJ) on January 29, 2016 at 6:05 p.m. and 3/10/16 at 5:55 p.m. Cross refer F223 Findings include: Record review for R#88 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] which documented in Section A- Identification Information that R#88 was admitted to the facility on [DATE]. R#88 had not been evaluated by Level Two (II) Pre Admission Screening and Resident Review (PASRR) to determine serious mental illness. Section C- Cognitive Patterns documented R#88 had a Brief Interview for Mental Status (BIMS) summary score of four (4), indicating severe cognitive impairment. No moods or behaviors were exhibited. Section N- Medications documented R#88 received an antipsychotic medication two (2) out of the seven (7) day look back period and received an antidepressant medication seven (7) out of seven (7) days. Section V- Care Area Assessment (CAA) triggered [MEDICAL CONDITION] Drug Use with the decision to be care planned. Review of the Quarterly MDS Assessment for R#88 dated 11/12/15 revealed a Brief Interview Mental Status (BIM) summary score of 4 indicating severe cognitive impairment. Continued review revealed R#88 had trouble falling or staying asleep, or sleeping too much with no behaviors exhibited. R#88 received antipsychotic medication one (1) out of the seven (7) day look back period and an antidepressant seven (7) out of seven (7) days. R#88 had multiple [DIAGNOSES REDACTED]. Review of the Care Plan for R#88 revealed a problem onset dated on 9/10/15 with an alteration in mood state related to a history of depression, inappropriate and combative behaviors, and the need for [MEDICAL CONDITION] medications. The care plan goal for R#88 is to have a stable mood, with a decrease in documented behaviors over the next review period with a target date of 2/18/16. Review of the Approaches/Interventions include the following for R#88 dated on 9/10/15 remove to a calm environment when needed; monitor effectiveness of prescribed medication; provide diversional activities as needed; provide non-drug related intervention as indicated and chart results; encourage family visits and support; Medication Management as ordered; monitor for s/s i.e.: sadness, crying, withdrawal/loss of interest in usual activities, appetite changes act.; evaluate for s/s of side effects i.e.: nausea/vomiting, constipation, dizziness, altered mental status, and report, and; allow R88 to verbalize feelings and express emotions. There is no evidence of revision of interventions after the numerous physical, verbal and sexual incidents that occurred involving R#88, including approaches/interventions to assist R#88 from further abusing residents. Review of the Physician order [REDACTED].½ tablet (2.5mg) at 6:00 a.m. in the morning daily for Major [MEDICAL CONDITION]; ordered on [DATE] [MEDICATION NAME] 10 mg daily at 8:00 p.m. for Major [MEDICAL CONDITION]; ordered on [DATE] [MEDICATION NAME] 125 mg Sprinkle, give four capsules = 500 mg twice daily at 9:00 a.m. and 9:00 p.m., and; ordered on [DATE] observe for S/S of Adverse reaction of [MEDICAL CONDITION] Medications. 1. Review of a facility report revealed that on 10/14/15 at 5:30 p.m. R#88 and a female resident (R#21) were in the hallway both in wheelchairs. R#88 attempted to get his hand up the dress of R#21. Staff members stopped him immediately and removed them to separate area. MD was notified and R#88 was sent to a Behavioral Health Center for evaluation. The female resident had BIMS summary score of 0, indicating an interview was not conducted due to the resident rarely or never understood and has a [DIAGNOSES REDACTED]. 2. Review of a Nurses note dated 12/10/15 at 1:36 p.m. revealed R#88 had a verbal altercation with a male resident zz in the dining room. After the verbal altercation with zz as R#88 was leaving the dining room he struck a female resident C with his fist striking her on the hand. Will have MD review medication on next visit. 3. Review of a Nurses note dated 12/12/15 at 8:15 p.m. revealed R#88 became violent hitting and kicking staff caring for him. R#88 tried to rip off the shirt of female staff. Doctor notified orders to send to a Behavioral Health Center for evaluation. Review of the physician progress notes [REDACTED].#88 exhibiting aggressive behaviors, may benefit from treatment at a Behavioral Health Center. 4. Review of Report of Incident Description dated 12/29/15 at 6:00 a.m. revealed that R#88 was in wheelchair when R#74 (female) passed by, R#88 grabbed the buttocks of R#74, then she turned around and swung at the head of R#88 and struck him on the shoulder. R#88 just laughed at her. No injury noted. 5. Review of a nursing notes revealed an entry dated 01/08/16 at 1:31 p.m. R#88 observed rubbing the thigh of a female R#20. The residents were separated. R#88 became combative, attempted to strike staff members. MD notified. New order to increase [MEDICATION NAME] to 5 mg in morning and 10 mg in evening. Message left for family. Will monitor. 6. Review of a Report of Incident Description dated 1/8/16 at 3:00 p.m. revealed the treatment nurse was walking down 300 Hall when she witnessed R#88 inappropriately touching female R#20. R#88, was seated in his wheelchair was next to R#20 who was sitting in her Geri chair with her eyes closed. The treatment nurse stopped the behavior and educated R#88 that behavior was inappropriate and needed to stop. The treatment nurse then removed R#88 from the area. While the treatment nurse reported the incident to the unit manager, R#88 once again made his away over to R#20. Before another incident occurred the treatment nurse removed R#88 to his room and provided education that the behavior was inappropriate. R#88 then told the treatment nurse to, shut up. A Certified Nursing Assistant (CNA) then attempted to place the R#88 in bed. R#88 attempted to strike the CNA at this time. 7. Review of Nurses note dated 1/17/16 at 2:19 a.m. revealed during late evening medication pass, R8#8 grabbed throat of nurse and began grabbing her. Notified physician who gave STAT (immediate) order for [MEDICATION NAME]. R#88 went to sleep after incident, the nurse did not administer [MEDICATION NAME] due to resident already sleeping. 8. Review of a Report of Incident dated 01/19/16 at 6:15 p.m. revealed R#88 was sitting in dining room in wheelchair when a CNA saw R#88 wheeling towards another female resident (R#20) hitting her on the left side of her face, striking her cheek. No injuries were noted. MD and family member notified. Continued review of the Report of Incident revealed the intervention is to leave R#88 out of dining room until the trays come out. 9. Review of a Nurses note dated 1/23/16 at 2:41 a.m. revealed R#88 in his room was placing trash in container, when his roommate xx began to yell at R#88 stating what the **** are you doing? R#88 began to get agitated and started to push himself toward roommate xx and said I will show you something you *******! This nurse pulled R#88 back with his wheelchair and instructed the residents to cease acting this way and calm down. This nurse had R#88 sit outside sit outside in the hall in his wheelchair until the Certified Nursing Assistant (CNA) came to toilet him. No further arguments noted. 10. Review of a Nurses note dated 1/23/16 at 6:50 a.m. R#88 having issues today with inappropriate touching of female staff. This morning R#88 came up behind a housekeeper at her cart and grabbed her crotch and buttocks. R#88 was removed from the hall and brought back to 100 hall. Nurse had R#88 to stay near her as much as possible today to avoid further issues, but the resident repeatedly went or tried to go into female rooms, upsetting female residents. This afternoon when being given his insulin shot, R#88 used the opportunity of this nurse bending down to roll up his sleeve of his shirt to grab this nurse's crotch from the front. I once again tried to educate the resident on the inappropriateness of touching females. Resident rolled his eyes and said he can do what he wants to. 11. Review of a Nurses note dated 1/24/16 at 8:10 p.m. LATE ENTRY - 2:00 p.m. R#88 had altercation with dining staff. R#88 ate two (2) trays of food and then went to another table and started eating another resident's food. Dining staff started taking the food away from him and he struck out at them, grazing one CNA. There is no evidence in the clinical record for R#88 of a Behavior Health Service Consultation, Evaluation or monitoring. Interview continued on 01/28/16 at 9:36 a.m. with the Director of Nursing (DON) revealed R#88 returned to the facility on [DATE]. R#88 had been sent to a Behavioral Health Center on multiple occasions to address his inappropriate sexual behaviors and increased aggressiveness. The staff have been educated regarding individualized care needs of R#88 to try and redirect R#88 and to provide diversional activities. The DON did not provide evidence of staff education by the survey exit on 1/29/16 at 10:00 p.m. Interview conducted on 01/28/16 at 1:30 p.m. with direct care CNA MM revealed they were not aware of any special concerns or needs related to the behaviors of R#88. Interview conducted on 01/28/16 at 1:33 p.m. with CNA NN stated R#88 was on his assignment today and they were not aware of any special concerns or needs related to the behaviors of R#88. NN stated they have only been working for just a few weeks and really doesn ' t know much at all about this resident. Interview conducted on 1/28/16 at 6:15 p.m. with the Administrator revealed the facility has taken numerous steps to prevent further abuse occurrences by R#88 and moved him from room [ROOM NUMBER] to room [ROOM NUMBER] away from the female resident he touched. The medications have been adjusted and R#88 was sent to acute care facility where he stayed for approximately one (1) week. They have tried diversional activities. They have spoken with the family attorney about hiring sitters. They have sought placement at other facilities. R#88 is currently on the waiting list for several facilities with locked units. The facility implemented the following actions to remove the Immediate Jeopardy: An audit was completed using all incidents involving physically or sexually aggressive behavior from 8/1/16 to 1/31/16. This allowed the review were to identify any other residents that have the potential to be affected in the deficient practice the administrator and/or designee will educate all staff immediately with mandatory and service concerning resident abuse, including facility policy, test, and handout and/or video any staff member that cannot attend will be educated by telephone and will receive in-house training prior to returning to work completed by 1/30/16. A quality assurance audit tool for physical or sexual aggression was created on 1/31/16. Incidence of physically or sexually aggressive behavior will be audited by the DON using quality assurance audit for physical or sexual aggression to ensure interventions were implemented, any findings of noncompliance will be reported to the administrator immediately effective 1/31/16 any findings of noncompliance will be presented to the quality assurance committee monthly for six (6) to determine if additional action is needed, then quarterly to ensure ongoing compliance at 1/31/16. Residents determined to be the aggressor in a physically or sexually aggressive situation will be placed on every 15 minutes visual monitoring until the resident was transferred to an inpatient psychiatric behavioral unit for evaluation. If unable to determine the aggressor both will be considered an aggressor as of 1/31/16. If the resident is the victim of the physically or sexually aggressive situation the residents placed on every shift pertinent chart for 72 hours as of 1/30/16. If the resident is the victim of a physically or sexually aggressive behavior the social services department will be notified and they will monitor the residence psychological wellbeing concerned in the resident as well as the resident ' s reaction to his or her involvement in the investigation. Social services will document in the resident social service notes for three days. Social services will report any psychological changes to the administrator and the director of nurses to determine if further intervention is needed. Upon return from inpatient psychiatric/behavioral unit the resident will be placed on every 15 minutes visual monitoring for 24 hours, every 30 minutes visual monitoring 48 hours and then hourly visual monitoring for four days. Effective 1/31/16. During the seven-day period of visual monitoring of the resident exhibits physically or sexually aggressive behavior without injury to either party every 15 minutes visual she will checks will be resumed until the resident can be transferred to an inpatient psychiatric/behavioral unit for evaluation. If the recurrence of sexually physically aggressive behavior results in injury to either party one on one supervision will be initiated immediately and will continue until the resident can be transferred to an inpatient psychiatric/behavior unit. Effective 1/31/16. All residents with physically or sexually aggressive behavior will be placed on the patient at risk program and will be reviewed weekly at the behavior patient risk meeting until they are free of physically or sexually aggressive behavior for four weeks. Effective 1/30/16. All residents with physically or sexually aggressive behavior will be evaluated by the facility contracted psychiatric group. Effective 1/30/16 Your administrator and director nurses will be notified of any reports of physically or sexually aggressive behaviors immediately. Effective 1/30/16 The nursing staff will be in serviced on completing an incident entry in the electronic medical record for incidence of abusive behavior. Effective 2/14/16 Care plan coordinators will be educated to implement revision of approaches and interventions to the plan of care related to both physical and sexual behaviors by 2/20/16 care plan revisions related to physical and sexual behaviors will be audited by the director of nurses and a minimum data set coordinator as part as the behavior patient at risk process. Any resident that were not updated will be updated immediately during behavior patient at risk meeting on 2/20/16. All license nursing staff were in serviced on calculation of sliding scale insulin dose/reading the sliding scale orders to determine the correct dose of insulin to be administered based on finger stick blood sugar results education of the nurses on importance of following physician orders [REDACTED]. All nurses were in serviced regarding reading and following physician orders [REDACTED]. The nurses will completed to nurse check on the sliding scale insulin and sign off appropriately according to the steps for insulin verification until the facility is free of errors for 90 days. All newly hired nurses will be in serviced on diabetic management policies and calculation of Scott sliding scale insulin as part of the orientation process. All newly hired nurses will complete a to nurse check on the sliding scale insulin and sign off appropriately according to the steps for insulin verification for their first 30 days of employment to ensure they are determining the correct dose of insulin to be given. Nurse management and administrator to be educated regarding the diabetic compliance monitoring policy and their responsibilities related to oversight of this policy. Education will be provided by chief nursing officer - clinical nurse consultant on 1/30/16. The DON and/or unit manager will complete the electronic Medication Administration Record [REDACTED]. The results of the audit and any identified issues will be reviewed in morning meeting and signed off by the administrator to begin on 1/31/16. Any findings of noncompliance will be presented to the quality assurance committee monthly for six months to determine if additional action is needed, then quarterly to ensure ongoing compliance. An allegation of jeopardy removal was received on 2/19/2016 and an amended AoC was received on 3/11/16. Based on the corrective plans developed, implemented by the facility, which were validated by the SSA on 4/3/16, the immediacy of the deficient practice was determined to have been removed on 3/12/16, and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication, behavior interventions and abuse protocol.

Based on observation, record review, review of the facility's Social Services Duties and Responsibilities form and interviews, it was determined that the facility failed to provide referrals as indicated for Behavioral Health Services, failed to assess the cause of behaviors, failed to identify interventions to assist residents in managing their behaviors, medically-related social services to address the physical, mental and psychosocial needs of four (4) residents (R#88, R#26, R#23 and R#97) of five (5) residents reviewed for behaviors of the sampled fifty-three (53) residents. This failure resulted in physical harm to R#26 when the resident's continued abusive behaviors resulted in a certified nursing assistant (CNA) physically abusing the resident and in mental harm to multiple female residents who were sexually abused by R#88. The failure to obtain a consultation for ongoing psychiatric services to address the behaviors of R#88 and R#26, and the failure to follow their PAR Behavior Tracking policy, is likely to cause serious injury, harm, impairment, or death to other residents. Immediate Jeopardy was identified on [DATE], and was determined to exist as of [DATE]. The Administrator, Director of Nursing, and Chief Nursing Officer for Reliable Health Care Management were notified on [DATE] at 6:05 p.m. and [DATE] at 5:55 p.m. of Immediate Jeopardy (IJ) existed. An Allegation of Compliance (AoC) was received from the Nursing Home Administrator on [DATE]. Findings include: 1. Record review of R#88 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Further review revealed R#88 was transferred to another facility on [DATE]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed R#88 had severe cognitive impairment; no behaviors in the seven (7) day look-back period; and received no Psychological Therapy. Review of the Quarterly MDS dated [DATE] revealed R#88 had no behaviors. Review of Care Plan for R#88 revealed a Category for Psychotropic Medication Use, with a Problem Onset date of [DATE], revised on date[DATE] for alteration in mood state with depression, history of inappropriate and combative behaviors as evidenced by need for psychotropic meds with related [DIAGNOSES REDACTED]. Review of the approaches revealed that they were not individualized, and did not reflect the sexual, verbal, and physical behaviors. Review of Nurses Notes from admission to discharge revealed the following behaviors exhibited by resident #88: On [DATE] at 7:45 a.m. R#88 talking extremely vulgar to a trainee and CNA. On [DATE] at 11:50 a.m. R#88 told a female nurse he would let her do the blood sugar if she kissed him on his private parts. Social Worker notified of behavior. On [DATE] at 1:26 p.m. R#88 continues to be sexually inappropriate, when confronted to stop the behavior he becomes violent at times. On [DATE] at 5:00 p.m. witnessed by 3 staff members, R#88 was trying to put his hand up the dress of R#21 (a female) attempting to touch her private area. When R#88 was approached by the charge nurse and told this was inappropriate, R#88 stated he didn't care. R#88 was asked to go back to his room by the respiratory therapist (RT-a female), he refused and stated they would stab the RT with a knife if she didn't get out of the way. On [DATE] at 1:00 p.m. CNA reported she was changing R#88 and he was swinging his arms which caused a skin tear to his right hand. On[DATE] at 12:46 p.m. Risperdal (an antipsychotic medication) 0.5 milligrams (mg) administered to R#88 due to attempts to strike/hit other residents. On [DATE] at 1:36 p.m. R#88 had a verbal altercation with a male resident in the dining room. After the altercation as R#88 was leaving the dining room he struck R#26 (a female resident) with his fist, striking resident #26 on the hand. Will have the MD review meds on his next visit. On [DATE] at 7:00 p.m. R#88 became violent, hitting and kicking staff caring for him. R#88 tried to rip off female staff member shirt. Order to send to Behavioral Health for evaluation. On [DATE] at 6:00 a.m. R#88 was in wheelchair in front of the desk when a female resident (R#74) passed by, R#88 grabbed her on the buttocks. Also sexually grabbing at other female residents and staff. On [DATE] at 1:31 p.m., 3:00 p.m., and 4:39 p.m. R#88 in the hallway, observed rubbing the thigh of a female resident (R#20), and was removed from the area by the treatment nurse. When the treatment nurse was reporting the incident to the unit manager, R#88 made his way over to the sleeping female resident, was removed by the treatment nurse and told again his behavior was inappropriate. R#88 told the treatment nurse to shut up, and he attempted to strike the CNA who attempted to place him in bed at this time. On [DATE] at 2:19 a.m. during med pass, R#88 grabbed the throat of the nurse (a female) and began grabbing at her. On [DATE] at 6:15 p.m. R#88 sitting in the dining room when CNA saw him wheeling towards R#20 (a female) and he hit her on left cheek of her face. On [DATE] at 2:41 a.m. R#88 in his room to place trash in container, his roommate (R#82) began to yell at him. R#88 began to get agitated, started to push himself toward R#82 and said I will show you something you _ _ _hole. On [DATE] at 6:50 p.m. R#88 having issues today with inappropriate touching of female staff. This morning he came up behind a female housekeeper at her cart, grabbed her crotch and buttocks. R#88 was removed from the hall and brought back to the 100 hall. R#88 repeatedly tried to go into female resident rooms, upsetting the female residents. When being given his insulin shot, R#88 grabbed the crotch of the female nurse from the front. When educated of the inappropriateness of touching females, he rolled his eyes and said he could do what he wanted to. On [DATE] at 2:00 p.m. R#88 had altercation with dining staff. R#88 ate two trays of food, then went to another table and started eating the food of another resident. Dining staff started taking the food away from him and he struck out at them, grazing one CNA. A female nurse was called to the dining room, R#88 was waving his arms around as if he were trying to reach out and hit staff. When the female nurse spoke to R#88, she was attacked by R#88. The female nurse left to obtain food for another resident in the dining room, R#88 wheeled himself down the hall and into the room of another resident and tried to take their food. R#88 blocked the door to the other room and tried to hit the other resident when they advanced. R#88 has also got into a shouting match with his roommate xx over the past 2 days. His agitation and aggression has escalated to the point that he has to have continuous monitoring. On [DATE] at 2:28 p.m. the MD was consulted in regards to R#88 continued sexual behaviors toward female staff and other female residents. R#88 has been sent to Behavior Health Center in the past with no significant changes in his medications (meds). On [DATE] at 9:18 a.m. a female sitter stated at 3:00 a.m. that R#88 put his hand on her thigh and began rubbing, she moved his hand and asked him to stop. At 6:00 a.m. the female sitter stated that R#88 made attempts to put his leg between her thighs and she stopped him. Review of Social Services Progress Notes from admission to discharge for behavior incidents included: On [DATE], R#88 has been moved from the dining room to eat all meals in room. R#88 had increasingly inappropriate behavior with all female staff. MD notified and working on changing meds. On [DATE], R#88 has become more aggressive with inappropriate comments. All staff is aware and MD has also been notified in order to help with medication. R#88 is banned from dining room due to inappropriate behavior. On [DATE], R#88 returned to Behavioral Health Center due to an increase in behavior over last few days. His aggravation appears to be high and he has acted out on his impulses. Staff saw R#88 hit another resident. Also got in a verbal fight with another resident. Will put on PAR when he returns to facility. On [DATE], R#88 returned to facility showing increasing inappropriate sexual behavior. Staff has witnessed him touching other residents extremely inappropriately or attempting to. Staff has been educated and is always quick to act to redirect R#88. Facility believes R#88 would benefit more wholly from a facility with a locked unit. On [DATE], R#88 had a room changed from 300 to 100 hall. Moved away from a female resident in which he was found touching inappropriately. On [DATE], other facilities declined R#88 admission. Look into a possible sitter. On [DATE], R#88 referred to a psychological and behavioral service for his behaviors, and received an initial evaluation. Further review of the Social Services Progress Notes revealed that there was no mention of R#88 putting his hand up R#21's dress and threatening to stab the Respiratory Therapist [DATE]; no documentation of R#88 striking R#20 on [DATE]; and no mention of the physical aggression toward staff and other residents and sexual touching of staff on [DATE] and [DATE]. Continued review of the Social Services Progress Notes revealed that there was no documentation that the SW was closely monitoring R#88's behaviors after the incidents described in the Nurses Notes, nor any evidence that the SW considered a psychiatric consult to address the ongoing behaviors until [DATE]. Review of the Initial Diagnostic Evaluation dated [DATE] for R#88 by the contracted behavioral health doctor noted that the R#88 was referred for aggression and sexual acting out towards staff and other residents. Further review of the Initial Evaluation revealed that the psychologist recommended lab tests to check for therapeutic levels of a psychotropic medication, and several psychotropic med recommendations. Review of the psychologist's risk assessment revealed that R#88 was a significant risk to others, and the other residents in the facility were at risk given their own mental and physical disabilities as it related to their ability to react to the behaviors of R#88. Review of the facility's Policy and Procedure (P&P) for Patient at Risk (PAR) noted that Social Services should attend behavior PAR. Review of the Behavior PAR section of this P&P revealed that all residents with an exacerbation of a behavior problem or a new behavior will be placed on Behavior PAR for individualized PAR tracking until the condition was stabilized for four weeks. Review of Patient at Risk (PAR) Behavior PAR Tracking forms revealed for R#88, he began on the program on [DATE], despite documentation of sexually inappropriate behavior as far back as [DATE] Further review of all of the PAR Tracking forms revealed that the section for Interventions on Care Plan were blank. During interview with the Social Worker (SW) on [DATE] at 8:21 a.m., she stated that the facility had a contract with an outside provider for behavior monitoring, psychiatric medication review of residents that she had referred to them. The SW further stated that this provider's psychologist put their recommendations in the charts of the residents, and that she didn't review their notes. The SW further stated that with some of the residents the psychologist ' s recommendations were taken to care plan meetings, but this was not consistently being done. Upon further interview the SW stated that when a resident had a behavior, she checked their psychosocial status daily for 72 hours, talked to them, observed them, and that if this was done it would be documented in the Social Services notes. During interview with the SW on [DATE] at 1:55 p.m., she stated she had worked at the facility since September of 2015, and that she was aware of the behaviors of R#88 including inappropriately touching female residents and the physical behaviors since October. Upon further interview, the SW stated that she did not know who was responsible for referring a resident to the Behavior PAR meetings. Upon further interview, the SW stated that she was a little late in referring R#88 to the behavior services provider, and that she dropped the ball and should have referred R#88 back in October. During interview with the DON on [DATE] at 4:01 p.m., she stated that the Social Worker would be the staff responsible for referring a resident for behavior health services. During interview with the Administrator on [DATE] at 10:00 a.m., he verified that R#88 would have been appropriate for being seen by psych services prior to February, and did not know of any reason the attending physician would have refused a behavior health services consult. During interview with the DON on [DATE] at 11:41 a.m., she stated that the Social Worker was responsible for contacting the contracted behavior health services provider if there was a recommendation for behavior health services, and that the nurses would let her know if this needed to be done. During interview with the DON on [DATE] at 1:07 p.m., she verified that a follow-up with the contracted psychologist or the behavioral health facility psychiatrist as recommended at discharge from the behavioral health facility on [DATE] was not done. Review of the Social Worker job description revealed the following: -Refer resident to appropriate social service agencies when the facility does not provide the services or needs of the resident. -Work with the consultants as necessary and implement recommended changes as required. -Interpret social, psychological, and emotional needs of the resident to the medical staff, attending physician, and other resident care team members. -Ensure that all charted progress notes are informative and descriptive of the services provided and of the resident's response to the service. -Assist in developing preliminary and comprehensive assessments of the social service needs of each resident. -Assist in developing a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident and the goals to be accomplished for each problem/need identified. -Review and revise care plans and assessments as necessary, but at least quarterly. During interview with the Administrator on [DATE] at 10:00 a.m., he stated that the SW had been employed by the facility since September or October of 2015, and that this was her first job as a social worker. Upon further interview, he stated that she had received training for the SW job at a sister facility and from a previous SW at this facility, and that he would be the one to evaluate her performance as a social worker. During further interview, the Administrator verified that R#88 would have been appropriate for being seen by behavior health services prior to January. 2. Record review for R#23 revealed a [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed no cognitive deficits; multiple Mood symptoms including little interest or pleasure in doing things; feeling down; trouble sleeping; feeling tired; appetite problems; and trouble concentrating, with a Total Severity Score of 14. Review of the Quarterly MDS dated [DATE] and [DATE] revealed no Mood symptoms, with Total Severity Scores of 0. Review of a Quarterly MDS dated [DATE] revealed that a Resident Mood Interview was not conducted, but a Staff Assessment of Resident Mood was completed instead. Review of the Staff Assessment revealed Mood problems of little interest or pleasure in doing things; feeling down; trouble sleeping; feeling tired; trouble concentrating; statements that life wasn't worth living, wishes for death, or attempts to harm self nearly every day; being short-tempered and easily annoyed, for a Total Severity Score of 20. Review of a Care Plan for Psychotropic Drug Use with a Problem Onset of [DATE] and revised on [DATE] revealed an approach for a behavior health services as needed and ordered. Review of the Medication Administration Records (MAR) revealed no behaviors in August, September, or October of 2015, nor January and February of 2016. Further review of the MARs revealed that the R#23 had behaviors including paranoia, delusions, hallucinations, and pacing on eleven (11) of the thirty (30) days in November, and eight (8) of thirty-one (31) days in December. Review of a contracted behavioral health provider 2015 Progress Notes revealed that R#23 was seen monthly from January to May, and again in July. Review of the behavior health services Treatment Plan Review dated [DATE] revealed the following: Current services provided Individual Psychotherapy ,[DATE] times a week/month. Resident referred for depression and anxiety, frustration leading to outburst of anger at other residents and/or staff. Continues stable in function, ambulating around facility and greeting other patients. Functioning stable and improved function overall, although physical weight loss and shaking of their hands indicates decline in physical health. Remains good candidate for verbal exercise and therapy. Able to participate in reminiscent therapy well. Service Plan: Individual Psychotherapy ,[DATE] times a month for 12 weeks. Review of the psych providers (a Licensed Clinical Social Worker) Closing/Termination Summary dated [DATE] revealed the following: Presenting Problems of depression, psychosis, and mood disorder. Referred for mood lability, history of bipolar and schizoaffective disorders. Summary of Treatment: Much better. Therapy Type: Individual. Much improvement, joined strongly with clinician and benefits evident from talk therapy. Summary of Last Session: Indicated in termination session he/she would be followed by new social worker. Reason for Termination: Contract expiration with the skilled nursing facility. Follow-up Recommendations: Social Worker with new psych provider. Diagnosis: [REDACTED]. Review of a fax sent from the new contracted behavioral health provider to the Social Worker dated [DATE] revealed that R#23 was verified and eligible for receiving their services. Record review for R#23 revealed that there was no documentation of a contracted behavioral health provider seeing the R#23 after [DATE] until [DATE]. Review of the new contracted Behavioral Health provider's (a Licensed Clinical Psychologist) Initial Diagnostic Evaluation dated [DATE] revealed the following: Reason for referral: Agitation, bipolar illness. History of Presenting Problem/Previous Psychiatric History: Patient reportedly has a long history of mental health issues and repeated psychiatric hospitalization s. Somewhat grandiose and irritable and with significantly perseverative religious thought process. Patient reportedly has a history of refractory bipolar episodes as well as treatment compliance issues. Current Emotional/Behavioral Signs and Symptoms that are altering baseline functioning: Reported feeling sad and apparently angry at what he/she perceived as forces in the facility and Satan plotting against them, but denied any intent to harm self or others. They appeared more preoccupied and ruminative regarding same and religiously preoccupied as opposed to delusional. Mental Status Examination: Delusions, obsessions, suspiciousness, flight of ideas, perseverative, circumstantial. Diagnostic Impressions/Problem Description: R#23 appears to have a long standing history of mental health issues, but the chart was unclear as to their prior treatment. Does not appear to be a threat to self or others at this time. I would recommend his/her meds be reviewed and a Depakote level obtained. Recommendations: Individual psychotherapy. Patient appears to have sufficient cognitive and memory resources as well as subsequent insight to process and remember therapeutic interventions and appears motivated for treatment. They will likely need some help with cognitive restructuring to address their schemas and assumptions regarding their mental health issues as well as work on coping skills training to address their anxiety levels at times. Review of attending physician Monthly Assessments dated [DATE], [DATE], and [DATE] revealed R#23 depression and schizophrenia were stable. Further review of the attending physicians Monthly assessment dated [DATE] revealed R#23 was refusing their meds and had active hallucinations at times, thought Trazodone (an antidepressant med) was the devil's medicine. Assessment/Diagnosis: [REDACTED]. Review of Social Services Interdisciplinary Progress Notes included the following: On [DATE], R#23 in a good mood and had zero depression. On [DATE], R#23 answered no to all questions on the mood interview (indicating no mood concerns). On [DATE], (late entry) R#23 reported that a Certified Nursing Assistant (CNA) had treated them with disrespect, but got very upset when asked to sign the statement of their allegation, and stated blacks had to take care of their own people. (Note: There was no notation in the SW's notes that she followed up with the resident between [DATE] and [DATE]). On [DATE], R#23 refused to answer the mood questions for the SW, and staff answered yes for almost all of the questions including thoughts that he/she would be better off dead. Staff also reported to SW that R#23 would make bizarre statements including that he didn't like white people, the facility was trying to get rid of black CNA's and that the nursing staff was trying to kill him. He has been refusing meds. During interview with the SW on [DATE] at 9:34 a.m., she stated that R#23 had been seen for an initial psychiatric diagnostic evaluation per a Billing Form on [DATE], but she had never seen the evaluation to see if the psychologist had made any recommendations. During interview with the Administrator on [DATE] at 9:55 a.m., he stated that they switched psych providers on [DATE], and did not know why R#23 would not have been seen by the psychologist between the termination of the previous psych provider on [DATE] and the initial evaluation by the new provider until [DATE]. During interview with the SW on [DATE] at 1:56 p.m., she stated that she completed the Mood section on the MDS, and verified that R#23 on [DATE] and [DATE] Quarterly MDSs had no Mood concerns, but the [DATE] the Quarterly MDS had a Mood score of 20, which the SW stated was off the charts. Upon further interview, the SW stated that if a resident had a high score above 9 on their Patient Health Questionnaire (which were the questions from the Mood section of the MDS), she would put the copy in the physician's problem book, and that the physician visited weekly and would review this book. Review of a Communication Record from the SW to the Physician/Nurse Practitioner (NP) dated [DATE] noted a decline in R#23 mental health and appearance, and it was initialed by the NP on [DATE]. During further interview, the SW stated that unless the resident expressed that they were going to act on a feeling of being better off dead, she would not immediately call the physician. The SW further stated that R#23 was already on the contracted behavior health services caseload, and due to the [DIAGNOSES REDACTED]. During further interview, the SW did not know why the behavior health services psychologist did not actually see R#23 until January, despite fax confirmation from them on [DATE] that R#23 was eligible for services. The SW further stated that she asked a SW that currently worked part-time with the ventilator residents, and who used to be a SW for the previous behavioral health provider, to informally see R#23 when she had a concern with the change in the R#23 mood, but there was no documentation of this, and no recommendations to address his declining mood. During interview with Licensed Practical Nurse (LPN) CC on [DATE] at 8:52 a.m., she stated that in January it seemed like R#23 meds were not working and he was very moody, hateful, and ill with staff, and was jumping all over everyone, and that the physician increased his meds and now everything seemed to be much better. During interview with the Administrator on [DATE] at 10:08 a.m., he stated that on the previous behavior health services termination summary for R#23 that the recommendation was to be seen by the new social worker. Upon further interview, the Administrator felt that this recommendation could be referring to the facility's SW, who was new to the facility around that time (note the Termination Summary dated [DATE] specified the resident should be followed by the new behavior health services SW in the Follow-Up Recommendations section). During further interview, he stated that the facility had a contract with the new behavioral health provider since September, and did not know why their staff did not start seeing residents until January. During interview with the contracted behavioral health service psychologist on [DATE] at 1:30 p.m., he stated that it was not ideal that R#23 was not being followed routinely by behavior health services for several months with a decline in mood or behaviors. 3. R#26 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed that R#26 had a Brief Interview for Mental Status (BIMS) score of 3 indicating that he was cognitively impaired. Continued review revealed that R#26 did not have any behaviors in the look back period. Review of the care plan dated [DATE] for R#26 revealed that the resident was very critical of facility staff and had problems with roommates with an intervention for staff to consider psychologist intervention. Review of the medical record for R#26 revealed that the resident verbally and /or physically abused certified and licensed nursing staff three (3) times in [DATE], one (1) time in [DATE], three (3) times in [DATE], one (1) time in [DATE], one (1) time in [DATE], two (2) times in [DATE] and three (3) times in [DATE]. Review of a Grievance/Complaint Report dated [DATE] revealed that a Certified Nursing Assistant (CNA) had complained about R#26 abusive behaviors and of administrative staff ' s lack of response. Continued review of the report revealed that the current psychiatric services contract had expired but, a referral would be made for R#26 with the new psychiatric service. However, there was no indication that a referral was made at that time. Further review of the medical record for R#26 revealed that he continued to have abusive behaviors toward staff, one (1) time in [DATE], two (2) times in [DATE], one (1) time in [DATE] and four (4) times in February 2016. Continued review of the medical record for R#26 revealed that the attending physician was notified of each incident and adjusted the for R#26 psychotropic medications. However, there was no indication that a psychologist evaluation was obtained. Review of the electronic Nurses Note dated [DATE] at 11:48 a.m. revealed that on [DATE] at 10:55 p.m., certified nursing assistant (CNA) LL notified the nurses that she had assisted CNA MM in transferring R#26 via Stand Lift to the bathroom. During the transfer R#26 began to pinch, hit and twist the ear of CNA MM . CNA MM then retaliated and pinched, hit and twisted the ear, yelled in the face daring R#26 to hit her and shoved R#26 against the wall in the bathroom. Continued review of the Nurses Note revealed that the nurse performed an assessment of R#26 and R#26 had two small scratches on his left hand. The attending physician and responsible party were notified of the incident and the physician adjusted the medications for R#26 again at that time. The facility took immediate action and terminated both CNAs MM and LL. Interview with the Administrator on [DATE] at 12:50 p.m. revealed that the contract with the psychological service was effective [DATE]. Continued interview revealed that psychological services received referrals for residents on [DATE] and that the psychologist came to the facility on [DATE]. Reviewed the [DATE] Grievance/Complaint Report with the Administrator at that time. The Administrator stated that the current Admissions Coordinator was the interim Social Services Director in ,[DATE] and should have made a referral for R#26 to psychological services at that time. Further interview with the Administrator revealed that no referral was made until [DATE]. R#26 was evaluated by the psychologist on [DATE]. Review of the Job Description for Social Services revealed that the duties of the Social Services staff included the assistance in obtaining resources from community social, health and welfare agencies to meet the needs of the resident. Interview with the Admissions Coordinator on [DATE] at 1:45 p.m. revealed that she was the interim SSD from ,[DATE] to ,[DATE]. Continued interview revealed that she had looked in her referral book but did not find a faxed referral to for R#26. Further interview revealed that she had changed her position to Admissions Coordinator and that the referral had fallen through the cracks . Continued interview revealed that R#26 was never treated by the former contracted psychological services prior to their contract ending in ,[DATE]. 4. R#97 was admitted to the facility on [DATE] from another long term care facility. R#97 was alert, oriented, and able to make his needs known. R#97 [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R#97 had a BIMS Score of eleven (11) which indicates moderately impaired cognitive function. Continued review of the Admission MDS revealed that R#97 mood was assessed as having a poor appetite or overeating and was assessed as exhibiting no behaviors during the look back period. Review of the Quarterly MDS assessment dated [DATE] revealed that R#97 had a BIMS Score of nine (9), moderately impaired cognitive function. Continued review of the Quarterly MDS revealed that R#97 mood was assessed as having a poor appetite or overeating. R#97 was assessed as having trouble falling or staying asleep or sleeping too much, feeling tired or having little energy, feeling bad about self or that you feel you are a failure or have let yourself or your family down, frequency was two - six (,[DATE]) days. Further review of the MDS revealed that R#97 was assessed as exhibiting no behaviors during the look back period. Review of the Quarterly MDS assessment dated [DATE] revealed that R#97 had a BIMS Score of thirteen (13), cognitively intact. Continued review of the MDS revealed that R#97 was assessed as having no mood concerns and no behaviors. Review of the electronic medication record revealed that R#97 medication orders were as follow: Pravastatin Sodium 40mg by mouth daily; Zoloft 50mg by mouth daily; Depakote 250mg by mouth daily; Depakote 500mg by mouth at bedtime; Pepcid 40mg by mouth daily; Seroquel 400mg by mouth at bedtime, and; Ambien 10mg by mouth at bedtime. Review of the medical record revealed for R#97 had a Psychiatric Medication Evaluation from Behavioral Health Services completed on [DATE] prior to leaving the other Nursing Home

Based on observation, record review, Abuse Policy and Procedure review and interviews, the facility failed to implement measures to protect from physical, verbal abuse by (R#88) who has a history of sexual advances and/or inappropriate behavior towards female residents, failed to follow their policy, on two (2) of three (3) halls, common dining room, seven (7) residents (R#20, R#21, R#30, R#74, R#88, C and zz) of the sampled fifty-three (53) residents. The facility census was ninety one (91) residents. It was determined that the noncompliance in one or more requirements of participation has caused harm to R#21, R#20, C and zz, R#74, and R#88, has caused harm, and is likely to cause serious injury, harm, impairment, or death to the ninety-one (91) residents who reside in the facility. This noncompliance began on 10/14/15, when R#88 first attempted to put his hand up the dress of (R#21) a female resident. The Administrator, Director of Nursing, and Chief Nursing Officer for Reliable Health Care Management were notified on 1/29/16 at 6:05 p.m. and 3/10/16 at 5:55 p.m. Findings include: 1. Review of a facility report revealed that on 10/14/15 at 5:30 p.m. R#88 and R#21 (female) were sitting in wheelchairs in the hallway. R#88 attempted to get his hand up the dress of R#21. Staff members stopped him immediately and removed them to separate areas. The Medical Doctor (MD) was notified and R#88 was sent to a Behavioral Center for evaluation. Continued review revealed the Brief Interview Mental Status (BIMS) assessment score for R#21 is 0 indicating severe cognitive impairment with a [DIAGNOSES REDACTED].#88 is 12 indicating moderate cognitive impairment. 2. Review of the Behavior Patient at Risk (PAR) documentation revealed that on 12/10/15 at 1:36 p.m. revealed that R#88 had a verbal altercation with a male resident zz in the dining room. After the verbal altercation as R#88 was leaving the dining room when he struck resident C (female) with his fist on her hand. Review of the PAR intervention included that the MD review medications on next visit. However there was no indication when the MD would be at the facility again. Interview on 1/28/16 at 9:36 a.m. with the Director of Nursing (DON) revealed she was not aware of this event and there is no generated incident report regarding this incident. 3. On 12/29/15 at 6:00 a.m. revealed documentation related to sexual abuse towards R#74 (female). The report revealed that R#88 was in wheelchair in front of nursing station. When R#74 (female) passed by R#88, he grabbed the buttocks of R#74. R#74 turned and swung at the head of R#88 and struck him in the shoulder. No injury noted. R#88 just laughed at her. Review of the interventions revealed that staff removed R#88 from the area. Redirection was given, and the MD was notified on 12/29/15 at 6:00 a.m. 4. Review of a facility report and investigation GA 467 that a Licensed Practical Nurse (LPN) observed R#88, touching a female R#20 on the right breast in the hallway. Review of the Nursing Notes dated 01/08/16 at 1:31 p.m., documented that R#88 was observed rubbing the thigh of a female R#20. The residents were separated. R#88 became combative with staff and attempted to strike staff members. MD notified. New order to increase [MEDICATION NAME] to 5 mg in morning and 10 mg in evening. Review of the Nursing Notes dated 1/8/16 at 4:10 p.m., documented R#88 to be sent to a Behavioral Health Center for behavioral modification in regards to continued sexually inappropriate behaviors. Social Worker (SW) has spoken with the family. Report called to a local emergency room (ER). Physician notified per consult book at 4:15 p.m. R#88 left facility via EMS stretcher at 4:30 p.m. Review of the Nursing Notes dated 1/8/16 at 4:39 p.m. written by the Director of Nursing (DON), documented R#88 was noted to be sexually inappropriate toward another female (R#20) resident who was sleeping at the time. Redirection was attempted as well as re-education but R#88 continued to attempt to get to the other resident. Review of the Nursing Notes dated 1/8/16 at 5:25 p.m. documented, at 3:00 p.m. the LPN treatment nurse was walking down 300 Hall and witnessed R#88 seated in his wheelchair next to a female R#20 sitting in her Geri chair with her eyes closed, sleeping. The LPN treatment nurse stopped the behavior and educated the R#88 that behavior was inappropriate, needed to stop, then removed R#88 from the area. While the LPN treatment nurse reported the incident to the unit manager R#88 once again made his away over to R#20 who was sleeping. Before another incident occurred the LPN treatment nurse removed R#88 to his room and provided education that the behavior was inappropriate. R#88 then told the LPN treatment nurse to, shut up. A Certified Nursing Assistant (CNA) then attempted to place R#88 into his bed and he attempted to strike the CNA at this time. Review of the interventions included R#88 moved away from other residents while arrangements could be made to send the resident to a Behavioral Health Center. Physician and family notified 1/8/16 4:15 p.m. R#88 was sent to a Behavioral Health Center via Emergency Management System (EMS) on 01/08/16. Review of Nurses Notes dated 01/14/16, documented R#88 returned to the facility from the Behavioral Health facility. 5. Review of a facility report dated on 01/19/16 at 6:15 p.m. revealed R#88 was sitting in dining room in wheelchair when the Certified Nursing Assistant (CNA) saw R#88 wheeling towards R#20 hitting her on the left cheek. No injuries was noted. Review of the interventions revealed to leave R#88 out of dining room until the trays come out. Physician notified on 1/19/16 6:15 p.m. On 1/23/16 at 6:50 a.m. revealed documentation related to the behavior of R#88 including the nurse had R#88 to stay near her as much as possible today but the resident repeatedly went or tried to go into female rooms, upsetting female residents. This afternoon when being given his insulin shot, R#88 was educated on the inappropriateness of touching females. R#88 rolled his eyes and said he can do what he wants to. Observation on 1/25/15 at 2:15 p.m. revealed R#88 sitting in his wheelchair in the hallway. The resident is able to ambulate via wheelchair independently. 6. Review of nursing notes dated 09/28/15 at 8:12 a.m. revealed R#88 was holding onto R#30 (female) arm. R#30 emphatically stated she did not want R#88 to do this (hold her arm). R#88 was asked to move and he told the nurse he was going to f_ _ _ R#30 and that she wanted him to. Review of the Abuse Policy and Procedure revealed: Section IV- Identification: Information related to incidents will be logged into the tracking and trending program aiTracker. Management staff will review data to determine any patterns or trends that may constitute abuse. If trends are identified the administrator or designee will investigate them. Any individual observing an incident of resident abuse or suspecting resident abuse must promptly report such incident to a member of the nursing staff or a member of management. Review of Section VI- Protection revealed that upon receiving information concerning a report of abuse, the Director of Nursing services or Administrator will request that a representative of the Social Services department monitor the resident's emotions concerning the incident as well as the resident's reactions to his involvement in the investigation. There is no evidence of monitoring of resident emotions or reactions in accordance to the facility policy. Interview conducted on 01/28/16 at 1:30 p.m. with CNA MM revealed not being aware of any special concerns or needs related to the behaviors of R#88. Interview conducted on 01/28/16 at 1:33 p.m. with CNA NN stated R#88 was on his assignment today and he was not aware of any special concerns or needs related to the behaviors of R#88. Interview conducted on 1/28/16 at 6:15 p.m. with the Administrator revealed the facility has taken numerous steps to prevent further abuse occurrences by R#88, including moving him from room [ROOM NUMBER] to room [ROOM NUMBER] away from R#20. R#88 medications have been adjusted, sent to Behavioral Health Center where he stayed for approximately one (1) week, tried diversional activities, spoke with the sister and family attorney about hiring sitters. In addition they have sought placement at other facilities. R#88 is currently on the waiting list for several facilities with locked units. Interview conducted with Director of Nursing on 1/28/16 at 9:36 a.m. revealed that R#88 has been sent to Behavioral Health Center on multiple occasions to address his inappropriate sexual behaviors and increased aggressiveness. We have educated staff to try to redirect R#88 and to provide diversional activities. We moved him from room [ROOM NUMBER] to Hall 100 to room [ROOM NUMBER]B. We have had his medications adjusted several times. We have tried to get him placed at another facility. The facility implemented the following actions to remove the Immediate Jeopardy: An audit was completed using all incidents involving physically or sexually aggressive behavior from 8/1/16 to 1/31/16. This allowed the review were to identify any other residents that have the potential to be affected in the deficient practice the administrator and/or designee will educate all staff immediately with mandatory and service concerning resident abuse, including facility policy, test, and handout and/or video any staff member that cannot attend will be educated by telephone and will receive in-house training prior to returning to work completed by 1/30/16. A quality assurance audit tool for physical or sexual aggression was created on 1/31/16. Incidence of physically or sexually aggressive behavior will be audited by the DON using quality assurance audit for physical or sexual aggression to ensure interventions were implemented, any findings of noncompliance will be reported to the administrator immediately effective 1/31/16 any findings of noncompliance will be presented to the quality assurance committee monthly for six (6) to determine if additional action is needed, then quarterly to ensure ongoing compliance at 1/31/16. Residents determined to be the aggressor in a physically or sexually aggressive situation will be placed on every 15 minutes visual monitoring until the resident was transferred to an inpatient psychiatric behavioral unit for evaluation. If unable to determine the aggressor both will be considered an aggressor as of 1/31/16. If the resident is the victim of the physically or sexually aggressive situation the residents placed on every shift pertinent chart for 72 hours as of 1/30/16. If the resident is the victim of a physically or sexually aggressive behavior the social services department will be notified and they will monitor the residence psychological wellbeing concerned in the resident as well as the resident ' s reaction to his or her involvement in the investigation. Social services will document in the resident social service notes for three days. Social services will report any psychological changes to the administrator and the director of nurses to determine if further intervention is needed. Upon return from inpatient psychiatric/behavioral unit the resident will be placed on every 15 minutes visual monitoring for 24 hours, every 30 minutes visual monitoring 48 hours and then hourly visual monitoring for four days. Effective 1/31/16. During the seven-day period of visual monitoring of the resident exhibits physically or sexually aggressive behavior without injury to either party every 15 minutes visual she will checks will be resumed until the resident can be transferred to an inpatient psychiatric/behavioral unit for evaluation. If the recurrence of sexually physically aggressive behavior results in injury to either party one on one supervision will be initiated immediately and will continue until the resident can be transferred to an inpatient psychiatric/behavior unit. Effective 1/31/16. All residents with physically or sexually aggressive behavior will be placed on the patient at risk program and will be reviewed weekly at the behavior patient risk meeting until they are free of physically or sexually aggressive behavior for four weeks. Effective 1/30/16. All residents with physically or sexually aggressive behavior will be evaluated by the facility contracted psychiatric group. Effective 1/30/16 Your administrator and director nurses will be notified of any reports of physically or sexually aggressive behaviors immediately. Effective 1/30/16 The nursing staff will be in serviced on completing an incident entry in the electronic medical record for incidence of abusive behavior. Effective 2/14/16 Care plan coordinators will be educated to implement revision of approaches and interventions to the plan of care related to both physical and sexual behaviors by 2/20/16 care plan revisions related to physical and sexual behaviors will be audited by the director of nurses and a minimum data set coordinator as part as the behavior patient at risk process. Any resident that were not updated will be updated immediately during behavior patient at risk meeting on 2/20/16. All license nursing staff were in serviced on calculation of sliding scale insulin dose/reading the sliding scale orders to determine the correct dose of insulin to be administered based on finger stick blood sugar results education of the nurses on importance of following physician orders [REDACTED]. All nurses were in serviced regarding reading and following physician orders [REDACTED]. The nurses will completed to nurse check on the sliding scale insulin and sign off appropriately according to the steps for insulin verification until the facility is free of errors for 90 days. All newly hired nurses will be in serviced on diabetic management policies and calculation of Scott sliding scale insulin as part of the orientation process. All newly hired nurses will complete a to nurse check on the sliding scale insulin and sign off appropriately according to the steps for insulin verification for their first 30 days of employment to ensure they are determining the correct dose of insulin to be given. Nurse management and administrator to be educated regarding the diabetic compliance monitoring policy and their responsibilities related to oversight of this policy. Education will be provided by chief nursing officer - clinical nurse consultant on 1/30/16. The DON and/or unit manager will complete the electronic Medication Administration Record [REDACTED]. The results of the audit and any identified issues will be reviewed in morning meeting and signed off by the administrator to begin on 1/31/16. Any findings of noncompliance will be presented to the quality assurance committee monthly for six months to determine if additional action is needed, then quarterly to ensure ongoing compliance. An allegation of jeopardy removal was received on 2/19/2016 and an amended AoC was received on 3/11/16. Based on the corrective plans developed, implemented by the facility, which were validated by the SSA on 4/3/16, the immediacy of the deficient practice was determined to have been removed on 3/12/16, and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication, behavior interventions and abuse protocol.

Based on review of the medical records, the facility ' s Policy and Procedure Diabetic Management-Compliance Monitoring, and staff interviews, the facility failed to follow physician's orders [REDACTED]. parameters. The total sample size was fifty-three (53) residents. It was determined that the provider's noncompliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Director of Nursing were informed of Immediate Jeopardy on 1/29/16 at 6:05 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/17/15, and remains ongoing. An extended visit was made at the facility from 3/3/16 - 3/11/16. Three additional insulin dependent Diabetic residents were added to the sample. Interview with the Director of Nursing (DON) on 3/8/16 at 11:15 a.m. revealed that the MARs had not been checked for errors before the survey ending 1/29/16. They would do random checks however, since that survey we have done 100% audits of all MARs and we are auditing s/s insulin everyday now. Additionally, review of the three (3) residents add to the sample (R 41, R 71 and R149), two (2) residents (R 41 and R 71) had medications errors after the exit date of the last survey 1/29/16. The DON confirmed knowledge of one error for R 71 however the Medication Error Report was completed 3/11/16 at 3:00 p.m. the last day of the extended survey. Findings include: Review of the Diabetic Management - Compliance Monitoring Policy and Procedure provided by the Corporate Consultant on 3/11/16 at 9:00 a.m. noted a revision date on May 2009 and noted that diabetic residents would receive their FSBS monitoring per MD order, and that the correct dose of insulin was given based on these results. It further noted that the DON or ADON would audit each resident's Diabetic MAR Monday-Friday for the prior 24 hours and complete the required documentation of this audit on the Diabetic MAR indicated [REDACTED]. 1. Review of the medical record for R 25 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order [REDACTED]. Obtain and Document FSBS before meals and at 8:00 p.m. For FSBS 150 or Greater Administer Humalog per sliding scale as listed below for the formula (Blood Sugar-100/30);*150 - 174 = 2 units; *175 - 204 = 3 units; *205 - 234 = 4 units; *235 - 264 = 5 units; *265 - 294 = 6 units; *295 - 324 = 7 units; *325 - 354 = 8 units; *355 - 384 = 9 units; *385 - 414 = 10 units; *415 - 444 = 11 units; *445 - 474 = 12 units; *475 - 500 = 13 units; Greater than 500 Call MD Review of the November 2015 MAR indicated [REDACTED]= 344 and 3 units administered. Per sliding scale (s/s) 8 units should have been administered. On 11/17/15 FSBS = 188 and 5 units administered. Per s/s 3 units should have been administered. On 11/21/15 FSBS = 183 and no units were administered. Per s/s scale 3 units should have been administered. On 11/26/15 at 8:00 p.m. FSBS = 214 and 3 units administered. Per s/s 4 units should have been administered. On 11/28/15 at 8:00 p.m. FSBS = 174 and 3 units administered. Per s/s 2 units should have been administered. Review of the December 2015 MAR indicated [REDACTED]= 295 and no units were administered. Per s/s scale 7 units should have been administered. At 4:30 p.m. FSBS was documented as High and 4 units was administered. Further review of FSBS document at 6:30 a.m. and 4:30 p.m. revealed the documented FSBS at 4:30 p.m. was 168 and 2 units should have been the amount administered. On 12/15/15 at 6:30 a.m. FSBS = 150 and no insulin coverage required was documented. Per s/s 2 units should have been administered. On 12/19/15 at 11:30 a.m. the FSBS = 180 and no units were administered. Per s/s 3 units should have been administered. On 12/22/15 at 8:00 p. m. FSBS = 172 and 3 units administered. Per s/s 2 units should have been administered. On 12/27/15 FSBS = 156 and no coverage required was documented. Per s/s. 2 units should have been administered. 3. Review of the medical record for R 41 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the December 2015 MAR indicated [REDACTED]. Check and document Pulse. If Pulse is less than 60 Hold (Do Not Give). Further review revealed the pulse was documented as 59 on 12/6/15 and the medication was given. Review of the January 2016 MAR indicated [REDACTED]. Review of the March 2016 MAR indicated [REDACTED]=6u; 301-350=8u; 351-400=10u; 401-450=12u; 450-500=15u; Greater than 500 Call MD. Further review revealed on 3/10/16 at 6:00 a.m. FSBS = 190 and 6 units were administered. Per s/s no units should have been administered. At 9:00 p.m. FSBS = 268 and no units were given. According to the s/s 6 units should have been administered. 4. Review of the medical record for R 71 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the February 2016 MAR indicated [REDACTED]=6u; 301-350=8u, 351-400=10u; 401-450=12u; 450-500= 15u; Greater than 500 Call MD. Further review revealed on 2/20/16 at 6:30 a.m. FSBS = 261 and 10u was administered. Per s/s 6u should have been administered. Review of the January 2016 MAR indicated [REDACTED]= 82 and 4u was administered. No units should have been administered. Review of the December 2015 MAR indicated [REDACTED]= 359 and 6u was administered. Per s/s 9u should have been administered.12/10/15 at 6:30 a.m. FSBS = 238 and no units required. Per s/s 5 units should have been administered. 5. Review of the medical record for R 85 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Obtain and document Finger Stick Blood Sugar (FSBS) before meals and at 8:00 p.m. For FSBS 150 or greater administer [MEDICATION NAME] per sliding scale as listed below for the formula (Blood Sugar - 100/30).*150 - 174 = 2 units;*175 - 204 = 3 units;*205 - 234 = 4 units;*235 - 264 = 5 units;*265 - 294 = 6 units;*295 - 324 = 7 units;*325 - 354 = 8 units;*355 - 384 = 9 units;*385 - 414 = 10 units;*415 - 444 = 11 units;*445 - 474 = 12 units;*475 - 500 = 13 units; Greater than 500 Call MD Review of the MAR indicated [REDACTED]. m. FSBS = 142. [MEDICATION NAME] 3 units was administered. Per the sliding scaled no coverage was required. 6. Review of the medical record for R 101 revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the physician's order [REDACTED]. Obtain and document Finger Stick Blood Sugar (FSBS) before meals and at 8:00 p.m. For FSBS 150 or greater administer [MEDICATION NAME] per sliding scale as listed for the formula (Blood Sugar - 100/30). Review of the September 2015 MAR indicated [REDACTED]= 150. No insulin coverage required was documented. Per sliding scale 2 units should have been administered. Review of the December 2015 MAR indicated [REDACTED]= 154. No insulin coverage required was documented. Per sliding scale 2 units should have been administered. 7. Review of the medical record for R 111 revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Give 1 tablet by mouth every other day. Check and document pulse. Hold if pulse is less than 60 (Do Not Give). Review of the December 2015 MAR indicated [REDACTED]. Interview conducted on 1/28/16 at 3:00 p.m. with Licensed Practical Nurse (LPN) BB revealed the dose should have been held due to the pulse being under 60. Interview conducted on 3/7/16 at 11:30a.m. with the DON revealed that on R 111 - medication error with [MEDICATION NAME] not being held for pulse of 58-the nurse was notified of the error and received a written warning. The doctor and the administrator was also notified. This nurse also worked two days prior. The order was for every other day and the pulse was 54 on that day and held appropriately. 8. Review of the medical record for R 135 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order [REDACTED]. Obtain and Document FSBS before meals and at 8:00 p.m. For FSBS 150 or Greater Administer Humalog per sliding scale as listed for the formula (Blood Sugar-100/30) Review of the January 2016 MAR indicated [REDACTED]= 176 and 2 units was administered. Per sliding scale 3 units should have been administered. Interview conducted with Licensed Practical Nurse Unit Manager BB on 1/29/16 at 3:00 p.m. revealed that the FSBS should have been obtained and documented. Subsequent interview conducted on 1/29/16 at 6:00 p.m. revealed there was no excuse for the insulin dosage errors because the sliding scale was right in front of the nurses. 9. Review of the medical record for R 143 revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the January 2016 MAR indicated [REDACTED]. Further review revealed on 1/24/16 at 8:00 p.m. FSBS = 164 and no insulin required was documented. Per s/s 2 units should have been administered. 1/27/16 at 6:00 a.m. FSBS = 151 and 1 unit was administered. Per s/s 2 units should have been administered. Interview conducted on 3/7/16 at 1:45 p.m. with the DON revealed that they have changed to using fewer sliding scales and they tell the nurse exactly the dosage to administer. The DON confirmed all of the above are medications errors and that they include in errors omissions or holes in the MAR indicated [REDACTED]. She further confirmed that their policy is that if there is a medication error then they are to call the doctor and document on the Medication Error Sheet that they called the doctor and what is discussed with the doctor. Further, after the survey they did a 100% audit of all of the charts for medication errors. They worked with the doctors clarifying the orders, making necessary changes, and making sure they reflected exactly what the doctor wanted. At this time they have only three (3) residents receiving FSBS with sliding scale insulin. Interview with the DON on 3/8/16 at 11:15 a.m. revealed meal times are 7:15 a.m., 12:15 p.m., and 5:15 p.m. As to the appropriateness of the last meal and the hs FSBS check with s/s, that is what the doctor ordered. I ' m sure if the resident has been of different formulas used by the physician to basically down to two. Before there has been as many as seven different formulas used. And nurses don ' t use the formula per se they use the scale listed with the particular formula to get the amount of units to be given. So I expect them to just use the scale. I expect nurses to report any and all errors to the physician, myself, the administrator and it is reported to the pharmacist. An example is: if a resident is given Tylenol instead of Aspirin. This is a medication error and should be reported. Right now we are auditing s/s insulin. If we find an error then we complete the Medication Error Report. Notify the nurse involved, the doctor, the administrator, pharmacist, etc. They errors before were not identified until after the surveyor identified them so they had not been reported but from that time on they have all been reported and addressed. Further interview with the DON revealed each medication error was reviewed specifically and she acknowledged they were all medication errors. Interview conducted with the Medical Director on 3/9/16 at 10:15 a.m. via telephone revealed he expects the nurse to use the sliding scale chart for determining doses of insulin coverage during med pass. This way there should never be a math error in calculating dose. He also expects the nurse to notify him of medication errors. And more important is the severity of the error. If minor the nursing supervisor should be able to give some guidance. He has received reports of med errors in the past, and when he comes into the facility on ce a week we discussed errors and other things going on. Occasionally, have received phone calls with reports of errors. Further revealed that 2-3 units of insulin absolutely, positively does not affect the residents ' health. In fact, I think it is so inconsequential to anyone. Even a person that is not Diabetic. It does not affect any person. The Medical Director feels it would have to reach double digits to cause a reaction. Then you could give glucose or orange juice. Several things before it reached emergency level. As to R 111 - [MEDICATION NAME] given with pulse of 58, he would just request they do the pulse for one full minute and see what it is. Actually, nowadays most residents on [MEDICATION NAME] are also on Beta Blockers for A Fib. The only [MEDICATION NAME] used is 0.125mg and that does is so low it is really the Beta Blockers that need the monitoring of the pulse. The Medical Director further revealed both the [MEDICATION NAME] and the [MEDICATION NAME] were discussed in detail with him and have been taken to QA and addressed there. Interview on 3/9/16 at 10:30 a.m. the DON regarding the [MEDICATION NAME] and some of the FSBS not in the computer revealed they have had many occasions where they would put things in the computer and then at the end of shift when they go back to check, everything would be gone. Interview conducted with the Pharmacy Consultant on 3/9/16 at 1:45 p.m. revealed he has been consulting here for about 3 years. They have met with the doctors. He stated he cannot say why the nurses would get the insulin wrong when the scale is right in front of them. Maybe there is so much on the screen. So much information they are not reading it correctly. Mostly when he does his review he will check the morning fasting BS, and the A1C. Really looks for reasons to reduce sliding scale insulin. He stated that he thinks residents are checked way too much. Anyway, the DON meets with the doctor and team once a week and discusses each resident. What I review is a sampling of issues going on in the facility. Interview conducted with the Pharmacist Consultant on 3/10/16 at 2:00 p.m. revealed that he visits the facility once a month but does not review MARs for medication errors. Usually focuses on the first Fasting Blood Glucose level in the morning. He further expects that nursing would be responsible for checking for medication administration errors. Interview conducted on 3/9/16 at 2:20 p.m. with the DON revealed they looked at orders and checked them but not necessarily the MARs. If in the am meeting for example someone says Ms. (NAME REDACTED) has eye drainage -I will look to see if there is an order for [REDACTED]. Search for descrepancies - it would also show open blanks or holes. We do not ask the nurses to fix these because 1) We cannot ask the nurse to go and back date and 2) if you know you put it in and it disappeared-then we ask her to go to the nurses' notes and document it there. We also have a Late Sign Off report. That is used when - like some one goes out to hospital and maybe the nurse has not had time to take them out of the system yet so their meds show up with holes. Or if a med is given but at a later time. I do talk with the doctors. I am not necessarily checking the MAR. Interview conducted with the Corporate Consultant on 3/11/16 at 9:00 a.m. revealed that revealed that the Unit Managers and the DON were responsible for checking MARs and the daily reports of unsigned meds is ran daily by Unit Managers and the nurses were responsible for checking at the end of the shift to ensure are holes are filled. They had a Diabetic Management policy and it was in place in the past and has now been re-instated. Before it was listed as the DON and ADON were responsible for checking for FSBS errors and now they have added the Unit Managers also. She further revealed that it should have been followed all along but when the ADON left it was not done. We have done in-servicing to the nurses on documentation, follow ups and holes on the MARs, however we did not focus on any one medication. She further revealed that this policy was not put in place because of this facility, it was another facility that the corporation had acquired that was the reason for this policy.

Based on record review and staff interviews, the facility failed to implement revised approaches/interventions for one (1) resident (R#88) with recurring behaviors of sexual, verbal and physical abuse directed at residents and staff members. The sample size was forty (40) residents. The facility census was ninety one (91) residents. It was determined that the noncompliance in one or more requirements of participation has caused harm to R#21, R#20, C, R#74, and R#82, is likely to cause, serious injury, harm, impairment, or death to the ninety-one (91) residents reside in the facility. This noncompliance was identified to have existed as of October 14, 2015, when R#88 first attempted inappropriate sexual behaviors toward a female resident and remains ongoing. The Administrator and Director of Nursing were informed of this Immediate Jeopardy (IJ) on January 29, 2016 at 6:05 p.m. Cross refer F223 During a Complaint Survey to investigate complaint # GA 467 regarding a sexual abuse allegation that occurred on 01/08/16 revealed a facility self-reported incident which documented; a Licensed Practical Nurse (LPN) noted a male resident R#88, touching a female resident R#20 on the right breast in the hallway. Record review for R#88 revealed review an Admission Minimum Data Set (MDS) assessment dated [DATE] which documented in Section A- Identification Information that the resident was admitted to the facility on [DATE]. The resident had not been evaluated by Level Two (II) Pre Admission Screening and Resident Review (PASRR) to determine serious mental illness. Section C- Cognitive Patterns documented the resident had a Brief Interview for Mental Status (BIMS) summary score of four (4), indicating severe cognitive impairment. No moods or behaviors were exhibited. Section N- Medications documented the resident received an antipsychotic medication two (2) out of the seven (7) day look back period and received an antidepressant medication seven (7) out of seven (7) days. Section V- Care Area Assessment (CAA) triggered [MEDICAL CONDITION] Drug Use with the decision to be care planned. Review of the Quarterly MDS assessment dated [DATE] the resident had Brief Interview Mental Status (BIM)S summary score of 4. The resident the mood of trouble falling or staying asleep, or sleeping too much. No behaviors were exhibited. The resident received and antipsychotic medication one (1) out of the seven (7) day look back period and an antidepressant seven (7) out of seven (7) days. R#88 had multiple [DIAGNOSES REDACTED]. Review of the Care Plan for R#88 identified on 9/10/15 a Problem Onset Alteration in mood state: s/s depression and history of depression, inappropriate and combative behaviors, need for [MEDICAL CONDITION] medications. The Goal is R#88 will have stable mood, decrease in documented behaviors over the next review period. Target date 2/18/16. The Approaches/Interventions are as follows: 9/10/15 Remove to a calm environment when needed; 9/10/15 Monitor effectiveness of prescribed medication; 9/10/15 Provide with diversional activities as needed; 9/10/15 Provide non-drug related intervention as indicated and chart results; 9/10/15 Encourage family visits and support; 9/10/15 Medication Management as ordered; 9/10/15 Monitor for s/s i.e.: sadness, crying, withdrawal/loss of interest in usual activities, appetite changes ect.; 9/10/15 Evaluate for s/s of side effects i.e.: nausea/vomiting, constipation, dizziness, altered mental status, and report, and; 9/10/15 Allow R88 to verbalize feelings and express emotions. There is no evidence of documentation related to the numerous physical, verbal and sexual incidents that occurred involving R#88. There is no evidence of revised approaches/interventions to prevent R#88 from further abusing residents and/or staff. Review of the Physician order [REDACTED]. [MEDICATION NAME] 5mg, ½ tablet (2.5mg) at 6:00 a.m. in the morning daily for Major [MEDICAL CONDITION] (Ordered 12/29/16) [MEDICATION NAME] 10 mg daily at 8:00 p.m. for Major [MEDICAL CONDITION] (Ordered 1/15/16) [MEDICATION NAME] 125 mg Sprinkle, give four capsules = 500 mg twice daily at 9:00 a.m. and 9:00 p.m. (Ordered 1/25/16) Observe for S/S of Adverse reaction of [MEDICAL CONDITION] Medications Review of the Electronic Medication Administration Record [REDACTED]. Review of the Nurses Notes, physician progress notes [REDACTED]. On 10/14/15 Facility Self-Reported to State Agency regarding Sexual Abuse Allegation documented the Description of Allegation: On 10/14/15 at 5:30 p.m. R#88 and a female resident were in the hallway both in wheelchairs. R#88 attempted to get his hand up her dress. Staff members stopped him immediately and removed them to separate area. MD was notified and R#88 was sent to Floyd Behavioral Center for evaluation. The female resident had BIMS summary score of 0, indicating an interview was not conducted due to the resident rarely or never understood and has a [DIAGNOSES REDACTED]. A Nurses note on 12/10/15 at 1:36 p.m. BEHAVIOR PAR: R#88 had a verbal altercation with a male resident in the dining room. After the altercation as he was leaving the dining room when he struck a Resident C with his fist striking her on the hand. Will have MD review medication on next visit. A Nurses note on 12/12/15 at 8:15 p.m. R#88 became violent at this time hitting and kicking staff caring for him. R#88 tried to rip off the shirt of female staff. Doctor notified orders to send to a Behavioral facility for evaluation. Sent by Emergency Medical Services (EMS). Attempted two (2) times to call the Sister with no success. On 12/13/15 the physician progress notes [REDACTED]. On 12/29/15 at 6:00 Report of Incident Description: R#88 was in wheelchair in front of nurse' desk. When a female resident passed by, R#88 grabbed her on the buttocks. Female resident turned and slapped him on the head. No injury noted. Also sexually grabbing at other female residents and staff. Correction at 6:38 a.m. documented; Correction to the previous nurse ' s note from incident report. Female resident swung at his head and struck him on the shoulder. No injury noted and R#88 just laughed at her. A Nurses note on 01/08/16 at 1:31 p.m. R#88 noted rubbing the thigh of a female resident R#20. Residents were separated. R#88 became combative with staff and attempted to strike staff members. MD notified. New order to increase [MEDICATION NAME] to 5 mg in morning and 10 mg in evening. Message left for family. Will monitor. On 1/8/16 at 3:00 p.m. Report of Incident Description: The treatment nurse was walking down 300 Hall when she witnessed an interaction between R#88 and a female resident R#20. R#88, seated in his wheelchair was next to a female resident, R#20 sitting in her Geri chair with her eyes closed. The treatment nurse stopped the behavior and educated the resident that behavior was inappropriate and needed to stop. The treatment nurse then removed R#88 from the area. While the treatment nurse reported the incident to the unit manager R#88 once again made his away over to the unconscious female resident R#20. Before another incident occurred the treatment nurse removed R#88 to his room and provided education that the behavior was inappropriate. R#88 then told the treatment nurse to, shut up. A Certified Nursing Assistant (CNA) then attempted to place the resident in bed. R#88 attempted to strike the CNA at this time. A Nurses note on 1/8/16 at 4:39 p.m. written by the Director of Nursing (DON), documented R#88 was noted to be sexually inappropriate toward another female resident who was sleeping at the time. Redirection was attempted as well as re-education but R#88 continued to attempt to get to the other resident. A Nurses note dated 01/14/16, documented R#88 returned to the facility from the Behavioral Health facility. A Nurses note on 1/17/16 at 2:19 a.m. During pm medication pass, R8#8 grabbed throat of nurse and began grabbing her. Notified Physician who gave stat order for [MEDICATION NAME]. R#88 went to sleep after incident, nurse did not administer [MEDICATION NAME] due to resident already sleeping. On 01/19/16 at 6:15 p.m. Report of Incident Description: R#88 was sitting in dining room in wheelchair when the CNA saw R#88 wheeling towards another resident hitting her on the left cheek. No injuries were noted. MD and family member notified. Interventions: Leave R#88 out of dining room until the trays come out. Physician notified on 1/19/16 6:15 p.m. A Nurses note on 1/23/16 at 2:41 a.m. resident going in room to place trash in container, roommate began to yell at him stating what the ****l are you doing? R#88 began to get agitated and started to push himself toward roommate and said I will show you something you *******! This nurse pulled R#88 back with his wheelchair and instructed the residents to cease acting this way and calm down. This nurse had R#88 sit outside sit outside in the hall in his wheelchair until the Certified Nursing Assistant (CNA) came to toilet him. No further arguments noted. A Nurses note on 1/23/16 at 6:50 a.m. R#88 having issues today with inappropriate touching of female staff. This morning R#88 came up behind a housekeeper at her cart and grabbed her crotch and buttocks. R#88 was removed from the hall and brought back to 100 hall. Nurse had R#88 to stay near her as much as possible today to avoid further issues, but the resident repeatedly went or tried to go into female rooms, upsetting female residents. This afternoon when being given his insulin shot, R#88 used the opportunity of this nurse bending down to roll up his sleeve of his shirt to grab this nurse's crotch from the front. I once again tried to educate the resident on the inappropriateness of touching females. Resident rolled his eyes and said he can do what he wants to. Note to doctor for Monday. A Nurses note on 1/24/16 at 8:10 p.m. LATE ENTRY - 2:00 p.m. R#88 had altercation with dining staff. R#88 ate two (2) trays of food and then went to another table and started eating another resident's food. Dining staff started taking the food away from him and he struck out at them, grazing one CNA. There is no evidence in the clinical record for R#88 of a Psychiatric Consultation, Psychiatric Evaluation or Psychiatric Monitoring. Interview continued on 01/28/16 at 9:36 a.m. with the Director of Nursing (DON) revealed R#88 returned to the facility on [DATE]. R#88 had been sent to a Behavioral Health facility on multiple occasions to address his inappropriate sexual behaviors and increased aggressiveness. The staff have been educated regarding individualized care needs of R#88 to try and redirect R#88 and to provide diversional activities. This Surveyor requested copies of staff education for R#88. The DON did not provide this information by the survey exit 01/29/16 at 10:00 p.m. Interview conducted on 01/28/16 at 1:30 p.m. with direct care CNA MM revealed they were not aware of any special concerns or needs related to the behaviors of R#88. MM stated they normally works the 200 Hall. Interview conducted on 01/28/16 at 1:33 p.m. with CNA NN stated R#88 was on his/her assignment today and they were not aware of any special concerns or needs related to the behaviors of for R#88. NN stated they have only been working for just a few weeks and really doesn ' t know much at all about this resident. Interview conducted on 1/28/16 at 6:15 p.m. with the Administrator revealed the facility has taken numerous steps to prevent further abuse occurrences by R#88 and moved him from room [ROOM NUMBER] to room [ROOM NUMBER] away from the female resident he touched. The medications have been adjusted and R#88 was sent to acute care facility where he stayed for approximately one (1) week. They have tried diversional activities. They have spoken with the family attorney about hiring sitters. They have sought placement at other facilities. R#88 is currently on the waiting list for several facilities with locked units ------------------------------------------------------------------------------------------------------------------------------ Original QP304 1) How many falls has the resident had in the last 30 days? = 2 (2 or more falls) Surveyor: RelevantFindings: (01/26/2016 12:54:39 PM) Resident fell on [DATE] at 2:45pm Resident fell on [DATE] at 9:55am w/head injury 2) Did any fall result in an injury? = 1 (Yes) Surveyor: RelevantFindings: () Injury of unknown origin Surveyor reviewed facility five (5) day investigation regarding the facility self-reported incident dated 01/07/16 of resident ' s noted bruising to right foot related to injury of unknown origin. Resident is a [AGE] year old female admitted to Chulio Hills Health and Rehab on 01/29/2007. Her [DIAGNOSES REDACTED]. On 01/14/16 NP wrote resident has two masses noted on her right breast. Daughter declined mammogram stated mom would not tolerate procedure therefore recommends comfort measures. Resident admitted to Homestead Hospice on 01/27/16. Interview conducted with DON Mary Gates, RN at 9:40am per facility incident report completed on 01/07/16 resident ' s right foot was noted to have swelling and small toe minimal bruising with some bruising to back of heel. Action steps taken by facility to prevent further incidents: Primo Boots to right and left feet and elevation. Educate staff to use of care when transferring Changed resident from a one person assist to a two person assist care plan updated. DON further stated the direct care nurse and CNAs were interviewed regarding their knowledge of the injury. Each employee denied having any knowledge of how the injury could have occurred. The assigned CNA demonstrated to DON how the resident is transferred from bed to wheelchair and from wheelchair to bed. Based on the CNAs demonstration the DON stated he/she felt it was a possibility that the resident could potentially injure her feet during a one person transfer. Based on these findings the DON changed the resident from a one person assist with transfers to a two person assist Interview conducted with Wound Care Nurse (Jennifer Calhoun) on 01/28/15 at 9:10am who stated she alerted the DON on 01/07/16 regarding the bruising noted on the resident ' s right leg. She stated the bruising was bluish/purpleish in color and extended from the right mid-calf area down to the resident;s toes. She further stated it was directly in the area of the Primo boot coverage. She stated it concerned her very much and was curious if the Primo boot had been wrapped a little too tight. She stated she was off the next day and saw the right leg and foot on 01/09/16 and found the discolorations were gone. The CNA stated were instructed to be careful not to apply the Primo boots too tight. She also stated the right heel wound was unchanged the bruising affected her whole lower leg from mid-calf area to her toes Review of resident ' s care plan for falls and ADLs did not reflect the resident care plan had been updated requiring assist times two for transfers. The care plan also failed to reflect apply Primo Boots at all times. Review of the physician order [REDACTED]. Interview conducted with DON on 01/28/16 at 11:00am who stated her expectation is that all physician orders [REDACTED]. Resident also has a recently identified shear wound to the left ischium first identified on 12/20/16. Interview with wound care nurse on 01/27/16 at 4:41pm. On the 12/21/15 she stated she received an e-mail from the weekend wound care nurse notifying her of a newly identified friction shear wound to the left ischium. She stated on 12/21/16 the wound measured at 1.0 x 1.0 x <0.1. No exudate, Non odorous, with no signs and symptoms of infection. Treatment included Sureprep and covering with [MEDICATION NAME] daily. There was no change up to the time the resident was first seen by the wound MD on 01/04/16. Shear wound of Left Ischium – initially identified on 12/20/15. First seen by wound MD on 01/04/16 Left Ischium measured 1.0 x 0.8 x 0.1 with a 0.80 surface area on 01/04/16. Light serous exudate with 100% yellow necrotic tissue Left Ischium measured 1.0 x 1.0 x 0.1 with a 1.00 surface area on 01/11/16. Light serous exudate with 100% yellow necrotic tissue. No change per wound MD. Left Ischium measured 2.0 x 1.8 x 0.1 with a 3.60 surface area on 01/18/16. Light serous exudate with 100% yellow necrotic tissue. No change per wound MD. Wound debrided, subcutaneous and necrotic tissue removed. Resident also has a recently identified unstageable wound to her Right Heel first identified on 12/23/16. Interview with wound care nurse on 01/27/16 at 4:43pm. On the 12/23/15 she stated she was called into the shower room by the shower team to assess an area on the resident ' s right heel. Upon arrival she stated she observed a closed rough, dry, flaky area to the right. She stated on 12/28/16 the wound measured at 2.0 x 2.0 x unable to determine. Wound remains closed. Discoloration purpleish in color. No exudate, Non odorous, with no signs and symptoms of infection. Treatment included Sureprep and covering with abd pad with Kerlix with Primo boot applied daily. There was no change up to the time the resident was first seen by the wound MD on 01/04/16. The Wound care nurse further stated it was noted on 12/23/15 that the resident ' s tennis shoe was bent in the back of the shoe at the heel and this bent area was repeatedly rubbing against the resident heel in an up and down motion because her shoes are slightly too big. Shoes shown to surveyor demonstrating the right heel was bent inward and unable to be straightened out. Weekly skin assessments reviewed by surveyor revealed on 12/03/15, 12/10/15, 12/17/15, and 12/24/15 stated wound to foot was normal. Wound to Right Heel – initially identified on 12/23/15. Resident first seen by wound MD on 01/04/16 Right Heel measured 2.0 x 2.0 x 0 with a 4.00 surface area on 01/04/16 – by Wound Care MD Right Heel measured 3.1 x 2.5 x 0 with a 7.75 surface area on 01/11/16 – by Wound Care MD – now with 100% black escar. Wound MD states wound has deteriorated. Indications listed were resident kicking out, causing own wounds. Right Heel measured 5.5 x 5.0 x 0 with a 27.50 surface area on 01/18/16 – by Wound Care MD – 100% black escar. Per wound MD wound has deteriorated due to generalized decline of patient. Review of the Nurses notes: On 12/23/15 at 2:53pm Wound Nurse was notified by shower team of abrasion to right heel area that they said she did not have earlier that week. TREATMENT INITIATED FOR THIS AREA. 12/27/15 FALL (unobserved) – no injuries reported. Family and MD notified. ACTION taken: Bed turned to wall so that resident cannot roll out of bed. She has a floor mat, Bed is kept in low position, she was placed on pertinent charting for post fall assessment which includes: VS, neurochecks, nurses assess for cognitive changes and body checks Updated fall care plan on 12/28/15 On 12/28/15 at 3:22pm Wound nurse in to dress wound abrasion to right outer heel. AREA IS LARGER THAN IT WAS ON 12/23/15. Resident had show on foot and it was moving up and down on the area causing further damage to wound bed Wound nurse remove shoe and dressed foot, instructed CNAs and nurse that residentis to have PRIMO Boots to foot until healed. On 12/28/15 Sister in facility in the Social Workers office and wanted to peak with wound nurse. On 12/30/15 Wound nurse stated right foolt has had no change. Right Heel light serous drainage, no odor, kand no S&S of infection. On 01/05/16 at 9:46am Wound nurse in with NP (Deborah McBride) to view resident ' s foot. WOUND MD IS FOLLOWING UNTIL PCP RETURNS TO THE STATES. FNP made aware of of resident wearing shoes with back of heels turned inward. Wound 2cm x 2cm x UTD with 100% yellow necrotic tissue to wound bed, light serous exudate, no odor, no signs and syptoms of infection Per physician progress notes [REDACTED]. History of present illness indicates no fall. LEAF (Lower Extremity Arterial Flow) ordered and performed on 01/13/16. Results were positive for moderate [MEDICAL CONDITION] disease at 50% or less. On 01/18/16 physician stated Wound Care MD to see resident based on new deep tissue injuries identified on right and left feet. Wound Care MD saw patient on 01/18/16 at request of Dr. B. Singh for unstageable DTI of the right lateral foot of at least 1 day in duration. There is no exudate. No indication of pain. Per wound report resident has: Unstageable Deep Tissue Injury of the Right Lateral Foot – duration < 1 day. Right Lateral Foot measured 1.3 x 2.7 x 0 with a 3.51 surface area on 01/18/16. No exudate. Unstageable Deep Tissue Injury of the Left Lateral Foot – duration < 1 day. Right Lateral Foot measured 1.0 x 1.0 x 0 with a 1.00 surface area on 01/18/16. No exudate. Interview with wound care nurse (Jennifer ______) on 01/27/16 at 4:37pm who stated she rounded with the wound care MD on 01/18/16 in the afternoon and observed the two lateral DTI wounds to the resident ' s right and left feet for the first time. She stated it was reported that the resident had fell earlier that day. She stated she last saw the patient on 01/15/16 and did not observe the right and left lateral foot DTIs at that time. Falls Last fall risk assessment was dated: 11/20/15 was 13. High Risk. Per falls care plan resident has a low bed, bed and chair alarms, bed has been placed against the wall, and one siderail is use when in bed. Per record review had a total of five (5) fall in the last thirty days. Each fall was listed as follows: Per nurses notes: On 12/26/16 at 2:45pm Resident fell (unobserved) Location: 111B Resident found lying on floor next to floor mat Physician notified: 12/26/15 at 3:00pm. Family notified: Yes. No injury noted. Treatment ordered: None New intervention: Turned resident bed towards the wall On 01/18/16 at 2:00pm Resident fell (unobserved) Location: 111B Resident found on the floor sitting on her bottom next to mat floor mat Physician notified: 01/18/15 at 2:00pm Family notified: Yes. No injury noted. Treatment ordered: None. New intervention: None On 01/19/16 at unknown Resident fell (unobserved) Location: 111B Resident found on the floor Physician notified: 01/19/15 at time unknown Family notified: Not documented Injury – unknown/not documented Treatment ordered: Unknown/not documented New intervention: unknown/not documented On 01/19/16 at unknown Resident fell (unobserved) Location: 111B Resident found on the floor Physician notified: 01/19/15 at time unknown Family notified: Not documented Injury – unknown/not documented Treatment ordered: Unknown/not documented New intervention: unknown/not documented On 01/22/16 at 9:45am Resident fell (unobserved) Location: 111B Resident found laying on the mat in between the bed and the heater. Head against the night stand. Resident was bleeding from her head where she hit the nightstand Physician notified: 01/22/16 at 12:00noon Family notified: 01/22/16 at 1:30pm Injury – laceration to Right Cheek 1 inch also with a hematoma to right side of face at hairline with abrasions to her nose Treatment ordered: Steristrips applied to facial laceration, ice to hematoma New intervention: Added a half side rail Per review of the nurse ' s notes no documentation was found regarding the details of the two fall which occurred on 01/19/16. Per review of facility policy titled Completion of Accident and Incident (A & I) form. Policy states an A & I review form will be completed immediately following an accident or incident with the follow-up investigation completed within 24 hours of the occurrence. Per review of facility policy titled Documentation of Pertinent Charting. Policy states pertinent charting will be completed on a daily basis to ensure that appropriate care is given when a resident has a new or changed condition. Incident reports require documentation for 72 hours or longer if needed. This documentation will be completed on each shift and will include full vital signs Interview conducted with Wound care nurse Jennifer Calhoun on 01/28/16 at 9:10am who stated she recalled the CNA informing her that the resident had fell twice on 01/19/16. She stated she mentioned the fall in the nurse ' s notes however, did not document any details regarding the event as the staff nurse was aware. Interview with the DON on 01/28/16 at 9:24am who stated she was not aware of the falls which occurred on 01/19/16 and she does not have a completed investigation on the falls due to lack of knowledge of their occurrence. She stated if the CNA told a nurse the nurse informed should have completed the initial documentation and assessment of the resident for each event. QP049 1) Does the resident currently have one or more pressure ulcers? If yes, describe the most advanced stage for each pressure ulcer when they were at their deepest visible anatomical level. = 6 (Suspected Deep Tissue Injury) Surveyor: RelevantFindings: (01/26/2016 12:56:51 PM) Resident has three DTIs: Right Heel measured 2.0 x 2.0 x 0 on 01/04/16 Right Heel measured 5.5 x 5.0 x 0 on 01/26/16 - Worsened by increased surface area Right Lateral Foot measured 1.3 x 2.7 x 0 on 01/18/16 Right Lateral Foot measured 1.0 x 2.1 x 0 on 01/26/16 - Improved by decreased surface area Left Lateral Heel measured 1.0 x 1.0 x 0 on 01/18/16 Left Lateral Heel measured 1.0 x 1.0 x 0 on 01/26/16 - Not change QP050 1) Does the resident currently have one or more pressure ulcers? If yes, describe the most advanced stage for each pressure ulcer when they were at their deepest visible anatomical level. = 6 (Suspected Deep Tissue Injury) Surveyor: RelevantFindings: (01/26/2016 12:56:51 PM) Resident has three DTIs: Right Heel measured 2.0 x 2.0 x 0 on 01/04/16 Right Heel measured 5.5 x 5.0 x 0 on 01/26/16 - Worsened by increased surface area Right Lateral Foot measured 1.3 x 2.7 x 0 on 01/18/16 Right Lateral Foot measured 1.0 x 2.1 x 0 on 01/26/16 - Improved by decreased surface area Left Lateral Heel measured 1.0 x 1.0 x 0 on 01/18/16 Left Lateral Heel measured 1.0 x 1.0 x 0 on 01/26/16 - Not change QP262 1) Does the resident currently have one or more pressure ulcers? If yes, indicate the stage of the most advanced pressure ulcer. = 6 (Suspected Deep Tissue Injury) Surveyor: RelevantFindings: (01/26/2016 01:05:16 PM) Resident has three DTIs: Right Heel measured 2.0 x 2.0 x 0 on 01/04/16 Right Heel measured 5.5 x 5.0 x 0 on 01/26/16 - Worsened by increased surface area Right Lateral Foot measured 1.3 x 2.7 x 0 on 01/18/16 Right Lateral Foot measured 1.0 x 2.1 x 0 on 01/26/16 - Improved by decreased surface area Left Lateral Heel measured 1.0 x 1.0 x 0 on 01/18/16 Left Lateral Heel measured 1.0 x 1.0 x 0 on 01/26/16 - Not change QP263 1) Does the resident currently have one or more pressure ulcers? If yes, indicate the stage of the most advanced pressure ulcer. = 6 (Suspected Deep Tissue Injury) Surveyor: RelevantFindings: (01/26/2016 01:05:16 PM) Resident has three DTIs: Right Heel measured 2.0 x 2.0 x 0 on 01/04/16 Right Heel measured 5.5 x 5.0 x 0 on 01/26/16 - Worsened by increased surface area Right Lateral Foot measured 1.3 x 2.7 x 0 on 01/18/16 Right Lateral Foot measured 1.0 x 2.1 x 0 on 01/26/16 - Improved by decreased surface area Left Lateral Heel measured 1.0 x 1.0 x 0 on 01/18/16 Left Lateral Heel measured 1.0 x 1.0 x 0 on 01/26/16 - Not change Injury of unknown origin Surveyor reviewed facility five (5) day investigation regarding the facility self-reported incident dated 01/07/16 of resident ' s noted bruising to right foot related to injury of unknown origin. Resident is a [AGE] year old female admitted to Chulio Hills Health and Rehab on 01/29/2007. Her [DIAGNOSES REDACTED]. On 01/14/16 NP wrote resident has two masses noted on her right breast. Daughter declined mammogram stated mom would not tolerate procedure therefore recommends comfort measures. Resident admitted to Homestead Hospice on 01/27/16. Interview conducted with DON Mary Gates, RN at 9:40am per facility incident report completed on 01/07/16 resident ' s right foot was noted to have swelling and small toe minimal bruising with some bruising to back of heel. Action steps taken by facility to prevent further incidents: Primo Boots to right and left feet and elevation. Educate staff to use of care when transferring Changed resident from a one person assist to a two person assist care plan updated. DON further stated the direct care nurse and CNAs were interviewed regarding their knowledge of the injury. The self reported injury of unknown injury was for the bruising noted along her right foot and upper ankle area. There were also two deep reddened areas noted along the outer lateral side of her right foot. The bruising initial looked deep red with some bluish areas to it but it resolved very quickly in the next one to two days. Each employee denied having any knowledge of how the injury could have occurred. The assigned CNA demonstrated to DON how the resident was transferred from bed to wheelchair and from wheelchair to bed. Based on the CNAs demonstration the DON stated he/she felt it was a possibility that the resident could have potentially injured her right foot during a one person transfer, however, CNA denies rec. Based on these findings the DON changed the resident from a one person assist with transfers to a two person assist Interview conducted with Wound Care Nurse Jennifer Calhoun, LPN on 01/28/15 at 9:10am who stated she alerted the DON on 01/07/16 regarding the bruising noted on the resident ' s right leg. She stated the bruising was bluish/purpleish in color and extended from the right mid-calf area down to the resident;s toes. She further stated it was directly in the area of the Primo boot coverage. She stated it concerned her very much and was curious if the Primo boot had been wrapped a little too tight. She stated she was off the next day and saw the right leg and foot on 01/09/16 and found the discolorations were gone. The CNA stated were instructed to be careful not to apply the Primo boots too tight. She also stated the right heel wound was unchanged the bruising affected her whole lower leg from mid-calf area to her toes Review of resident ' s care plan for falls and ADL

Based on record review and interview the facility failed to thoroughly investigate and report allegations of resident to resident altercations in which three (3) resident (R#147, R#88, an R#26). The sample size was forty (40) residents. The facility census was ninety one (91) residents. Findings : 1. Review of the Nurse ' s Notes for R#88 dated 12/10/15 at 1:36 p.m. revealed documentation related to physical abuse towards Resident C. BEHAVIOR PAR: R#88 had a verbal altercation with a male resident in the dining room. After the altercation as he was leaving the dining room when he struck a Resident C with his fist striking her on the hand. Will have MD review meds on next visit. There is no evidence of a facility Incident Report and no evidence that this incident was reported to the State Agency. Review of the Nurse ' s Note for R#88 dated 01/19/16 at 6:15 p.m. documented a Report of Incident: Description: R#88 was sitting in dining room in wheelchair when the Certified Nursing Assistant (CNA) saw R#88 wheeling towards R#20 hitting her on the left cheek. No injuries was noted. There is no evidence this incident was reported to the State Agency. An interview conducted on 1/28/16 at 9:36 a.m. with the Director of Nursing (DON) revealed she was not aware of the incident that occurred on 12/20/15 between residents R#88 and Resident C. The DON confirmed there is no evidence of a generated incident report for this resident to resident altercation. Further interview with the DON revealed an incident report was generated related to the incident that occurred on 1/19/16 between residents R#88 and R#20. The DON stated she faxed the physical abuse allegation to the State Agency on 1/19/16. The fax cover sheet provided by the DON at this time was dated with the wrong day, month and year (2007) of the incident. The DON was unable to provide a copy of the State ' s acknowledgement letter of receipt for the 1/19/16 facility reported allegation of resident to resident physical abuse. The DON was unable to provide evidence that the facility completed an investigation in five (5) days. The DON stated further, she did not complete the investigation because she was on vacation from 1/20/16 through 1/22/16. Review of the Nurse ' s Notes for R#88 dated 12/10/15 at 1:36 p.m. revealed documentation related to physical abuse towards Resident C. BEHAVIOR PAR: R#88 had a verbal altercation with a male resident in the dining room. After the altercation as he was leaving the dining room when he struck a Resident C with his fist striking her on the hand. Will have MD review meds on next visit. There is no evidence of a facility Incident Report and no evidence that this incident was reported to the State Agency. Review of the Nurse ' s Note for R#88 dated 01/19/16 at 6:15 p.m. documented a Report of Incident: Description: R#88 was sitting in dining room in wheelchair when the Certified Nursing Assistant (CNA) saw R#88 wheeling towards R#20 hitting her on the left cheek. No injuries was noted. Interventions: Leave R#88 out of dining room until the trays come out. Physician notified on 1/19/16 6:15 p.m. There is no evidence this incident was reported to the State Agency. An interview conducted on 1/28/16 at 9:36 a.m. with the Director of Nursing (DON) revealed she was not aware of the incident that occurred on 12/20/15 between residents R#88 and Resident C. The DON confirmed there is no evidence of a generated incident report for this resident to resident altercation. Further interview with the DON revealed an incident report was generated related to the incident that occurred on 1/19/16 between residents R#88 and R#20. The DON stated she faxed the physical abuse allegation to the State Agency on 1/19/16. The fax cover sheet provided by the DON at this time was dated with the wrong day, month and year (2007) of the incident. The DON was unable to provide a copy of the State ' s acknowledgement letter of receipt for the 1/19/16 facility reported allegation of resident to resident physical abuse. The DON was unable to provide evidence that the facility completed an investigation in five (5) days. The DON stated further, she did not complete the investigation because she was on vacation from 1/20/16 through 1/22/16. 2. Resident #26 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating that the resident was cognitively impaired. Review of the electronic Nurses Note dated 6/26/15 at 8:55 a.m. revealed that a CNA was assisting the resident to the toilet when the resident began verbally abusing the CNA. The CNA reported the incident to the nurse who interviewed the resident. Continued review revealed that the resident told the nurse that the CNA had papers in his/her hand and had thrown the papers at the resident. The resident denied cursing at the CNA and assured the nurse that the CNA had verbally abused him/her. Further review revealed that the nurse had not seen the CNA enter the resident's room with any papers in his/her hand. Although the resident had alleged that a CNA had thrown papers in his/her face and had verbally abused him/her, there was no indication that the facility had investigated the allegation of abuse. Review of the facility's Abuse Policy revealed that it was the responsibility of employees to promptly report any incident or suspected incident of resident abuse to facility management and that a thorough investigation would include completing an incident report, interview all pertinent staff members who had contact with the resident during the period of the alleged incident, interview the resident's roommate if cognitive and obtain written witness statements. Interview with the Administrator on 3/8/16 at 11:30 a.m., revealed that he was unaware of the resident's allegation of abuse on 6/26/15. Continued interview revealed that the allegation by the resident on 6/26/15 was not investigated because the nurse had assessed the resident's room and did not find any papers. Further interview with the Administrator revealed that after reading the 6/26/15 Nurses Note, the allegation should have been reported to administrative staff and thoroughly investigated. 3. Review of Resident #147 ' s medical record (closed record) revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Discharge Minimum Data Set ((MDS) dated [DATE] revealed that the resident had severely impaired decision making skills. Continued review of the resident ' s medical record revealed that on 2/16/16, the resident became limp and his/her blood pressure was 90/54. The physician was notified and the resident was sent to the hospital and discharged from the facility on 2/16/16. Review of the Social Services note dated 2/15/16 revealed that a family member of the resident reported that $40 was missing. Continued review revealed that the resident had $90 in his/her wallet when he/she was admitted . When family came to the facility to pick up the resident ' s personal items, the family member noticed that $40 was missing from the wallet. Further review of the Social Services note revealed that a full investigation was initiated and included interviewing all staff and family members and a report sent to the State Agency (SA). Staff were to be educated on placing residents ' valuables in a lock box. Staff were also to be educated on misappropriation of property. Social Services would inform family the importance of not sending valuables with the resident. Review of the facility's investigation (#GA 673) into the alleged missing $40 revealed that a Grievance Report was completed on 2/15/16, a follow up completed on 2/19/16 and a summary of the facility's findings faxed to the State Agency (SA) on 2/19/16. However, continued review of the investigation revealed that written statements from all pertinent parties were not obtained. Review of the facility's Abuse Policy revealed that staff members on all shifts who had contact with the resident during the period of the alleged incident as well as the resident's roommate and family members will be interviewed and witness reports will be in writing. Interview with Certified Nursing Assistant KK on 3/8/16 at 10:50 a.m. revealed that she/he was not aware of a lock box in which residents' valuables could be secured. Continued interview revealed that if she/he saw a resident with expensive jewelry, money or other valuables she would notify the nurse. Interview with Payroll personnel on 3/8/16 at 11:10 a.m. revealed that the facility reimbursed the resident $40. Continued interview revealed that the money would have been placed in the resident's trust account but, the resident was discharged from the facility and his/her family member/responsible party was given $40. Review of the Petty Cash receipt revealed that the resident's family member was given $40 on 2/19/16. Interview with the Social Services Director on 3/8/16 at 11:40 a.m. revealed that an e-mail was sent to all staff on 2/18/16 that residents were not supposed to have any valuables on their person or in their rooms. Further interview revealed that inservices had not been provided to all staff regarding placing residents ' valuables in a lock box for safekeeping. Interview with the Social Services Director on 3/8/16 at 3:10 p.m. revealed that she verbally notifies residents/family on admission that valuables and money need to be kept in a locked box in the Administrator ' s office. Review of the Inservices provided by the facility revealed that the last inservice provided to staff on misappropriation of property was on 10/14/15. Interview with the Administrator on 3/10/16 at 8:30 a.m. revealed that the Social Services Director had interviewed all pertinent staff regarding the missing money. Continued interview revealed that he, the Director of Nursing (DON) and the Social Services Director (SSD) interviewed the Licensed Practical Nurse and the two certified nursing staff who had provided care for the resident prior to the time the money was reported missing. Further interview revealed that the DON and SSD were responsible for obtaining written statements from all pertinent parties. Interview with Licensed Practical Nurse II on 3/10/16 at 8:40 a.m. revealed that on admission, the resident had given a CNA his/her wallet with the $90 and that LPN II counted the money prior to placing it in the lock box in the medication cart. Continued interview with LPN II revealed that the resident asked for the wallet the next morning and after counting out the $90, LPN II gave the resident his/her wallet. Further interview revealed that the resident ' s sister provided the resident a container for his/her clothes and had placed the wallet in the container. Continued interview with LPN II revealed that she/he thought she/he had provided a written statement to administrative staff. On 3/10/16 at 10:20 a.m. the Administrator provided a written statement from the resident's family member regarding the missing $40. Interview with the Administrator at that time revealed that he could not locate any written statements from staff. Continued interview revealed that the resident was not cognitively able to provide a written statement. Further interview revealed that the resident ' s roommate was cognitively intact but, staff failed to obtain a written statement from the roommate. On 3/10/16 at 10:20 a.m., the Administrator provided written statements dated 3/10/16 from LPN II and the two CNAs who had provided care for the resident at the time the money was identified as missing. Interview with the SSD on 3/10/16 at 1:05 p.m. revealed that she had obtained a written statement from LPN II but, that she does not know what happened to it. Continued interview with the SSD revealed that she had not obtained statements from the two CNAs or the resident's roommate.

Based on observation, record review, Abuse Policy and Procedure review and staff interviews, the facility failed to implement measures to protect five (5) residents (R20, R21, R74, R82, and C) from physical, verbal and sexual abuse by a resident (R88) with a history of sexual advances and inappropriate behavior towards residents, staff members including eleven (11) separate episodes between 12/10/2015 through 1/23/2016, on two (2) of three (3) halls and the common dining room. The sample size was forty (40) residents. The facility census was ninety one (91) residents. It was determined that the noncompliance in one or more requirements of participation has caused harm to R#21, R#20, C, R#74, and R#82, is likely to cause, serious injury, harm, impairment, or death to the ninety-one (91) residents reside in the facility. This noncompliance was identified to have existed as of October 14, 2015, when R#88 first attempted Administrator and Director of Nursing were informed of this Immediate Jeopardy (IJ) on January 29, 2016 inappropriate sexual behaviors toward a female resident and remains ongoing. Findings include: 1. Review of the Facility Self-Report revealed that on 10/14/15 at 5:30 p.m. R#88 and R#21 were sitting in wheelchairs in the hallway. R#88 attempted to get his hand up R#21 ' s dress. Staff members stopped him immediately and removed them to separate areas. The Medical Doctor (MD) was notified and R#88 was sent to a Behavioral Center for evaluation. Continued review revealed the Brief Interview Mental Status (BIMS) assessment score for R#21 is 0 indicating severe cognitive impairment and she has a [DIAGNOSES REDACTED].#88 is 12 indicating moderate cognitive impairment. 2. Review of the Behavior Patient at Risk (PAR) documentation revealed that on 12/10/15 at 1:36 p.m. revealed that R#88 had a verbal altercation with a male resident in the dining room. After the altercation as he was leaving the dining room when he struck at Resident C with his fist to her hand. Review of the PAR intervention included that the MD review medications on next visit. Interview on 1/28/`6 at 9:36 a.m. with the Director of Nursing (DON) revealed she was not aware of this event and there is no generated incident report regarding this incident. 3. On 12/29/15 at 6:00 a.m. revealed documentation related to sexual abuse towards R#74. Report of Incident Description: R#88 was in wheelchair in front of nurse ' s desk. When R#74 passed by R#88, R#88 grabbed R#74 on the buttocks. R#74 turned and swung at the head of R#88 and struck him in the shoulder. No injury noted. R#88 just laughed at her. Interventions: Removed R#88 from the area. Redirection given, Physician notified: 12/29/15 6:00 a.m. 4. During a Complaint Survey to investigate complaint # GA 467 regarding a sexual abuse allegation that occurred on 01/08/16 revealed a facility self-reported incident which documented; a Licensed Practical Nurse (LPN) noted a male resident R88, touching a female resident R#20 on the right breast in the hallway. Review of the Nurse ' s Notes dated 1/8/16 at 5:25 p.m. documented, Report of Incident: Date: 1/8/16 Time: 3:00 p.m. Description: The treatment nurse was walking down 300 Hall when she witnessed an interaction between R#88 and a female resident R#20. R#88, seated in his wheelchair was next to a female resident, R#20 sitting in her Geri chair with her eyes closed. The treatment nurse stopped the behavior and educated the resident that behavior was inappropriate and needed to stop. The treatment nurse then removed R#88 from the area. While the treatment nurse reported the incident to the unit manager R#88 once again made his away over to the unconscious female resident R#20. Before another incident occurred the treatment nurse removed R#88 to his room and provided education that the behavior was inappropriate. R#88 then told the treatment nurse to, shut up. A Certified Nursing Assistant (CNA) then attempted to place the resident in bed. R#88 attempted to strike the CNA at this time. Interventions: R#88 moved away from other residents while arrangements could be made to send the resident to Floyd for behavioral modification. Physician and family notified 1/8/16 4:15 p.m. Review of the Five (5) day Facility Investigation dated 01/12/16 documented, Interventions: R#88 was sent to a Behavioral Health Center via Emergency Management System (EMS) on 01/08/16. Review of the Nurse ' s Notes dated 01/08/16 at 1:31 p.m., documented R#88 noted rubbing the thigh of a female resident R#20. Residents were separated. R#88 became combative with staff and attempted to strike staff members. MD notified. New order to increase [MEDICATION NAME] to 5 mg in morning and 10 mg in evening. Will monitor. Review of the Nurse ' s Notes dated 1/8/16 at 4:10 p.m., documented R#88 to be sent to a Behavioral Health Center for behavioral modification in regards to continued sexually inappropriate behaviors. Social Worker (SW) has spoken with the family. Report called to a local emergency room (ER). Physician notified per consult book at 4:15 p.m. R#88 left facility via EMS stretcher at 4:30 p.m. Review of the Nurse ' s Notes dated 1/8/16 at 4:39 p.m. written by the Director of Nursing (DON), documented R#88 was noted to be sexually inappropriate toward another female resident who was sleeping at the time. Redirection was attempted as well as re-education but R#88 continued to attempt to get to the other resident. Review of Nurses Notes dated 01/14/16, documented R#88 returned to the facility from the Behavioral Health facility. Continued record review for R#88 revealed additional documentation of abuse towards residents and staff members as follows: 5. On 1/17/16 at 2:19 a.m. revealed documentation related to physical abuse towards staff. During prn (as needed/requested) medication pass, R#88 grabbed throat of nurse and began grabbing her. Notified Physician who gave stat order for [MEDICATION NAME]. R#88 went to sleep after incident, nurse did not administer [MEDICATION NAME] due to resident already sleeping. 6. On 01/19/16 at 6:15 p.m. documented Report of Incident: Description: R#88 was sitting in dining room in wheelchair when the Certified Nursing Assistant (CNA) saw R#88 wheeling towards R#20 hitting her on the left cheek. No injuries was noted. Interventions: Leave R#88 out of dining room until the trays come out. Physician notified on 1/19/16 6:15 p.m. There is no evidence this incident was reported to the State Agency. On 1/23/16 at 6:50 a.m. revealed documentation related to sexual abuse towards staff. R#88 having issues today with inappropriate touching of female staff. This morning R#88 came up behind a housekeeper at her cart and grabbed her crotch and buttocks. R#88 was removed from the hall and brought back to 100 hall. Nurse had R#88 to stay near her as much as possible today to avoid further issues, but the resident repeatedly went or tried to go into female rooms, upsetting female residents. This afternoon when being given his insulin shot, R#88 used the opportunity of this nurse bending down to roll up his sleeve of his shirt to grab this nurse's crotch from the front. I once again tried to educate the resident on the inappropriateness of touching females. Resident rolled his eyes and said he can do what he wants to. Note to doctor for Monday. On 1/24/16 at 8:10 p.m. revealed documentation related to physical abuse towards staff. LATE ENTRY - 2:00 p.m., documented R#88 had altercation with dining staff. R#88 ate two (2) trays of food and then went to another table and started eating another resident's food. Dining staff started taking the food away from him and he struck out at them, grazing one CNA. Observation on 1/25/15 at 2:15 p.m. revealed R#88 sitting in his wheelchair in the hallway. The resident is able to ambulate via wheelchair independnetly. Review of the facility ' s Abuse Policy and Procedure documented in Section IV- Identification: #1 Information related to incidents will be logged into the tracking and trending program aiTracker. Management staff will review data to determine any patterns or trends that may constitute abuse. If trends are identified the administrator or designee will investigate them. #2 Any individual observing an incident of resident abuse or suspecting resident abuse must promptly report such incident to a member of the nursing staff or a member of management. Section VI- Protection: #1 Upon receiving information concerning a report of abuse, the Director of Nursing services or Administrator will request that a representative of the Socical Services department monitor the resident's emotions concerning the incident as well as the resident's reactions to his/her involvment in the investigation. There is no evidence of monitoring of the resident's emotions or reactions in accordance to the facility policy. Interview conducted on 01/28/16 at 1:30 p.m. with direct care CNA MM revealed they were not aware of any special concerns or needs related to the behaviors of R88. MM stated they normally works the 200 Hall. Interview conducted on 01/28/16 at 1:33 p.m. with CNA NN stated R#88 was on his/her assignment today and they were not aware of any special concerns or needs related to the behaviors of for R#88. NN stated they have only been working for just a few weeks and really doesn ' t know much at all about this resident. Interview conducted on 1/28/16 at 6:15 p.m. with the Administrator revealed the facility has taken numerous steps to prevent further abuse occurrences by R#88 and moved him from room [ROOM NUMBER] to room [ROOM NUMBER] away from R#20. The medications have been adjusted and R#88 was sent to Floyd Medical Center where he stayed for approximately one (1) week. They have tried diversional activities. They have spoken with the sister and family attorney about hiring sitters. They have sought placement at other facilities. R#88 is currently on the waiting list for several facilities with locked units. Interview conducted with Director of Nursing on 1/28/16 at 9:36am.who stated resident has been sent to Floyd Behavioral Health on multiple occasions to address his inappropriate sexual behaviors and increased aggressiveness. We have educated staff to try to redirect him and to provide diversional activities. We moved him from room [ROOM NUMBER] to Hall 100 to room [ROOM NUMBER]B. We have had his medications adjusted several times. We have tried to get him placed at another facility.